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Miscellaneous - 80 LACONIA CIRCLE 4/30/2018 (2)
kh, 7b r Crawford & Company 1001 Summit Blvd Atlanta, GA 30319 Phone 877-346-0300 Re 4/1/2015 Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 Insured: Claim Number: Policy Number: Our File: Date of Loss: Type of Loss: Location of Loss To Whom It May Concern: 7ENKINS_DALE_CHAPTER 139_LETTER_CRAW.PDF Dale Jenkins 033566983 24611400003 6776-2589951 2/16/2015 Ice Damming 80 Laconia Circle North Andover, MA 01845 A claim has been made through Ar bella Mutual Insurance Company which involves loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, James Warren James Warren Crawford & Company 361-332-9387 CC: City/Town Fire Dept, City/Town Health Dept Date ........ � _h? —/ ?— . ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............v1,t�w!�..4� . . ........................ ........................ has permission to perform ...................... .... . . .............................4........ wiring in the building of .................J.v..s ........................... at AC...L �/.......... eA.L ......... North Andover, Mass Fee... Lic. No.. �G> LECTRICAL INSPECTOR' Check # / 77�� p' 0891 I 10 Cariancrtiveaith of tlassachnseffs Official Use Only Department of Fire Services Permit No. _ ' Qg g/ Occupancy and Fee. Checked BOARD OF FIRE PREVENITION 1 REGULAT101 S [Rev. 9/05] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALLI FORMATION) Date: V l t ll j - City or Town of: To the Inspector of Wires: By this application the undersigned gives notice 'ONs or her intention to perform the electrical work described below. Location (Street & Number) cQVI to: Owner or Tenant -JgN ICI h Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Existing SerAce Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �hC4. U)y yk� Qoo Completion of thefollowing table may be waived hv the In ector of Wires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above n- Swimming Pool rnd. ❑ rnd. ❑ 79—o.—of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers eat Pump Num er ons o. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KWo. of No. of Data Wiring: Heaters Signs Ballasts No, of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP i e ecommurucattons r: trt., : No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabi ' insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such col rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under th ains and penalties o e th 'ury, tlta e information on this application is true and complete. FIRM N co � e. LIC. NO.: Licensee: ignatureA&fUlA, LIC. NO.:al (Ijapplic ent "ex t " ' t nse ber ne.) Bus. Tel. No.. Tyr Addres .% Alt. Tel. No.: *Security ystem Contractor License required for this work; if applicable, enter the license number here: OWNS, R'S INSURANCE WA -%"ER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner` ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ��� A V^'V vtA X4 j Ok I '71-1-z, N r Town of North Andover E VtORTH it 0`yt�io K6. �•� Office of the Conservation Department 0 Community Development and Services Division 1600 Osgood Street North Andover, Massachusetts 01845 'SS�cHus�s CONSERVATION COMMISSION PUBLIC HEARING Telephone (978) 688-9530 Fax (978) 688-9542 Pursuant to the authority of the Wetlands Protection Act, Massachusetts General Laws Chapter 13 1,. Section 40, as amended, and the North Andover Wetlands Protection Bylaw, the North Andover Conservation Commission will hold a public hearing on: WEDNESDAY, September 8, 2010 at 8:00 P.M. in the Town Hall Meeting Room 2na Floor located at 120 Main Street, North Andover, MA 01845. For the filing of a Notice of Intent by (applicant) Dale & Tiffany Jenkins To alter land at 80 Laconia Circle, Map 1051), Parcel 156. For the purpose to: construct garage, in -ground pool, patio, paved driveway, retaining walls and associated grading within the Buffer Zone to Bordering Vegetated Wetland. Plans are available at the Conservation Office, 1600 Osgood Street, Building 20, Suite 2-36. By: Louis Napoli, Chairman N.A.C.C. APPLICANT INFORMATION: Run once in the Lawrence Eagle Tribune on Tuesday, August 31, 2010 DELIVER OR FAX THIS LEGAL NOTICE TO THE LAWRENCE EAGLE TRIBUNE BY: Friday, August 27, 2010, by noon ADnlicant(s) must brim proof of publication of this Lejeal Ad to the meetin Tribune Fax # 877-927-9400 Legal Ad Billing Info: The Neve -Morin Group, Inc 447 Boston Street Tomfield. MA 01983 Phone # 978.887.8586 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 r til ber El.2010 at 8:00 P.M. in the Town Hall Meeting R06ni.2nd Floor located: at 120 Main Street, North: Andover, MA 01845. For the filing of a Notice of Intent by (appli- catit):: Da.le>_&;Tiffany i To:_.al.ter.,land.. at.,80 iconla Circle;Map 105D; Parcel 156:. For. the purpose to: construct garage; in - Plans are. available. a the. Conservation -Office 1600 Osggod :Street Building 20:`Suite.2-36. By:':Louis,. apol Oh airmai FIN i�f R G C A Date... TOWN OF NORTH ANDOVER . PERMIT FOR WIRING This certifies that ............ ('04 IA -4 -(z) ............................... has permission to perform ........ ........,/........... wiring in the building of ...... j f z . ............ ........ at . . ......... ........... ........ . North Andover, Mass. Fee..k� l.... Lic. No. ....... ........ .... . . ............. . CAL INSPECTOR Check # `10572 ,.r or Commonwealth of Massachusetts Official Use only Department of Fire Services Permit N �° �% 2. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 f I- a City or Town of: &1 � �i y E 2 . To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) '�Q L A Co141 A D012 – Owner or Tenant bA L>r ZLN KI N 3 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ✓❑ No ❑ (Check Appropriate Box) Purpose of Building Dt url.C11JL-1 Utility Authorization No. Existing Service ,o Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: U ,,Zg Apo, riwJ Cmmnletinn nftha fnllmvino tnhln mnv ho ivnived by the Invnortnr of Wiroc No. of Recessed Luminaires 9 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs — Generators KVA No. of Luminaires / '� AboveIn- Swimming Pool grnd. . El o. o mergency Lighting Battery Units No. of Receptacle Outlets )14 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches / No. of Gas Burners _— No. of Detection and InitiatingDevices No. of Ranges No. of Air Cond. --Tons total No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons IKW No. of Self -Contained Detection/Alerting Devices I I No. of Dishwashers Space/Area Heating KW Local ❑ Municipal E3 Other No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Wateru Heatera_ –�—W No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs --- No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: gay), o 0 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that suchcv ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) F e2n r Eo . I certify, under the pains and penalties of perjury, that the inforinationonilds application is trite and complete: FIRM NAME: -' Licensee: Sant. (/fapplicable, enter "exempt " in the license number line) _ LIC. NO.: a2r33 G E _ LIC. NO.: I83 5o A Bus. Tel. No.:g-rg 777 Sg'S Fl Address: /i L,gee y sr- ,w,eo,e<rd,,l 1.14 o AMR • Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature _ Telephone No. I am the (check one) ❑ owner ❑ owner's agent. $ PERMIT FEE. �f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelribly Name (Business/0%wizationl1ndividual): 3pMFS - T C41Zsro;1F C--LE:e- Address: /G 1-rt3werY s-;— City/State/Zip: r City/State/Zip: Mcoi rrb i MA 019 is: Phone #: 9 78' -�-7 7. S'93 R, Are ou an employer? Check the appropriate bog: Type of project (required): 1 _ I am a employer with 3 4. ❑ I am a general contractor and I 6. Q New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. + ❑Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for me in any capacity. workers' comp. insurance. g, Q Building addition [No workers' comp. insurance 5. ❑ We. are a corporation and its 10.Q Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box mast attached an additional sheet showing the name of the sub -contractors and their workets' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: i gaFPn T-F—n Policy # or Self -ins. Lic. #: Expiration Date: 3131 62 Job Site Address: Arn%, ► A t'JZ 1J �1�1pod� - V'r , 2' City/State/Zip- M +A -_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine - of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for i#surance coverage verification. I do hereby certify undAf tWpains and penalties of perjury that the information provided above is true and correct Phone #: 97 9 7-7 7 S9 3 FS' Ojjicild use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date. 0-3.. A ........ TOWN OF NORTH ANDOVER + 9 -PERMIT FOR GAS INSTALLATION Thris certifies that . M.�'? I Ft! U-` ...((�,, 4���4? .�..�� has permission for gas installation ;.) Ar �T.` - .. i�k �?rl,� . vizn4s in the buildings of P . d (h ................... at . Cc tt– oZF r, M�s.Fee.b. Lic. No.. �...... GAS IN Check # 1 7984 t 'IS C1VTI IDCC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: /2.AJ rrev'' MA. Date: k)ec— 3 /. Zotrl Permit# Building Location:_ Owners Name: _ �og" �� TVA (C " s Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ C1VTI IDCC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 9K"*" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and TWO•V lily..IIVW�CUytl d1i l'Id[ do piumaing worK ana Instauanons perrormea unaerthe permit issued forthis application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chanter 142 of the Genaral I nwc Type of License: [3y ❑ Plumber %6 V Title y^ ❑ Gas Fitter El Master Sign re of Licensed Plumber/Gas Fitter a0l— Cit❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer - c/ W Y m W w m Q 2 w O0 LU � W 0 U cA H O= 1- w W OZ Z W z g p m tX W W R O FQ- m X Z5 W W W cn v W W Z O Q = cn d IW- o F 0 t li > Z> V W Z -W 0 J 1. J F- O Lu z J U F- U. �= W � W W O 0 O IY D O u. N Q (9 Q W (9 == Q W m Q> J W 0 z 0 Q 0 am R 0 0 N> W Z F- >>> z Z w _ Q I- O SUB BSMT. BASEMENT fSTFLOOR 2 Nu FLOOR 3 FLOOR 4 TH FLOOR 5TH FLOOR '6TH FLOOR FLOOR 8TH FLOOR Installing Company Name: ("-o' t �� 6v4er-, Chec ne Only Certificate # Address: 3 1 -i-u /� s% / Corporation 2 2 G Ak City/Town: State: Business Tel: /- 7 )k- S3(,- ? / 3 Fax: ❑ Partnership ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 9K"*" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and TWO•V lily..IIVW�CUytl d1i l'Id[ do piumaing worK ana Instauanons perrormea unaerthe permit issued forthis application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chanter 142 of the Genaral I nwc Type of License: [3y ❑ Plumber %6 V Title y^ ❑ Gas Fitter El Master Sign re of Licensed Plumber/Gas Fitter a0l— Cit❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer - c/ 3' r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ..600 Washington Street Boston, AM 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nniirantt Tnfn,•..,.,f:.... Name (Business/Organization/Individual): Address: ' 3 / City/State/Zip: Phone #: Are you ane er? Check the appropriate boa: 1 • E>aer with Y 4. ❑ I am a general contractor and I employees (full and/or part-time).*' have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub=contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ _I am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation ane. officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] I ny EYphCEnt that checks box rl must alsU fill out the section belo4' S -00V M-9 their won"ems' CCypensyttiou policy informa�10Il. ' T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policyinformation. _ am an employer that is providing workers information. ' compensation insurance for my employees Below is the policy and job site � Type of project (required): 6.construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Insurance Company Name: Policy # or Self -ins. Lic. #:� s� �/ S" 3 Expiration Date: { Job Site Address: 3,12 ��5 /' City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing In 6. Other Contact Person: Phone #: 0 0 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), addresses) 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 reed to the city or town that the application for the pe f is e a being requested, not the Dep rtm ent o_ Wait o_ 1 e_s s ,n z f Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business, or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of lnvestibatons 600 Washington Street Boston, MA 02.111 Tel. # 617-72.74900 ext 4.06 or 1-8.77 MASSAl{E Revised 5-26-05 Fax # 617-72.7-7749 wvm%mass.gov/dia V i CL LL Ln 0 rn 0 V) Z rn V) rn m C) > N 3: n 0 CD rn 1-4 rn < rn cl CD 0. N M rmn x LL2 Lou :i 08 gn .0 r-4 LU ol < 1-1 V i CL LL Ln V) '0 NVLD N 0. LU z 0 0. z x LL2 Lou :i 08 gn .0 r-4 LU -j < 1-1 0 > a. f r-4 zu) 0 Ln Ln w u 0 Mr,U=" MPC (A LUz ix "n 0 Z • coLU C4:UN C) MF- < N Din 1: LL 0= uj in � Z LL LLI W LD < p Q 4 l Jy � C 0 E mm CL F- O �O cc o CL K ca •C C W CL o , v� 0 CL C C ■ii SN-Ddh OWE EOOZ'E1 'NNf w zn- cn W W w ui co C 1 A nl a 00 o l Jy � C 0 E mm CL F- O �O cc o CL K ca •C C W CL o , v� 0 CL C C ■ii SN-Ddh OWE EOOZ'E1 'NNf w zn- cn W W w ui co Location a o No. __;2 Date M0"TN TOWN OF NORTH ANDOVER ' i # Certificate of Occupancy $ �'�s'••° • Eta CNUS Building/Frame Permit Fee 010 $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 11-1 �jG '1 3 4 Building Ins i(�ector J I n 0 C Z rr C OT r -4 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .. BUII:,DING PERMIT NUMBER: ,% DATE ISSUED: SIGNATURE: Building Commissio22fmEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �D 1 A C n i C•`rc le 010/ 105; D -0 156 -0000.0 clove r Map Number Parcel Number t 1.3 Zoning 1nfotmation: 1.4 Property Dimensions: i -7g, any a6� Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard - Required Provide Required Provided Required Provided 1.7 Water Supply M.G L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private it Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System SECTION 2 - PROPERTY OWNERSIIIP/AUTIIORIZED AGENT 2.1 Owner of Record t yy Name (Print) Address for Service Sign re Telephone 2.2 Owner of Record: Name Print Address for Service: . Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable , Licensed Construction Supervisor: License Number Address —_ Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone I n 0 C Z rr C OT r -4 SECTION 4 - WORKERS COMPENSATION (M.G.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 ....... ❑ SECTION 5 Descri tion of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description({of Proposed, Work: ��ir�`'�I\'� T`Y11J� 17�82�v►^Q+1� lfpexx 50% SO&Cc- �i�`�• c-2Yl i Pew Ff SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b y pernut applicant ` f O?FICIAL USE E}NLY , . 1. Building >s 1 (a) Building Permit Fee Multiplier D 2 Electrical � (b) Estimated Total Cost of Construction DQ�� 3 Plumbing 2, gat Building Permit fee (a) X (b) i 4 Mechanical HVAC 'b 1 1 dcio 5 Fire Protection 6 Total 1+2+3+4+5 0 7 t10o Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby d Aare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and bel Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS Is 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS D1Iv1ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE rAP It& l i`lN1� `L FORM U.- LOT RELEASE FORM Yt 5Lt NA �T 1 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** R APPLICANT VIa (� I PHONE o ` b a �( O' LOCATION: Assessor's Map Number / / PARCEL SUBDIVISION j (? LOT (S) �. STREET Lac ov 4 `i ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COM FOOD INSPECTOR- EALTH DATE APPROVED DATE REJECTED INSPECTOR -HEALTH COMMENTS b DATE APPROVED Ia1146l 0 i DATE REJECTED N PUBLIC WORKS - SEWER/WATER CONNECTIONS. DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 0 CERTIFIED FOC WDA71-oNPLAA1 LOCATED /N IJ)I NrAr<rL- SCALE."I"- - -L S. L. G14 Es R Z LAWRENCEa NoH7-H,4)V1)n,1rQ 11 N L= JH -?TIFY THAT OFFSETS SHOWN ARE FGR THE USE OF V "ETS SHOWN THE BUIL DING INSPECT01? oNL y, er S Jr - UCH 7 'ORM TO THE USE IS FOR DETERUI�,IA 77ON OFZOAIING All an-� 0 W . , 2 IVGSrLAWOF CONFORMITY OR, IVON C01VFbi?1W1TY WHEAV' CONSEfUr Eo �J. 0 w Ilk. t '-' 0 Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM v t=L¢o •�Y -Y JD 0 y h �Isle, Teo 4-P¢�,i�j In accordance with the provisions of MGL c 40s 54, and. a condition of Building permit-# the debris resulting from the work shall.bedisposed of in a properly licensed solid waste disposal facility as defined by MGI; cl ], sI50a: The debris will be disposed of in /at: Facility location Signature ofApplicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. .... v. .. 1.. -.--T V1 Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE JOB LOCATION Number Street Address "HOMEOWNER Name lyrtgq Home Phone PRESENT MAILING ADDRESS e— f- R y JSAC)4u a101A6-1b-61 02 ?78 Map / lot Work Phone N City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does . not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/orfarm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other Applicable codes, by -saws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFICIAL i ui am EM cm CO) O.� L4 O O 'E m m 0 CD = O� 3.0 O O i d �a O *- � c qCc C CD CL � C C ■ C CO2 0 0 LLJ U) W w W 04 far w U w a U w" w w - w w w" w w ao cn cn ui am EM cm CO) O.� L4 O O 'E m m 0 CD = O� 3.0 O O i d �a O *- � c qCc C CD CL � C C ■ C CO2 0 0 LLJ U) W w W Location�' No. Date _r.�A'A / &CRT" C."'60 TOWN OF NORTH ANDOVER '.,SCC Certificate of Occupancy $ i Building/Frame Permit Fee $ AC E� J�CyNS Foundation Permit Fee $ Other Permit Fee / v oL $ Sewer Connection Fee $ Water Connection Fee $ r.. f TOTAL-,,, $ �' r Build inonspector Div. Public Works Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works a - a_ Y 0 0 � m n0 w q N_ N X� p� W W z G O Z Z W o 0 JxM J W_ E" It LL 0 0 0 F Z w U) N w I d IL I O W p N L i JM J f� H 1 LU W IL OC U Z *VVlI Q Z ` 0 IL I� z o 0 m J V N N\ N W C i O CIO z Q O Z Q O 0 N N T it ix w Q WW p Q z u z z E+ N 0 0 w wI 0 Ir M O z N F N N Ir W m i F fr O 0 J LL LL 0 W N N N N W Z x u_ I F I N Z It 0 } J_ N F W C Z 0 N a 17 Z 0 = LL n Z u 0 O LLO 0 O 0 0 0IL J LL Q Z = 0 E N W Q L 0 O I N F 4 4 \ V 1] N N W 0 0 u o A N T m W1 0 W I - z Q IC 0 W r W rc IL OW W z G W 10 IL 0 0 o G ac 0 u W OL O Q mO W U) WW UI Z Q0: NO _a �I OF. Z3z J 0 J19�. LL 0 Oaa N Z5(n OMW FnLL z0a INw UNI QZF WSW 3oN 0. NVF f' X jWW IL fZ] ZQUI 0 u W W WZ_ . N '� W Nva F0m NI Imo- -1111111 I 1 1-11111 111111111 F I I I� I1 I I1 ZW 2 Z LL Z0 I 1 Q ¢ U Z d Z ,, LL0 0 t: z0 0 �m o wsnw0 V ►-]d' y Z vaZ pZ i s x wz 0 ?n¢.Z y ZZmo 0¢¢O� ¢>x0Q0 D 00 z a3¢xwa 0 D,iLL i Yv7 TI I I I I I I IZ I 0 M __ UF O F 4 W wZ Z O Q y z d Y y m w h p NxrLL-Wx _Z fLL J O O,1n O at OZ LLOZn vNmO O 0 aZ¢ a p N w O °� �¢ oN LD U= C f='1 z Z Z LLZ ¢ 1o3 -0 o00Z 0 ZZ .0 SO O , mm�OnO0 z U V OO Y O Z ¢0 W>od m N O 0 a � m � 0O ,wm 3:N z LL 0 3 0 Fmi CST C m rl �e f.� LO z (f) W J M o � E a �e C _0 C O O J u u u 0 O rYY: c O V 0 N G Z m W W YL Z Z � 0 O z to Un z I.J z u ? cc oc Q ° m N M u o O m m u LAj m L C J t a L U t m .Y O L O O O m a O c 7 E m U ii oc U. oc co ii. cc U. m co �e f.� LO z (f) W J M O z E a C C O O rYY: c O V 0 G m . _ to I.J O z Location No. .412Y -- C- XIC v til' f+ (/x - Date —off/ NORTh TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ GMUS Building/Frame Permit Fee $ 1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0,6511 5-35 / Building Inspector TOWN OF NORTH ANDOVER l BUILDING DEPARTMENT f i APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING tea: a BUILDING PERMIT NUMBER: n DATE ISSUED: SIGNATURE: C Building Commissioner/ITdtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: FO Lac01,,g 1-r- C. r C ljp 1.2 Assessors Map and Parcel /06- D Map Number Number: 1� Parcel Number Ivor j n t►'1i1U1 I I 2.2 Owner of Record: Name Print Address for Service: 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Not Applicable ❑ Front Yard . Side Yard 3.2 Registered Home Improvement Contractor Ckrl s Ce-Se-� Rear Yard Required Provide Required Provided R 'red Provided Addre g&�� (q,)g) Signature Telephone 1.7 Water Supply M.G.L.C.40. 54) Public 0 Private ❑ Zone 1.5. Mood Zone Information: Outside Flood Zone 0 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Jo�, IOvIIjf S Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone e Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Ckrl s Ce-Se-� Not Applicable ❑ C . S Company Name 4�CA �� S7 �C, Registration Number Expiration bate Addre g&�� (q,)g) Signature Telephone z sa SECTION 4 - WORKERS COMPENSATION (M.G.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 .......0 No ....... 0 SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ ` Other, Specify Brief Description of Proposed Work.- QC ork:2t r*.0 0 G e )L r �1GU, r I SFrTTnN b - F.W"WATIRn drnNCTRTTjrTTnN MCTC I Item Estimated Cost (Dollar) to be� Completed b permit a licant 4IMCLU USEr,10NII Kg rff k Building Permit Fee Multiplier 1. Building(a) SOO(a) 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 011<.11V1\ Iis V V11\i A Au 111UM-11A11V1\ 1 V BE UgJMrJbh JL to WMN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date r Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM ° o� 0 y ,4 �q•ITEa ^?¢� �5 sS�c�-ios�-c In accordance with the provisions ofMGL c 40 s 54, and.a condition of Building permit-# the debris resulting from the work shall 'disposed of in a properly licensed solid waste disposal' facility as defined 'by ci 1, s)!Spa. The debris will be disposed of in /at: Lis r"acility location Signature ofA-pplicant 5/a11. Date NOTE.- A demolition permit from the Town of.North Andover must be obtained for this project through the Office of the Building Inspector. Name Location: a$ WAScth n -r, S 1 xl --s3-) F-1 am a homeowner performing all work myself. ®1 am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name Address City Phone #: Insurance Co Policv # Company name: Address City' Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify I er the pains and Grin-nfi iro Print It of perjury that the information provided above is true and correct. Date q j id' 1 Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: FORM WORKMAN'S COMPENSATION Phone # q) ? 74 201 r-1 Building Dept C] licensing Board ❑ Selectman's Office E] Health Department 11 Other 0 z W Cd x w A o w a °D cin 04 O 9) z A w° U `° w O U w v� z C2 —coW x O w a�' cn `° w p U a z d A `° w w w a z cn v o o cn c o CD c .c s o � Com: :oma v: C3C.3 zt: CLcc ccc \ : : CD V s o CD o CD � N ra v �� =CD L m _ E c 0 : ,o m J: OO • ee11 L ` H CD 3 w N O � N � • Cm 0 � .� �� N A O E m o mo 2 CMD aD = CD N = �; T _ ._ o �I scom C7 y O . v.-Zcm p w = O c CL. m : y m Z :5 BCD uj W.r E ca=r IS oo ya g _ •Na .0�y*0 C F- .0.. aim F z `C 4 W O O U a O O v CA H E CLO L O O O v O ,-.7 L O V O CL CO) c C co 3 .o co L O �' CL Qm Q C COca Z s CDy C 0 U) Cn crW W W U) ,%ORfF, � p 4 •: ,O•. SSAOMUS� Date . � .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .............. has permission to perform ... 1.I' ... ................. . plumbing in the buildings of ... ......'....................... . at .................... . North Andover, Mass. Fee. Lic. No..':,.( ........ ......... PLUMBING INSPECTOR Check # Y r 514 2 r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New rl Renovation ®� -v/" Owners Name Type of Occupancy Replacement 0 FIXTURES Date Permit # Plans Submitted Y s ❑ No (Print or type) -�— Check one: Certificate Installing Company Name C / df /' Corp. Address Partner. Business Te ep one Lz Zzz _ 11-firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy n/ 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 Signature Owner ❑ Agent ri 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 instal performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach etts te:j'Q�W Code and Chapter 142 of the General Laws. 1VIL.yl 1UW11 APPROVED (OFFICE USE ONLY Type of Plumbing License 77 ense Mumoer Master 0—_.Journeyman ❑ -3O 7 Date.... ... �..�.... NORTH TOWN OF NORTH ANDOVER °c PERMIT FOR WIRING This certifies that 4 ` t✓.�1... �.�.!.. .............. .:.................................................. has permission to perform ............................................................................ wiring in the building of................................................................................... �(......a .......�� ..... .' ..... . orth And ye -, ass. Fee................................ ................ . Lic. No. %.!. .. ............... //ELECTRICAL INSPECTOR Check # DEPARTMENTOFPUBLICS4MY Permit No. _ _ 36;p 7 BOARD OFFIREPREVEWONRWM 4TIOAN 527CMR 12:00 VA Occupancy &Fees Checked PPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 8O Gfi-c,3n % P, C C-ke Date To the Inspector of Wires: Owner or Tenant aal�,n pvt �; tr •- Ovt der a � Owner's Address _ 6o L4Can ip, 6"T-ke, �® Is this permit in conjunction with a building permit: a39 Yes No a (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service��� Am -..�/— Volts OverheadUnderground ® No. of Meters New Service Amps �� Volts Overhead M Underground No. of Meters i 4umber of Feeders and Ampacity Location and Nature of Proposed Electrical Work US.—i- -AAA- ,9 -f -k + Oe A,,- l No. of Lighting Outlets 0No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA No. of Receptacle Outlets f No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch OWets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of DisposalsO No. of Heat Total _ _ Total '` Pum s Tbns KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW (7 — -- -- No. of Self Contained Detection/Sounding Devices Local Municipal Connections © Other No. ut Dryers O Heating Devices KW No. R` Water Heaters KW No. of No. of S'gnsBailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER hm mwCmerage. Rusint1olhemWmiiazdfMmmdiN&CanalLaws IhaseaamaiLiabkhnr&=Pd yarlvdigCcrVkt Co�geerisskstfft lacgnWat YES ® NO Iha%e%bnfdvAdga(bfsa 1otheOliioa YES rl NO Ffjwha%edxcWYES pimeindicatethet WofineaWbydiadnthe INSURANCE ® BOND OTHR WotktDStalt2 t Ztia�... jpecionD*RapeWd Sigwd undefs anal&s ofpajtey: FIRM NAME ftweSpeafy) /2 - 2,10 Z. Dra6e a EstirrgMdVakxofl3ecftical Wak $ �bOA R.0 a FM Lioa>.seNa AlTdNa OWNER'SRq JRANCEWANFR;IatnawaethattheLk=do vd etheitmrmxwmp"salstar>We asmpedbyNbmadxs&CcnaalLaws and that my signatuteon the pemm6 app)kabon waives this reverter (Please check one) Owner M Agent Telephone No. PERMIT FEE .S A Cac CLAIMS DEPT. March 11, 2003 Ccmmerce Insurance The Commerce Insurance Company Citation Insurance Company Members of The Commerce Group, Inc. 11 Gore Road, Webster, Massachusetts 01570 (508) 949-1500 RECEIVED www.Commerceinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL N ANDOVER MA 01845 Board of Health or Board of Selectmen Town/City Hall RE: Our Insured: JOHN W BOULLIE / GIA L OEI Property Address: 80 LACONIA CIR Policy#: TW 1723 Date of Loss: 02/20/2003 File#: RK4315-KPW329 MAR 2 0 2003 BUILDING DEPT. Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. SUSAN BUTLER Claim Adjuster Telephone: (508)949-5588 Toll Free: 1-800-221-1605, Ext: 5588 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. March 11, 2003 C4)mm0ro Companies .... COME GROW WITH us CIC 254 (Rev. 4/95) MAIL E49 f Date... x f Of NORTH .1 41 TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that .0,4. 1%d.`I.A&.1..../. _'-i..4.. ........... has permission for gas installation .r!r'v`�c' in the buildings of ... 4�011 1 .......................... . CPWla at .. ��North Andover, Mass. ^ :�f ......................... Fee . ' s . Lic. No...�/.`w ... -... ..!`. ........... GAS INSPECTOR ' Check # 1(,R303 ti A87- C MASSACHUSETTSNIFORM APPLICATIO (Print or Type) P'A woot4' - ' N Mass. Dat Building Location —2 'A co New p- Renovation ❑ FOR PERMIT TO DO GASFITTING Y Permit # �1_0�wner's Named U LL Type of Occupanct)l,,h Al t ent ❑ Plans Submitted: Yes[] No ❑ Installing Company Name, Check one: Address f SH i) ii✓ EI—Corporation ❑ Partnership Business Telephone_ -�- ❑ Firm/Co. NaTe of Licensed Plumber or Gas Fitter `V C -14a,4 1 Certificate # 111,/' r -_ IN:$URANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 0— No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy E Other type of Indemnity O 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 ❑ hereby certify that all of the details and Information I have submitted (or entered) in above application are true and accurate to the best otvy knowiedge and that all plumbing work and Installations Performed under the permlt Issued for this appilcalion V1111 be In compliance with all pertlnent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Gensral Laws, J -/ rCity/'Pbwn T e of license: W �h Plumber Sig alure o cense um er or Gas titer asfitlar aster License Numberxm r p(�'F C Journeyman NN ���i iii ii���iinn�ii�iiiwadi 0 lawn= MENNEN ONMINENEMENNIEN MEN INson INEEMMINN OEM 0ONE EMEME no SOMMENONE ENEVENEEMEN INN MEN MENEM Installing Company Name, Check one: Address f SH i) ii✓ EI—Corporation ❑ Partnership Business Telephone_ -�- ❑ Firm/Co. NaTe of Licensed Plumber or Gas Fitter `V C -14a,4 1 Certificate # 111,/' r -_ IN:$URANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 0— No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy E Other type of Indemnity O 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 ❑ hereby certify that all of the details and Information I have submitted (or entered) in above application are true and accurate to the best otvy knowiedge and that all plumbing work and Installations Performed under the permlt Issued for this appilcalion V1111 be In compliance with all pertlnent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Gensral Laws, J -/ rCity/'Pbwn T e of license: W �h Plumber Sig alure o cense um er or Gas titer asfitlar aster License Numberxm r p(�'F C Journeyman Po R 7- 0 0 m m m m u. m in r- 0 0 0 0 T m 0 m c: N m O x r -i O D C 0 3: rnp C3 a. z 0 p v a m In Ci cc D C -n N f q to m v 7- 0 0 m m m m u. m in r- 0 0 0 0 T m 0 m c: N m O x r -i