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Miscellaneous - 81 ADAMS AVENUE 4/30/2018
North Andover Board of Assessors Public Access Page 1 of 1 Noen� F � • F moo• 4d 7F Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial North Andover Board of Assessors roperty Record Card Location: 81 ADAMS AVENUE Owner Name: TOMKIEWICZ, WARREN C Owner Address: 81 ADAMS AVENUE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.10 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 882 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 228,800 224,700 Building Value: 86,500 79,900 Land Value: 142,300 144,800 Market Land Value: 142,300 Chapter Land Value: htti)://csc-ma.us/PROPAPP/disi)lay.do?linkld=2253036&town=NandoverPubAcc 3/19/2013 W m z W Q co Q p Q w in vco 72W U � -o O �a W U 20 - CD 0- O c O O O O O of J M N O O Y U O J m 0 N er O 4. Q w oo' rte, 0O 00O0 O O`e N N' jN N NN� Ve SlN6 V � a cc ,.. M N�k"N m Sd N Y Y N)N a) 00 NN�O r O} 1 M 00 LU C) O 'Z �; ;? Zq(c O� 1—a2— H g c c G 2 Z �d o O ui 0 'R w0 y�� oo 95- NU�rNi� m N ZO ZO �d f �' o�)zU) p..' o a - 1 �, tai V 'z j CO CO W M M (A 0 0 ? Q 0 0 m.E 0 rl. 0 0 U) N Z ,N: CO�i a) O CC) I:t Q N N ti.. o, '� ,W E U O 0 oil: o cm = a) Q E o Q Ca a?U., g p U p ,4) p) Q m m_ 00 Z p C O O (L = Q o z U)- U d r o a LL U [ OV. W f6: T.c6 ,L:CO C4 0o Q co co. N+c 00 �. LL co _ W . _ C4 a LL Em E Za �n��o O loo co O. a� N �c tn', 0' O O O 'O QCO LL CO; Or! (0 UQ.Q� �p @Iv LO m O o0 0o ICD 0)O) L) C5 ijl'J' E d co D H i� H W LL (D a) G a) a�- cacC ;Li1 O' V �:D Dp WEU` Udo L6 04 Z z Z as )C) N �� (O F LM pW U)x Lli Q .. a) LL Vn 4i ULL ON* U co yyLLL m ONN Ew G ML. m `mom armor- O'm m,m '� Y U'� m rr v6i cm 0. W Q of _ — V i L ✓, O� NORTFa q BUILDING PERMIT,_ �t��eO X61 �c 6 TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION �7 Permit No#:`�/ Date Received 30 b A°q TED f 9SSACHUS�C Date Issued: �© IMPORTANT: Applicant must complete all items on this page LOCATION '� 1 )q 1.) mS � E° Print PROPERTY OWNER L1'C 6- SI R ECc S- f Print 100 Year Structure yes no MAP 4�'& PARCEL: 2 3 ZONING DISTRICT: Historic District yes no Machine Shop Village yes n TYPE OF IMPROVEMENT ❑ New Building ❑ Addition ❑ Alteration ❑ Repair, replacement ❑ Demolition Ei Septic ❑ Well o Water/Sewer PROPOSED USE Residential ;?6ne family ❑ Two or more family No. of units: ❑ Assessory Bldg ❑ Other ❑ Floodplain ❑ Wetlands Non- Residential ❑ Industrial ❑ Commercial ❑ Others: ❑ Watershed District DESCRIPTION OF WORK TO BE PERFORMED: E PL Y�C�I N G ' IRM R :0M 5?A NJ I- SrA l les 1/vl -T IA a E U4Si S r A f 4 S R FPuP-C46- D prrvklJ-&- a 51,E V 6- W1 O w Sl DI NG- 6N r+L L Sl O s Identification - Please Type or Print Clearly OWNER: Name: LL' C G Sl 13+�iIC/ Phone' Address: g (� p� mS /�/F • G . fM`J D Yf Q '-!S'� Fil: Name: Phone: s Construction License. Exp. Date: ovement License: Exp. Date: ARCHITECT/ENGINEER 1) I A. Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ b FEE: $ Check No.: �J Receipt No.:Q NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location e47,1 1p,41,7e' Al"r- rM No.;?/4 q r� Check # f Date 2, TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 9b Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Building Inspector Plans Submitted El Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans F1 TYPE OF SEWERAGE DISPOSAL Public Sewer El Tanning/Massage/Body Art El SwiM113-ing Pools EJ Well El Tobacco Sales El Food Packaging/Sales [J Private (septic tank, etc. E] Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signaturei— COMMENTS CONkRVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: ,Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: LOcatea 384 Osgood Street nteno ! s i ---_,nog, F,ir, �Pep ,COMMENTS..- n 5Vl • I I�--1 Ae I� J Q i LL O O Q O m V O O LL v y V RFo (n n p W N z z O J m c O i 6 7 O LL L 7 O 0_' T C L V cO C LL O N O _Z m J a L OD O Or C LL N J U oC u J NI OO O cr •U N Ln — C I.L 0 N Z N LOp p Of C IL z W Q W C LL 3 m O z N N Y N Y O N 4.o 3 r L Cl) i Z Z �O Z V Cl) aZ X0 W V H Cl) Wo J W a= z- 0 O O O Z y •� m m CD �o� CL O- cn Q O J0 .CL O rz O U y c N O c O y t6 p V y+ •Q Q Q 6 fq C) Q. 4.o 3 r L Cl) i Z Z �O Z V Cl) aZ X0 W V H Cl) Wo J W a= z- 0 O O O Z y •� m m CD �o� CL O- cn Q O J0 .CL O rz O U y c N O �+ The Commonwealth ofMassgehusetts z . Department of J.ndusiri alAccidents s 1 Congress Weet, Suite 100 =d ;= J Boston, MA 02114-2017 wwsv mffs.govldica Wa kers' Compensaiionbusu ance.Effidavit: B-aUcexs/ContraetoxslEIeciriciansiTlwtbers. TO BE Fff D 'i�SI'.H THl! RMMUTING AUTHORITY. A Iicant7nforxnation PleasePxint Legibly Name (Business/Orgmizaiion/Iu di- dual): Address: g 1 A oRrn E " -� City/State/Zip: Igo ,oto v L , O Y�'Phone Are you an employex7 Checkfe ap,propriaie bog: Type of project Ys ed . Q l am a employeivA employees (full andlor pari time).* 7.- [] New co&,s I cfiou 2.E] I am a sole propaetor,or partnership and have no employees Worlang forme m 8. 5&Remo daag My capacity. [No workers' comp. insurance regmred.J 9, ❑ Demolition 'IxIam a hameownerdoingalt workmyselt [No workers' eomp.ansmance required J 10 Building addition 4.[—] lam a homeowner and will be hiring contractors to conduct all work onmy property. I wi11 ensure that all contractors either have workers' compensation insurance or are sole 17.0 Electrical repairs or.additions proprietors wiftuo emplogees. 12: Q Plumbing repairs or additions 5.❑ I am a general contractor and l have hired the sub-contractorslisted on the attached sheet 13: [] Roofrep airs These sub-co�actorsliade employees andhave workers' comp. ins=ce. ' � 6.Q We are a corporation audits officers have exerciodthe r right of egemptien perMGL c. 14.L] Other nplores. TNoworkers' comp. insurancerequired.J 152, §l(4), and wefiaveno,er:. *Any applicaaithat checksbox#1 must alsofIIouttbesection below showingtheirworkers'compensationpolicy idb mafion. T Homeowners wao ua ifilvs affidavit indicafmgthey are doing all workaudthenhirc outside contractors must srl7:mit a new affidav indicating such tConfracinrs_ that checkthis box pr s&atfaghed an. additiorral sheet shouting the name of the sub -contractors and state whether ornot those entities have .. ,... employees. Ifthesub-c�racbnhaveemployees, lieymustpravic theirworkers'comp.policynumber. .T aitz au employer tTz ctt isproviding-two,-ke7s, compensagon insurance for my employ ees.' Beloit/ is thepolacy aril job site iftfomatiom Insurance Company Name: Policy# or Self -hs. Ea. ExpirafionDate: Yob Site Address: City/Statc/Zip: Attach, a copy ofihexrorkers' compas�sationPolicydeclaxafionpage (showiugihepolicynumbex and expiration date). Failure to secure coverage as required under MGI, 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 S'T'OP WORK ORDIR and a fine of up to $250-00 a day against the violator. A, copy of this statement may be forwarded to the Off cc) of Investigations of the DIA. for insuxance, ;e verification. Ido hereby certify u_'KTer -% 7-3- I 3 I pentdffes ofpetjz y ilaat the info7mation proahoy 1� rue ar'd coy: eel Date: ��nJ Official use only. -Do not-wfite in this area, to he completed by city or town official City or Town • Pen it/License # IssuingAuthority- (circle one): i 1. Board of Healfh 2. BuildingDepartment 3. City/Town Clerk 4. Electrical fmspector 5. RiumbingYnspector 6. Other 11 Cozetact Person: Phone #: I Gerald A. Brown Inspector of Buildings Please print DATE: S 361 (,�, TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION DUIDINO PERAUT APPLICATION JOB LOCATION: �_ 1 Number HOMEOWNER Ltd Name PRESENT MAILING ADDRESS City Town Street Address Home Phone C. II State Telephone (978) 688-9545 Fax (978) 688-9542 45-6r / 2 9U -273_516V Work Phone Zip Code The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hue who does not possess a license,rop vided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one -or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned "homeowner" assumes responsibility for compliance with State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNA APPROVAL OF BUILDI Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 North Andover MIMAP August 30, 2016 045!:Gr0020 0.45uG X0,027 70:tN1ARTIN,AVE} b45G ;0025: t , t 045'°G�0021. 045:4-0022 `I � 7,.5rADAMStAVE IR4 , 045'.4 X0023 ,i 045;:4=0024 '+ 87 AD`AMS,AVE 93;;'AOAM$B, VEI 049 G=00,02. ' 1- IMADAMS AVE' 46' 43' 103' 0,45'°Gs-003,0: 045G-0028 Q MVPC Bc Zoning Overlay Zoning C Municipal Boundary 0 Adult Entertainment Distric 0 Machine Shop Village Ove Busine 8 Busine s1 District s 2 District Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, -- Rail Line Watershed Protection Dist O Busine 5 3 District Meters Data Sources: The data for this map was produced by Merrimack Interstates 0 Historic Mill Area O Busine s 4 District NoRTN Valley Planning Commission (MVPC) using data provided by the Town of _ I Medical Marijuana a Generst Business District pt so '9,', ' North Andover. Additional data provided by the Executive Office of — SR [3 Downtown Overlay District O Plann Commercial Do t� �+° �0 ? Environmental Affaim/MassGIS. The information depicted on this map is 0 Historic District .. Corrido Development Dist e� 3 L for planning purposes only. It may not be adequate for legal boundary Reads Easements L! Osgood Smart Growth (40 Hydrographic Features oComdo d Comdo Development Dist Developmenl Dist .._. p ., definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING It.11 District % THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY 0 Parcels Streams . Industn 12 Distnct a� s .^ y OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT -. Wetlands q IndusM 13 District • o� •+ • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Exempt Lands O Industn Reside I S Distinct ce 1 District +O+wn° •�'�� THIS INFORMATION :. Reside ce 2 Distnct ,SSACMUs�t A Reside ce 3 District a District 1" = 31 ft oe e6Dlstricit jee 6 District esidendal District J Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application �. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses � Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 I ECC Energy code Engineering Affidavits for Engineered products All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 6 Date/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... /..! . P -S has permission to perform ..�� (,< ........ d...... wiring in the building of ....... /2�. Ji U�f�1........................................ .............. . .. C ........ at �:,,t�/�'' L� /q✓e . . No ndover, Mass. Feev... ...... Lic. No./.. .......................... ............ ..1N.1'... ELECTRIC INSPECTOR Check # tr Commonwealth of Massachusetts Official Use Only V Department of Fire Services Permit No. f j Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev.1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: % o,3 13 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) S( /Ngml Owner or Tenant Telephone No. 9 7Y Owner's Address 21 44-5 &rte Is this permit in conjunction with a building permit! Yes ❑ No 0 (Check Appropriate Box) Purpose of Building 1'c3 i cI e'wei Utility Authorization No. Existing Service NO Amps I Volts Overhead Q Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: J -k2 rlohk Q "4hrr f " P•,l�(� 1�1h y &71e,- &md CollAce heml &1-/&-- ft-ld- Hed Lr _ eM�6oA tVAOA-6- Com letion o the following table may be waived by the Inspector 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. ❑ No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. oDetection an Initiating Devices No. of Ranges No. of Air Cond. Togs No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I-' - Tons o. o Sel-Containe Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KW No. o No. o Data Wiring: Heaters Signs Ballasts No, of Devices or E uivalent No. Hydrmassage Bathtubs No. of Motors Total HP a ecommunicationsW1 No. of Devices or Eq uivalent 1OTffl# Q p,040 C a 2- I v Attach additional detail if desired, or as required by the Inspector of Wires. i Estimated Value of Vectric Work: �0 (When required by municipal policy.) Work to Start: LQ 12 13 Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER 0 (Specify:) vci(Ve,_4 I certify, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: �� Jn rS f<t Signature�� LIC. NO. l (If applicable, enter "exempt" in the license number line) Bus. Tel. No.; Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signator Blow, I hereby waive this requirement. I am the (check one) gowner ❑ owner's agent. Owner/Agent Signature Telephone No. 9 7i'- 2 —616 PERMIT FEE: $ S A Q '/3 ƒ_ #� � » o ° m, �� �: : ,ir 2 0 , + o � d �• g LL. \ o. Q Q LLJ 4 © 7-77? < LAJ.,.-; & LLJ , °» LAJ�<. f �a mcJ ,, �. o�±r ® c# I" Date.... l ..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r 151; L,�.�� S �� Thiscertifies that...........:.....................................^..........i......................................................... ihas permission for gas�i^nstallation ......�, i P `fin the buildings of .,.......J....t �'S.� +............. at ..... 3i......... i. !,O u`!` g.:r`:�..... North Andover, Mass. Fee .."..... Lic. No....... . !` ........................................................... GASINSPECTOR Check #N_ r . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK UIVCITY A/0' 4W00!/ MA DATE /d - Z' 13 PERMIT # sq -LO JOBSITE ADDRESS /9 &I An S /9 V F-, OWNER'S NAME /- E- E S r �('L IC GOWNER ADDRESS % 19 1904,,-45 11!/15 , P,9 � gTEL / .,Y-2 7-?` `FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL�4 PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:4 PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW INSURANCE POLICY E]OTHER TYPE INDEMNITY ❑ BOND ❑ ILIABILITY OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts ene i ; and that my signature on this permit application waives this requirement. LLa CHECK ONE ONLY: OWNER X AGENT ❑ 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al Pertine pr visjno the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # / % / /10"SIGNATURE MP ❑ MGF ❑ JP$( JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME CCI Vi11AQ S, W C- CF_ Sh i ADDRESS /°O- 9 -OX / S t7 CITY S. -p STATE /V ZIP O SO /22 TEL 0 3' V 9'8- 2 8 9 � FAX 601- 89.3 -2 54,' z. CELL 663 - '�i5'-- 1Y 9 i EMAIL C (-,6 0 2 cio G o. CAsi , 11 /C I -- :COMMONWEALTH OF MASSACHUSETTS : PLUMBERS AND GASFITTER LICENSED AS A JOURNEYMAN PLUMBER'S ISSUES THE ABOVE LICENSE TO: EDWARD J SIBELESKI -:110 BOX 1580 -S/,ILEM NH 03079-1144 19.476 05/01/14 16641141�w 9 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:/ y� rf J Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION__ PROPERTY OWNER _J tC 1 ANG LeJ/Cf /�' Print 100 Year Old Structure yes no MAP NO: �6ARCEL: 3 ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building eOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 11 Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification lease Typ� ox Print Clearly) OWNER: Name: S Address: v CONTRACTOR Name:_ (�iAll Phone: Address:(4__�' Supervisor's Construction License: Z Exp. Date: Home Improvement License: / Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ,-• �� 6 FEE: $ ��'b� Check No.: y4/ Receipt No.: a C37 NOTE: Persons contracting with unregistered contractors do not have access guaranty fund Signature bf Agerjt_/bwner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stampedlans ❑ E Location e?/ A01�G yrt.S A!, f No. 7 �/ i — /3 Check # 26374 Date 4S V0 3 i TOWN OF NORTH ANDOVER Certificate of Occupancy $ " Building/Frame Permit Fee $�X1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 2, �- } Buildi g Inspector J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ ... Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Sionature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit I' Dtl W Town Engineer: Signature: LOCatea 3tM4 us ooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main'Street Fire Departinert signature/date COMMENTS x LL O v Q m C N O O LL N u O. N (o 0 F- L) z -N z 0 mC * a 7 O LL r 7 O w c L V _ O LL 0 z z C d t O 1 c0 O LL 0 z W -i W t b�L O •Z N N c LL o ? Ln Q L bo 00 w C LL z a W W LL y i E m ? N L1 V1 O Y O (A r : 0 Q. N J O 43 a V O u O � � � Qc c a h Ir 1VA `1: 0- d..r �a 3 ti tm _ 00 r : 0 Q. N J y C a u O � � � Qc c a h Ir 1VA `1: 0- d..r .o 3 E d CL c 0 m O a, 0 N 4, t O Z O t t i J O W a. .o m M z �O � U W d � w0 F„ U W az a W O Eo zCL O N a W Q 0 1- U) a0� �S O �+ v D O �O � CL CL �Q OM v c ��- O =z U U) s •C j N J a ami � m ti tm E o CDoZ CL c ... V: 00 N3 O ~ Q0 -d =w H v o = c �41 V m LL. 2 • W V E d v c 0-0 YO CL 4, > H 4- U m Z a 0 E d CL c 0 m O a, 0 N 4, t O Z O t t i J O W a. .o m M z �O � U W d � w0 F„ U W az a W O Eo zCL O N a W Q 0 1- U) a0� �S O �+ v D O �O � CL CL �Q OM v c ��- O =z U U) s •C j I . Extra caution will be taken to protect house exte- rior and landscaping as best as possible. (tarps etc.) Magnets run at final clean up. 2. Remove two layers of shingles from entire main house. 3. Inspect and re -nail any loose or lifted plywood or roof boards. 4. Any compromised roof boards will be replaced at an additional cost of $2.75 per linear foot of 1x8 spruce. Any compromised plywood will be re- placed at an additional cost of $60.00 per sheet of 1'2" CDX Fir. 5. Install heavy gauge 8" aluminum drip edge to all eaves and rakes. 6. Install 6' of IKO Armourguard ice and water shield along all front eaves. 7. Install all new pipe boots. 8. Above the ice and water shield, install IKO roof guard synthetic underlayment to the remaining sheathing up to the ridge. 9. Install starter shingles to all eaves and rakes. 10. Install IKO Cambridge AR or Certainteed Land- mark Limited Lifetime architectural shingles to entire main roof and garage. 15 year non pro -rated warranty by IKO mfg. 10 years with Certainteed. All shingles will be installed and fastened accord- ing to mfg.specs. 6 nails per shingle 1-2-2-1 pat- tern for wind ratings and mfg. warranty. 11. Install new GAF Cobra ridge vent, capped with mfg. color matched hip and ridge shingles. 12. Counter -flash chimney lead with ice and water shield, tie into new shingles and seal. Acceptance of Proposal—The above prices, s accepted. You are authorized to do the work as 12. Building permit included. 13. Removal of all work related debris. Planks will be placed under dumpster to prevent any damage to driveway. 14. Contractor workmanship warranty: 6 years under normal wind and rain conditions. Total cost: $ 5,200.00 Please be advised. Valuables in the attic should be moved or covered due to minor debris, dust and asphalt particles that may accumulate during the stripping process. All Under One Roof not respon- sible for any damage or clean up that may occur in the attic. Balance due upon completion Referrals available upon request Highly rated member of the accredited BBB and Angie's List Thank I is and conditions are satisfactory and are herby Payment will be made as outlined above. t)Itict of Consumer AI(airs 1 Business Regulation - Mass.vuv Affairs gusmess Rzguiauon (OCABR), I UV - The OffWai vvebsae of the ptix a of Consumer Reg Consumer Affairs and Busy !iam4 Consumer Name Improvement Conitactmg Home Improvement Contractor Re9eti Loafkup You can search/filter the fegi,t,-ation tilt by any of the criteria bel" Search by RegistraWn Number 37057 { Search Search by Registrant Namee---------- r�------�p Cede ��— Search by City 6 Search Registrants Int history. You can alsoustomFuntl Glick on the registration nurntrer to view compla W901tember 20, 2012. The list is current as of Thursday, SeP REGISTRANT RESPONSIBLE NAME INDIVIDUAL at.t. uf10ER BPIF- ROOF LANZAFAME, .iOHN Search Results REGISTRATION ADDRESS NUMBER 137057 166 A FINACHARO BUILDING METHEUN, MA 01844 01011 OI�(CiO�Yl alth i Massachusetts. Mass.Gov@ is a ,eq,Wed service mark of the COntffl�flW®9ni1 Oi wti�g���1�Da�� I Massachusetts - L)epartnsent of Public Safety Board of Building Regulations and standards Cim%tructirin Supcnicor License: GS a8 ,120 _r � f. jCM N W LAP/ 38 TELE DR 111P = METHUEN MA 0184� „,<�'` Expiration EXPIRATION STATUS DATE 10/02/2014 Current The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations quo 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �Please Print LeLyibly Name (Business/Organization/Individual): 0"-L Address: --, ,` r,7City/State/Zip: �-� '`� � Phone #: ?Id - . Are you an employer? Check the appropriate box: - 1. am a employer with 4. ❑ I am a general contractor and I Type of project (required): 6. El New construction ' employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet.1 ?• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance,g Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.0 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i 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 submitthis affidavit indicating they a' a doing all work and then hire outside contractors must submit anew affidavit indicating such. (Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' camp. 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 N Policy # or Self -ins. Lie. 1J - 1-Y pr, �JCP7 o -D 7 Y � Expiration Date: Job Site Address: /City/State/Zip: *N`r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as wellas 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. ldoherelycertfy der pains dpenalides ofperjury that the information provided aii ve isfirue and correct. Si ature: II �! Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: 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 j oint 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 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-contractor(s) 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commo wealth ofMassaehvsPtts Department of Xn dustdal .A,ccxdents Office ofIntveRstigatious 6.00 Washington Street Boston, MA. 02111 TeX. # 617-727-4900 ext 406 or 1-877. MASSAE Revised 5-26-05 Fax # 617"727-7749 XVIMrnaee an-ITMIa Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofiv,g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Buil Jing permit Revised 2012 Date. . � `.,�! �G • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �u ACMU c7 %% This certifies that .... .�.<<! •••••r ................. has permission to perform .. ,T+..... T. ..................... . plumbing in the buildings of .....� ......................... . at .. � . , � f�`.': r... ........... North Andover, Mass. Fee.Lic.No. Z(<� ........ PLUMBING INSPECTOR Check x 8375 is r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location O 41->11141S 101v ile Permit # 00 Amount 3 Owner ��� i(/stJ ' O f �G�j� New r Renovation Replacement MTi TR IPQ Plans Submitted Yes r No R] (Print or type) �j Check one: Certificate Installing Company NameiJ/gL�%�7 /� �Ll�/i%l'41f� ❑ Corp. Address t A L �= 5 y✓ 4 �'� ❑ Partner. Business Telephone Fum/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 El 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 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be m compliance with all pertinent provisions of the Massachusetts toPlumb' ode and Chapter 142 of the General Laws. By: 1PELLUR; 01 i.1CenSW room Title Type of Plumbing License t?v 3 City/Town rcense Number MasterElJoumeymanrM APPROVED (OFFICE USE ONLY 2 Date. 2/ L Z'�� ....... V NORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSACMUSEt This certifies that ..#e e.'. 174? .............. has permission for, gas installation ... .1411 ................... in the buildings of ... ............................ at .... k1. . 11.49. � /OX ............No Mass. Fee.--.... Lic. No..ZYP. ...... GAS INSPECTOR Check # 73U6 M 4 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date ,,7—/ 10 Building Locations 2/ 4811111-S /4 tic Permit # ?✓o -1 SVZA?VQe PO of Owner's Name Amount New D Renovation Replacement 19 Plans Submitted ❑ (Print or type) j� J /��o Che k one: Certificate Installing Company Name /"/ �/�/al�/� / � A//%• f�AI e Corp. uD Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter 7; ZyJ zy2y—&1fW1411 INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes ® No13 If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity13 Bond 13 Owner's insurance Waiver: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. .� Check one: D g D Signature of Owner or Owner's Agent Owner Agent 1 herehv rartifv that .II of 4L,., A.*�;6 —A : F — - - -- - •- -•-- •••-�••••_-•�•• • •• --� kv, --avu) in auuve appncanon are true ano accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town IAPPROVED(OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 9[1433 Gas Fitter License Number D Master ® Journeyman � a U CW7 a y W C U m F J H z Z w V p U w N C eC F E. m �' m >' Z/ p Iw. a E, w Cz r1 O x f� a 3 A CQ7 a U z > a A C F O SU B-BASEM ENT off. B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) j� J /��o Che k one: Certificate Installing Company Name /"/ �/�/al�/� / � A//%• f�AI e Corp. uD Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter 7; ZyJ zy2y—&1fW1411 INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes ® No13 If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity13 Bond 13 Owner's insurance Waiver: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. .� Check one: D g D Signature of Owner or Owner's Agent Owner Agent 1 herehv rartifv that .II of 4L,., A.*�;6 —A : F — - - -- - •- -•-- •••-�••••_-•�•• • •• --� kv, --avu) in auuve appncanon are true ano accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town IAPPROVED(OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 9[1433 Gas Fitter License Number D Master ® Journeyman AORTM � s Y ♦ � _ # SA US Date . 3/,? VU. G. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ...j... / c. "' ... �.............. . has permission to perform .... W k Y.' "t . plumbing in the buildings of .. 1.�-� .1�.'.S. . . .................... at. r... ,�'~%� - ...... .... , North Andover, Mass. Fee..% L... Lic. No..r,.?. (.. ,.. - ..... ....... / PLUMBING INSPECTOR Check # 6901 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location (KiA&, Owner tun? 2 n 'e� �('L New D Renovation D a Date L a 1O Permit # Amount IAC Replacement 0��ans Submitted Yes No i P, OEM L>� NMI E MMMMWMMWMWMWMMMWMWMMWMWWM (Print or type)/ Check one: Certificate Installing Company Name :S� t� 4 , lw'l "" 4-17 D Co rp. Address ' ✓ ! o%LL - Partner. JA BusTs I e ep one Ll— Z f ^ -1 L � , c7 D Firm/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 D Bond D Insurance Waiver: [, 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 D 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 i lationsjpTormed under Permit Iss d for this plication will be in compliance with all pertinent provisions of the Mass4��l�etts Sta liymhing Cale and Ch fr 142 of eneral Laws. By: 31g0ture M Licenseuum er Title Ty of Plumbing License City/Town e APRDAPPROVED (OFFICE USE ONLY Iceur Master Journeyman Date.. J�. n'�...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ': �- ...:. o..r+............................................ has permission to perform ... ......'�.,� ...... �--a� % // .... ...�.� wiring in the building of.............................:......:.:..�...:.:........................ at.. ...... ... .......................................�-'`-- �. North�Andover, Mass. Fee—,A ...�....... Lic. No: � %,-(.�.......1' :... � ... ELECCRICALINSPECTOR Check # /T�D N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 4r J— BOARD Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATION p Y �5 [Rev. 11/991 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: 3/31/2006 City or Town of. North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 81 Adams Ave Owner or Tenant Warren Tom kiewicz Owner's Address Telephone No. 691-5201 Is this permit in conjunction with a building permit? Yes X No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: wiring of bathroom light, sw, & mise as needed ComDletion of the following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: p (Paddle) TSusFans Transr Total sformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above ❑ In- ❑ Swimming Pool rnd. grnd. 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 of No. In Detection and InDetection Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Totals: Number ........................................................ Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection of Dryers Heating Appliances KW SteNo. Sec No of Devices or Equivalent No. of Water Kms, Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: On File (When required by municipal policy.) Feb/2006 (Expiration Date) Work to Start: 3/31/2006 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Kelly M. Casey Signature LIC. NO.: 37200 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-697-4453 Address: 700 Robbins Ave Unit 3 Dracut, Mass 01826 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 25.00 CD C Commonwealth of Massachusetts Department of Fire Services y< BOARD OF. FIRE PREVENTION REGULATIONS Official Use Only Permit No. el�JW Occupancy and Fee Checked _-07� [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3/31/2006 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & :Number) 81 Adams Ave Owner or Tenant Warren Tomkiewicz Telephone No. 691-5201 Owner's Address same Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts Yes X No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed :Electrical Work: wiring of bathroom light, sw, & mist as needed No. of Recessed Fixtures --.: No. of Ceil.-Susp. (Paddle) Fans epi r u rries. No. o Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- LJo. rnd. rnd. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat PumpNumber TonsKW No. of e - ontained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of No. No. of Devices or Equivalent Heaters KW Bas Si Ballasts Signs alts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: t,uucn auumona[ aerau q aes:rea, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) On File Feb/2006 Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: 3/31/2006 Inspections to be requested in accordance with NEC Rule 10, and upon completion. I cert, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Kelly M. Casey Signature LIC. NO.: 37200 (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No., 978-697-4453 Address: 700 Robbins Ave Unit 3 Dracut, Mass 01826 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: S 25.00 v1;40-tf C/A-� �� � � �-(� 2 � •— c9 co v1;40-tf C/A-� AORTH - TOWN OF NORTH ANDOVER `• _ ,�:.= •' APPLICATION FOR. PLAN EXAMINATION - SSACHUSE Permit NO: Q Date Received:-.. Gd' Oz, 6 Date Issued: 1IMPORTANT: Applicant must complete all items on this page LOCATION 91, PROPERTY OWNER MAP NO.: PARCEL: 7-1 ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential J New Building '; Addition :Alteration %6rte family Two or more family No. of units: ` Industrial repair, replacement C Demolition i_; Assessory Bldg I-' Commercial t_ Moving (relocation) Other C; Others: -! Foundation only I DESCRIPTION OF WORK TO BE PREFORMED I -I Identification Please Tyne or Print Clearly) OWNER: Name: Phone: Signature Address: CONTRACTOR Name: 14N NL d 9• (C4'El Phone97% 660 LO Address: 2 ( d5iui-, IT 4wc Fj, i Nj . /11/4 Supervisor's Construction License: o,5' it Z 'V s Exp. Date: 3-21-0'1 Home Improvement License: 2383 Exp. Date: $ ^!$ -06 ARCHITEC'T.r FNGINEER Name: Phone: address: Reg. No. FEE SCHEDULE: BULDING PERMIT. 510.00 PER S1000.00 OF THE TOTAL ESTI.-VA TED COST BASED ON 5115.00 PER S F. a Total Project Cost :$� 0 0 °" xIO.00= FEE:$ Check No.: Receipt No.:_ 6fl; Location d 0v►1 C ;,1y -� No.ffDate TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee!. $ TOTAL Check # � V S 19(16`i Building Inspector It- TYPE OF SEWARGE DISPOSAL i I Tanning/Massage; Body Art_ Swimming Pools Public Sewer Tobacco Sales Well l I Food Packaginlo;Sales i -- ,. Permanent Dumpster on Site Private (septic tank, etc. i NOTE: Persons cowractittr with tnrregistered contractors du nut have acees:s to the guaranty fat Sicnature. of Agent/Owner Signature of Cotatracto . Plans Submitted ❑ Plans Waived ❑ ; Certified.Plot Plan ❑ Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY i INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS CONSERVATION COMMENTS DATE REJECTED DATE APPROVED ❑ n • • {� w • .1. DATE REJECTED HEALTH ❑ 'COMMENTS 1` Zonin_ hoard of Appeals: Variance, Petition No: Zoning Decision•'reccipt submitted yes hltlllnill,', Board Decision: ---comments— Conservation _____Coll ments___Conservation Dccision: Cornnlent5 'A,ater h Sewer connection signature & date Temp Dumpster on site yes_ no _ Fire Department signature,'date Buildin" Pert -nit ,approved and ISSLIed by: ' DATE APPROVED I 0 IMM4 0 oN o O w n v V) '� 0 O w O pG U C w a O C a W O Cr.. O h G p C w G " o vii U O w 0� pm CA co m m CL co 3� in O O i M CL CL CMQ C 0 C O =�p J .0 •C Z d cam Li H O C — C C cc CL CIO W 0 N N W W 19 W U) ,w o_ C Gni O O Cr.. O h C ' � O v G3 CLC �p {p m C :L O CDEa CE _+r o n y O a co C.3 S ts OS all E E o mm3 y s w... C C i no _m o y O O 1.: Co m e o act L: m _ 4D _ = oc c v► o m 0 m :coa-` z o ` a C o c Q 42 m 4D : m= o = m-ZM r`3 m Z C O 9 m W E G� C w.0low Z O h a CD C35 C3 CL m U O w 0� pm CA co m m CL co 3� in O O i M CL CL CMQ C 0 C O =�p J .0 •C Z d cam Li H O C — C C cc CL CIO W 0 N N W W 19 W U) Aze TOarnmtoouaea�l�t o^acfiuJelt4 BOARD OF BUILDING REGULATIONS I, icgnse: CONSTRUCTION SUPERVISOR I Number: *,CS 058245 r Birthdate 03/24/1943 Expires ;03/24/2008 Tr. no: 1-3436 Restricted; 00 KENNETH B-KEENa�'' + _ 21 HEWITT AVE, N ANDOVER, ,MA 01845_x, _; Commissioner ✓ /W V/ O%%7�YI7iO%ZI.(M�LLL./G O�✓l�GQ6dlLGLLIo�t+ Board of Building Regulations and Standards HOME IMPP,R-OVEMENT,CONTRACTOR lug 108383 Registration : E st R 1,812006 KEEN CONSTR(t( Kenneth Keen. 21 Hewitt i'. No, Andover, MA 01845 Administrator k The Commonwealth of Massachusetts ^; Department of Industrial Accidents tom, Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �i Please Print Legibly Name (Business/Organization/Individual): _K1 P_ " t- O,5 $ i tmc i C ; ©••� Address: 2l E i M '09 41C City/State/Zip: A ;9 N lJb iti n 1W4 Phone #: 0' ?S ' (,>!t I —C Z O 1 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 13.1 tqClams /?UC, 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 tlytpains 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 offcciab 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 #: KEEN CONSTRUCTION CO. c 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 Tel: (978) 691-5201 Fax: (978) 682-3231 SubmittTdo WA2.(-+'.D�n'l.l�(_EWICZ�t_/rQ��1JF!'li � c. _. /-fid ,4�c5 _f�.✓.E ._.. _.._ ._.. ___ . .......... NO— 1628 PROPOSAL All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. PHO IEg 3-3-7/4 DATE REGISTRATION NO. F.I D. N0. ?79 7 3- Z7-66 MA. H.I.C. 108383 04-325-8052 C/S = Customer Supplied S + I = Supply + Install We hereb ubmit specifications and estimates for work to be performed and materials to be used: _rnoa�� L c ;ftp y aft._ U seq. 'I IcT�Stiew.-_l.u_c- -_Piw, 777;A7 -S� wlc, £...w (IlE fou Nd _ u b ton-Z.9."...r%am rL, Construction related permits: WORK SCHEDULE ContracloFwill UQt begin he work or order the materials before the third day following the signing of this Agreement, unless specified here)- wnLin Contractor will begin the work on or about_2 -7�- � (date) Barring delay caused by circumstances beyond Contractor's control, the work will be completed by - — 7�n /li (date) The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of _-—FV/` following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, s sF11 ubcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of : (� e S -x—f Pi6u56,-A S'i 14 uNan�g `ildM is dollars ($ 6 G 00mo) Payment to be made as follows: % ($ OD upon signing Contract; KENNETH B. KEEN Name of Contractor/ Designated Registrant ($ Oe upon completion of%sem '.n 1 ��� 21 HEWITT AVE. Street Address ($ / 0400 �) upon completion of X10 f- &twj N. ANDOVER, MA 01845 city / State $ /600" shall be made forthwith upon (978) 691-5201 (978) 682-3231 ( ) completion of work under this contract. Phone Fax Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price Name or Salesman or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and Authori uatyre equipment, whichever amount is greater. NoteThis proposal may be wilhdray us it not accepted within days. Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. I�Signal— `�� Date 44 "� �^'� Signature Dale IMPORTANT INFORMATION ON BACK I? NOTICE OF SCHEDULE CHANGES The Contractor agrees that when delays become known to the Contractor, the Contractor will advise the Owner as soon as is reasonable, DELAYS IN COMPLETION DUE TO HIDDEN CONDITIONS The Owner hereby acknowiedges and agrees that in certain remodeling work, the demolition of portiQns of the pre- existing structure may reveal additional defects, conditions or the need for additional work, which must be repaired, altered or carried out in order to ccryii-nence or to comp!ete the work described under the contract. In Such case(s), the Owner agrees that the price, duration of the work and the scheduled date of completion may differ from the date stated on the front, and that suers variation which is not avoidable by the Cortractor shall not be considered to be a violation of this contract. ADDITIONAL WARRANTY INFORMIATION All warranties for equipment supplied by the Contractor under this f,rjree e -it sial be those given by the manufactur- ers of such equipment, wJch shall be and are hereby passed lnr^� nr r! Ctitothe Owner. Under such manufactur-' ers' warranties, the Owner maybe required to register or r- -i i in a war - -,'y card or other evidence of ownership and use of such equipment in oder to activate such warranties. J rie Own - s la'.re to mail in or register such documen- tation, which failure voids the manufacturer's warranty, shall not create any responsibility for the Contractor to war- ranty such equipment. The warranty gives the Owner specific legai rights, aid -the Owner may also have other rights which vary from state to state. Under Massachusetts law, sales of goods carry an implied r.,arranry cl merchantability and fitness for a particu- lar purpose. All material is guaranteed to be as specified. Ail work to be completed in a workmanlike manner according to stan- dard practices. Any alteration or deviation frorn above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over the estimate. AJ ag,eemerts contingent upon strikes, accidents or delays beyond our control. SUBCONTRACTING Contractor agrees that, notwithstanding any agreement foe materials ardior labor between Contractor and a third party, Contractor is responsible to Owner for completion of al work described in a timely and workmanlike manner. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED The Contractor may not require payments to be made in advance of the times specified in Payment Section (front) for the reason that he deems himself or the payments to be insecure. If, however, he deems himself to be insecure, he may require, as a prerecuisite to continuing the work described herein, that the balance of the payments under this contract that are in the control of the Owner, shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner for withdrawal. INSURANCE Contractor will be responsib!e to Owner or any third party for any property damage or bodily injury caused by himself, his employees or his subcontractors in the performance of or as a result of tie work under this Agreement. Contrac- tor agrees to carry insurance to cover such damage or injury. CONSTRUCTION RELATED PERMIT ACQUISITION The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction- related permits. The Contractor shall not be deemed responsible for delays in the work described in this agreement caused by regulatory, permit granting or inspectional agencies, agencies, authorities or individuals. Notice: If the Owner obtains his orin construction -related permits for the work described under this agreemznt or deals with unregistered contractors, the Owner is hereby advised that in the event of a dispute, judgment and nonpayment of the Contractor, the Owner will not be entitled to make a claim to or collaction from .hie guaranty fund established by Chapter 142A, iii.G.L. MODIFICATION This Agreement, including the provisions relating to price and payment schedule cannot be changed except by a writ- ten statement signed by both Contractor and Owner. However, cancel'ation by Owner is allowed in accordance with the Notice of Cancellation. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unIcss and intil all blank sections have been filled in or marked as void, deleted or not applicable, and until all axhibits, and related or referenced doc- uments that are Incorporated herein nina, zMached hereto. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and an original, signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner of a copy thereof. Building Setback Front Yard Side Yard Rear Yard ReqUired Provided Required Provides Required ided DIMENSION Numbcrof5kxim:___ Total land area, sq. ft.: »xxmand omm (, Total 'uore feet uffloor area. based onExterior dimcoxiunn`_________ Building Department The following Is a list of the required.forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Debris Removal Form ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Form U ❑ Surveyed Plot Plan ❑ Debris Removal Form ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Pen -nit Application Form U ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses • Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydrauli Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks off -lee must stamp the decision from the Board of ;appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Dne: 1\SPE.("I IONA1. SFR\ ICES nFPART\IFVF:BPFOR.NIU5 . ^ -- � �-.... >�•-.-�c^�^v ti+-�-�..._ .... • ;,,_.�..-�.�:�:,�•+.,.ra—...ti•`+�Lr.._1� Date`.'3 -5 7V- Ic3p <= 3982 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� This certifies that ..... �—J �`............. has permission to perform A plumbin in t. uildings of.................... at. . F.. ±`�.. ,�......... , North Andover, Mass. Fe&?QS ...... Lic. Nord /4 . .-+ 4- , -?-►tr `•�... . PLUMBING INSPEPTO 'A 03/26/94 08:48 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer (Type or Print) NORTH ANDOVE Building Location I Renovation ❑ (Print or Type) Installing CC000mpa Address / Owners Name Replacement Plans Submitted II FIX ORFS CheO one: Certificate Corp. . Partner. Firm/Co. Business Telephon Name of Licensed turn Insurance Coverage: Indicate t e typ-- of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity D 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 coverages. Signature of owner/agent of property Owner Agene,, ( bateby ccttify drat all of the details and information 1 have suburi(lcd lot enletcd) in atm- applicaliort tae htae+wa♦ sya/t {O Uss btlt M tty ltasowkdga aad tha/ all plumbing work and installatimu l,cr(nrnrcd under remail hiucd for this applicaliow wiU ii bls a4 ratitwat PW trl mmu of lbs Masaehrscus State Numbing Code and Cluptct 142 Ac Genual U i By Title City/Town: i - A oopovpn iaF:ri(F USE ONLYI Signature of --Licensed Plumber 'vp�e off Plumbing LJcense •, License Number El Mas te Journeya&4 e 4: U a u z C N O C z Z 7_ 2 _ � w Z O L- W J < ~ Q Z ^. < 3 LLJ O k U ' r Z C O _ L L - Z Z o C U r w U N U U (U� Z Z � WW ••,,��;jj zuj � E O � y _ <_ Z 2 _ � O L- Z O U ' r Z L L - w U N � � zuj � E O � y _ <_ Z .. N - U ul U J C C C _ ..a Z Z 2 _ � The Commonwealth of Massachusetts Department of Industrial Accidents 9MV 6711MOstYMONs 600 Washington Street Boston, Mass. 02111 workers' t,ompensanon insurance Affidavit name: JCS G,� J E f /`f aL /, -N S city Al ' 1 /1t d 6V --V — MA A phone # (9 d6 C] I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity �]�I•�n an employer providing workers' compensation for my employees working on this job. comanv riffle: Li'f%y & A- Rhone #. �er (f insuranceco / /TI�L� ,7 `LdS�{.✓Ii� A�� �l� oolicYt♦ V " U I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contactors listed below who have the following workers' compensation polices: company name: address: city. phone #• insurantx>co. f. i'z Failure to secure coverage as required under Section 25A of IVIG L 152 can lead to the imposition of criminal penalties of a line up to 51 500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. l understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby cerr!fy_ua4er the paint' and pens of at the information provided above is trite and correct Print name —e j ate/ ZS loneG tSA" 77� official use only do not write in this area to be completed by city or town official city or town: permit/license p [7 Building Department C]Licensing Board C] check if immediate response is required Selectmen's Office C]Hcalth Department contact person: phone a: 00ther (revved 3/91 P1A) N 0 z �m IV 14 h) O c� c �- . o V)] U U)w° A Gq o c -n .r 0 v G U w a ° rz ° w a O � U � w w ° r� c w x .c o c w z w v ' m z C/)cn o v o CO 0 1>1 Frr� 1>1 L.L�1 --4 U a 0 Cly a �S W QfTr, U N Ico CC CA O :2 co .M Cc w .CD O Q O C O C O Ri !d v J .O C Z co CC �C C Cp h Q 0 U) w cr w W crW W U) c �- . o m c o c o c L C h O g O a� :acc = �- cc h E ¢ `- IS c " o ».. m e o w Q H E= o m _-- : o 0 m� �m ocz� H m Cf � C y, m ,O � C 0: � cc H s E �: LL ® H > O a L oc CD 't C o� ..: c a o U O ¢ C65- n= .0 3 CL +- O ll COO A m $ m ui C, m F— H =2 O C .y w E Q; ME CL C.3 CD m cc a moIN _E 7 �a,m CO 0 1>1 Frr� 1>1 L.L�1 --4 U a 0 Cly a �S W QfTr, U N Ico CC CA O :2 co .M Cc w .CD O Q O C O C O Ri !d v J .O C Z co CC �C C Cp h Q 0 U) w cr w W crW W U) . ;�/fie (panrmzanruea�r/z oFr_ �/�r�;;�acf.u.�er�.�i DEPRRTNENI OF PUBLIC SAFETY { CONSTRUCTION SUPERVISOR LICENSE + NUeber Expires: Birthdate: a CS 036863 06/04!2000 06/04/1960 Restricted TO: 00 I BRADLEY J JONES « 91 ORUIO HILL RO "' x'� HEIHUEN, hR 01844 a