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Miscellaneous - 85 LACONIA CIRCLE 4/30/2018
3 0 H 1 V O • • rA H Z-0 E o= 0 c.i L 2 � H •. Q J m� > _ °' _ v, a) O 00cn -u 0 S U a i 2CL=� U,00 y 3 O~ FO Q W O W = vai Z � � Z N Z u W � LL O l7 Z Q W Q J op F- Ln 0 LU co m J W O LU LL u � O v ++ Y U fY0 a N L C to L O L OA U OA Z N Y O d cu N 7 L0 LL 0 -CC w U LL ca d' LL 0 (ULL d' - 3 - v O (A K LL m N Ln H '> To�°- 0. '00 _ ~ mm =c co .r to as m W_ _ '0— O O E: .y d -;5 N = �cLt O LU � N O �+S �+ v v w E 0 (D.- � a)1 N �o4-c F- t c 0 0 Q. 0 U IL U) t U) a rn m a� m 0 0) 0 N 4) t O Z O Q J O 0 W CL cn C9 Z CO -� Cl) - -- ON W � �_ y z O W V • H W a Cl) J M Q w E � O z O o � �o� �E m m CL O �+ > v O O � O � CL CL c Q t Cc Cc V J -a �CL O 4) =z a O CL U) B Z-0 E o= 0 c.i L 2 � H •. Q J m� > _ °' _ v, a) O 00cn -u 0 S U a _tom 2CL=� U,00 y 3 '> To�°- 0. '00 _ ~ mm =c co .r to as m W_ _ '0— O O E: .y d -;5 N = �cLt O LU � N O �+S �+ v v w E 0 (D.- � a)1 N �o4-c F- t c 0 0 Q. 0 U IL U) t U) a rn m a� m 0 0) 0 N 4) t O Z O Q J O 0 W CL cn C9 Z CO -� Cl) - -- ON W � �_ y z O W V • H W a Cl) J M Q w E � O z O o � �o� �E m m CL O �+ > v O O � O � CL CL c Q t Cc Cc V J -a �CL O 4) =z a O CL U) B WOWOR I solar Structural Group Jon P. Ward, SE, PE Structural Engineering Manager jon.wardL7a vivintsolar.com February 17, 2017 J. Matthew Walsh, SE, PE Senior Structural Engineering Manager james.waish@vivintsolar.com Re: Post Structural Certification Keating Residence 85 Laconia Cir, North Andover, MA S-5321696; MA -01 To Whom It May Concern: 1800 W Ashton Blvd. Lehi, UT 84043 Clint C. Karren, PE Structural Engineering Manager clint.karren@vivintsolar.com Pursuant to your request, a representative from our company conducted a post installation site visit under my supervision and provided post installation photos for the above referenced solar panel installation. As you are aware, this office initially prepared a structural assessment of the proposed solar panel installation, the adequacy of the connections for this system and identified maximum spacing of the connections. The photographs show panel support locations and spacing which conform to our structural assessment. Acceptable minor changes to the layout include panel position, support spacing less than or equal to 64", and/or additions or deletions of panels at roof locations. Based upon the post installation site visit, our office certifies the solar panel installation for this roof and that it was in conformance to our structural assessment report dated December 5, 2016, Ecolibrium Solar product installation criteria, and the layout plan as specified in our report. This letter pertains only to the panel support attachments to the roof framing and not the engineered photovoltaic panel products, components, panel positioning, or electrical related installations/connections. This certification is based on the 8th Edition Residential Code (2009 International Residential Code with Massachusetts Amendments), professional engineering assessment and judgment and covers this dwellings assessment for solar panel connections and support only. Should you have any questions regarding the above or if you require additional information do not hesitate to contact me. Regards, Jon P. Ward, SE MA License No. 52584 Page 1offtenon onl soI^r Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING rtifies.that This certifies.. -1 .. ...................... , ....... 4.vrr�o., C............................................................. has permission to perform -D -al ........................................... ............................................................. wiring in the building of........, ..................................................................... at 4 �? �....... .. ................. Fee.... ....... Lic. No. .. ....................... ........ Check ELECTRICAL INSPECTOR 26 14 I..II.N.vwYYI4 � I I�WiIJWYINNC/GYiJ I �� �� � � . cc�� ec77 Permit No. t .lJeParlmeni o�,}ire �ervacee BOARD OF FIRE PREVENTION REGULATIONS. Occupancy and Fee Checked of -1107] 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 RV flVK OR TYPE ALL INFORMATIOl9 Date: a -1 Q - 1b City or Town of: b(1 f tM(Ef To the Inspector of Wires: e By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ':R S LZk Cor 101 C ( r Owner or Tenant U (01 Telephone No. %n %2 2y9 r&` i Owner's Address Is this permit in conjunction with a building permit? Yes W No ❑ (Check Appropriate Bog) Purpose of Building f(1_[R 1 Jftj-n•9_ Utility Authorization No. Existing Service Zl�o Amps V aO / 840 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 0 + D � •O- 'air fmskk a n @.olid R-CA1 5 2 Irv✓ Comoletion ofAefiollowing table be waived the Ins ctor Wires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets No, of Hot Tubs Generators K -VA No. of Luminaires No. of Receptacle Outlets Above n- Swimming Pool grad. ❑ d, ❑ No. of Oil Burners o. o Emergency mg Battery Units FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of ction an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers T19t, p Totals: .No er ons „_,� M" o. o e - ontam Detection/Alertin . Devices No. of Dishwashers Space/Area Heating KW Local ❑ Con�ncc'Paal ❑ Other eciieNo. of Dryers Heating Appliances K --W SecuritySystems:* No. of Devices or Equivalent No. o Water KW Heaters o. o o. of- Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommuni ns" No. of Devices or Equivaient OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _ rJ �0 , (When required by municipal policy.) Work to Start: 1-2D-15 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 59� BOND ❑ OTHER ❑ (Specify:; I certify, under the pains and penalAles ofpe#ury, that the information on this application is it d complete FIRM NAME: 1 ' LIC. NO.; j )q Licensee: t ZOIYYI '� Signator LIC. NO.: Ij y I Pr (If applicab , enter nw in the lice "" a number line.) Bus. Tel. No.:�k1 ? t��j Address: Alt Tel. No.:to14•1c1q -5 o� *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one El owner ❑ owner's agea 5s Signature Telephone No. one FEE: $ ac.) 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Q 'h` W-2 a CL U C>w V �o U) U) 2 ymo Www I N zz5 y-0 ob \ z aN s' R ma= wzw "o OYy N 1 2w mz zm u0 l7 l7 p oo O ¢¢z a ; Z, z Doo uz> 'D a„ m� �Fo fog zzw � S w O O B 0 0 o I o R ma= wzw "o OYy N 1 2w mz zm u0 l7 l7 p oo O ¢¢z a ; Z, z Doo uz> 'D a„ m� �Fo fog zzw � S w O O , t 4 W Cl) t .I0 4 ci m O 0 C O c O m 3n mcn m m m ZZ z n C O Z Z Z D r- - D mo co tin0 �� ;om 'm nm 10 000 30 1T1 D O z 30 30 00 o0m crn 0� mcg pcx -n r -m r -m mcg mcg D0 rm m �z Nm Cn m �0 10 rnm ZC .�iZ NZ((nno Wm "m 2M cg Fn o Oo mO C� c� « ?J gal rt a, as =9 En m— 0? 0z z z 11,;x" OC Oz Oz CC AC �C C C o- y e z 7 1 T X1 0 C O� Z 0 10 0K M x� NO m0 Op Cp 0 'n 0 cn cm m z DO ro0 �� 0 zz O T (n x rn z ou_ cz <ju m m! Omr Xm O 0� n0 z 0� Om D=T_ zrn 2 00 0 r (Dm O z°0c om m m m In 0 0 m Z 3(n cnM z o� -nim C Z $ o� D I—V C Z � xC O' C= m m (n DESIGN 9 m m INSTALLER: V11 NT MO[\�'�/,7O'�{�'�' j :a jr Keating Residence INSTALLER NUMBER: 1.877.404.4129 87.404.4129 PV 4.0 m LOGIC ' MA LICENSE: MAHIC 170848 �✓ �+ u �+ LJ O Laconia Cir DRAWN BY: JerryS R4535961 Last Modified: 8/6/2015 North Andover, MA 01745 UTILITY ACCOUNT NUMBER: 16312-15043 EcolibriumSolar Customer Info Name: Paula Keating Email: Phone: Project Info Identifier: 44908 Street Address Line 1: 85 Laconia Cir Street Address Line 2: City: North Andover State: MA Zip: 01845 Country: United States System Info Module Manufacturer: Trina Solar Module Model: TSM 260-PD05.08 Module Quantity: 22 Array Size (DC watts): 5720.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: SolarEdge Technologies Inverter Model: SE6000A-US (240V) Project Design Variables Module Weight: 43.0 lbs Module Length: 65.0 in Module Width: 37.0 in Basic Wind Speed: 100.0 mph Ground Snow Load: 50.0 psf Seismic: 0.0 Exposure Category: B Importance Factor: II Exposure on Roof: Partially Exposed Topographic Factor: 1.0 Wind Directionality Factor: 0.85 Thermal Factor for Snow Load: 1.2 Lag Bolt Design Load - Upward: 820 Ibf Lag Bolt Design Load - Lateral: 288 Ibf EcoX Design Load - Downward: 722 Ibf EcoX Design Load - Upward: 765 Ibf EcoX Design Load - Downslope: 297 Ibf EcoX Design Load - Lateral: 233 Ibf Module Design Moment — Upward: 3655 in -Ib Module Design Moment — Downward: 3655 in -Ib Effective Wind Area: 20 ft2 Min Nominal Framing Depth: 2.5 in Min Top Chord Specific Gravity: 0.42 Plane Calculations (ASCE 7-10): 1 Roof Shape: Gable Roof Type: Composition Shingle Average Roof Height: 35.0 ft Least Horizontal Dimension: 15.0 ft Roof Slope: 16.0 deg Truss Spacing: 16.0 in Snow Load Calculations Edge and Corner Dimension: 3.0 ft Stagger Attachments: Yes Include Snow Guards: No EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.99 0.99 0.99 psf Roof Snow Load 41.6 41.6 41.6 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf Adjustment Factor for Height and Exposure Category 1.05 1.05 1.05 psf Design Wind Pressure Uplift -20.4 -33.5 -50.3 psf Design Wind Pressure Downforce 16.0 16.0 16.0 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.6 2.6 2.6 psf Snow Load 41.6 41.6 41.6 psf Downslope: Load Combination 3 11.7 11.7 11.7 psf Down: Load Combination 3 40.9 40.9 40.9 psf Down: Load Combination 5 12.1 12.1 12.1 psf Down: Load Combination 6a 38.5 38.5 38.5 psf Up: Load Combination 7 -10.7 -18.6 -28.7 psf Down Max 40.9 40.9 40.9 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 52.8 52.8 52.8 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 17.6 17.6 17.6 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 39.1 39.1 39.1 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 13.0 13.0 13.0 in EcolibriumSolar Layout Skirt o Coupling O Clamp Q Bonding Jumper Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal expansion and contraction. See Installation Guide for details. Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. EcolibriumSolar Roof Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 22 Weight of Modules: 946 lbs Weight of Mounting System: 86 lbs Total Plane Weight: 1032 lbs Total Plane Array Area: 367 ft2 Distributed Weight: 2.81 psf Number of Attachments: 43 Weight per Attachment Point: 24 lbs S EcolibriumSolar Bill Of Materials Part Name Quantity ECO -001_101 EcoX Clamp Assembly 43 ECO -001_102 EcoX Coupling Assembly 29 ECO -001_105B EcoX Landscape Skirt Kit 2 ECO -001-105A EcoX Portrait Skirt Kit 3 ECO -001_103 EcoX Composition Attachment Kit 43 ECO -001_116 EcoX Flat -Tile Flashing 0 ECO -001_117 EcoX S -Tile Flashing 0 ECO -001_118 EcoX W -Tile Flashing 0 ECO -001_363 EcoX Lower Support - Tile 0 ECO -001_109 EcoX Electrical Assembly (optional) 1 ECO -001_106 EcoX Bonding Jumper Assembly 4 ECO -001_104 EcoX Inverter Bracket Assembly 0 ECO -001_338 EcoX Connector Bracket 0 ECO_001-359 EcoX Lower Support - Low Slope 0 VIVINT SOLAR DEVELOPER LLC PHILIP f ZAMP ITELLA JR (EL) 4931 N 300 v - PROVO Err 84604 FOK Ttun usumh 11b w m Pl.roral[o.s ICtAM6 f itSUES 7WE FOLLOWING C�5E AS: S SWRM MAST6R AL E CTR t C I AN V!V'1'Ei t SOLAR DEVELOPER LLC F% I L I P 1--~ LLA A 4931 M. 3oQ w 0. 84604 �i The Commonwealth of Massachusetts Department of IndustrialAccidents - Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-20.17 www mass.gbov/did Workers' Compensation Insurance Affidavit: Builders/Con>tractors/Electricia>ns/Plumbers applicant Information, Please print LeEi Iv Name (Business/Organization/individual): V(vint Solar Developer, LLC Address: 3301 North Thanksgiving Way, Suite 500 /State,'Zip: Lehi, UT 64043 Phone #: 801-377-9111 Are you an employer? Check the appropriate box: LE I am a employer with l C) 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees_ [No workers' comp. insurance required.] Type of project (required): b. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other Solar Installation *Any applicant that checks box # I 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Zurich American Insurance Company Policy # or Self -ins. Lic. #: WC 509601300 Expiration Date: 11/112015 Job Site Address: ?'S ��1Ia b City/State/Zip: 1 ^�► - And0Ve Mfl 01?4 5 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 sunder the pains and penalties of perjury that the information provided above is true and correct. Signature:- Date: Phone #. 801-2296459 Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Heaith 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Phimbing Inspector 6. Other Contact Person: Phone 1#: Ac"R h®CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY) 01/0512015/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC. 122517TH STREET, SUITE 1300 DENVER, CO 80202-5534E-MAIL Attn: Denver.CertRequest@marsh.com Fax: 212-948-4381 CONTACT NAME: PHONE FAX A/C No Ext): AIC No ss: LIMITS A INSURERS AFFORDING COVERAGE NAIC # INSURERA: Evanston Insurance Company 35378 INSURED Vivint Solar Developer LLC 3301 North Thanksgiving Way INSURER B: Zurich American Insurance Company 16535 INSURER C : American Zurich Insurance Company 40142 Suite 500 Lehi, UT 84043 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA -002524287-01 REVISION Nt1MRER-2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL N SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY 14PKGWE00274 11/01/2014 11/01/2015 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR PREMISES Ea occurDAMAGE TO rence) $ 50,000 MED EXP (Anyone person) $ 5,000 X $5,000 Ded. BI & PD PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY X PRO-JEcT F-1 LOC $ B AUTOMOBILE LIABILITY BAP509601500 11/01/2014 11101/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ A X UMBRELLA LIARX_ EXCESS LIAR OCCUR CLAIMS -MADE 14EFXWE00088 11/01/2014 11/0112015 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I I RETENTION $ $ C B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N I N / A WC509601300(CA,HI,MD,NJ,NY,OR,UT) WC509601400 (MA) 11/01/2014 11/01/2014 11/01/2015 11/0112015 X WC STATU- OTH- R L M TS E E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ 1,000,000 A Errors & Omissions & 14PKGWE00274 11/01/2014 11101/2015 LIMIT 1,000,000 Contractors Pollution DEDUCTIBLE 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Town of North Andover 1600 Osgood St. Building 20 Suite 2035 North Andover, MA 01845 LL.H I IUIY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M. Parsloe m. 4,� v IUt$ts-ZU1U ACUKLI CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD . I' 8 9 y J Date..(?:. �.-� i ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING •• 6 This certifies that �To$ . �-�................. i4 has permission to perform ............... plumbing in the buildings of .. C., F -v 0& at ........ pC ....................... . North Andover, Mass. Fee.: C.O—�. Lic. No.+:Y1225Q/. PLUMBING INSPECTOR Check # ">3 o,v�3 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or type) Mass. Date --L— Permit * y Building, Lotioniei s Name f9 � � �kC) of Occupancy Ve`Si ' ` t 4 L New O Renovation O Replacement'• 1i Plans Submitted: Yes O No O FIXTURES r Installing Company Name of Licensed Plumber Lo INSURANCE COVERAGE: I have a curt n Iiabliity insurance policy or Its substantial equivalent which Yes No O meets the requirements of MGL Ch. 142: If you have cked yee,;, please indicate the type coverage by checks the a ng ppropriate box A liabiifty insurance policy A Othar type of Indemnity ❑ . 1 Bond C] OWNER'S INSURANCE WAIVER: I am aware that the licensee doI„s not have the insurance coverage required b Chapter 142 of the Mass. Genera! Laws, and that my signature on this permit ppOcatlon waives this requirement. y Sip Check one: nature of Owner or pw,ner'4 Nam Owner ❑ Agent ❑ I hereby certify that all of the details and information I have sutxrirtted for an in above knowledge and that all plumbing work and installations performed under the APPli=b*n are true and accurate to the best of my Pertinent provisions of the Massachusetts State Plumbing Code and Pe issued for this application will be in complian ith all By Chapter t the General La r. Title ture o n umber City/Town jYPe of Licence: Master Journe O l`"c L License Number�j��� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 600 _4� City/State/Zip: " i o r -P b Are you an employer? Check the appr 1. ❑ I am a employer with employees (full and/or part-time).* 2.[ , I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t M1L-C LvPhone #: Gtl _l c :date box: l 4. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have A/C) employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised Mr right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reouired.l M5 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions l Lambing 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 state whether or not those entities have * employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: L Q a 0!1 / �City/State/Zip:��, �,/CcJ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dat�K 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. Ido hereby certify under the pnd penalties ofperjury that the information provided above is Prue and correct V 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 #: Date......` #• NOR7q / . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... ...... has permission to perform .... �.. ................ . plumbing in the buildings of ....� .. �� �--✓.t:--......... at . ... ...._:........._ . , North .Andover, Mass. O -e" Fee . , .1.... Lic. No........ ............ PLABA INSPECTOR Check # �.3a 8198 P MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING IVB "' )�"VeN' (Print or Type) G (` Date q S 20O� Reoeipt# 1Permit# Building Location _Owner'sName Map: Lot: tone: Type of Occupancy T�Q.,\ (Xk\ ('1 New 0 Renovation O Replacementv Plans Submitted: Yes D No Installing Company Name�ynw✓Ol'kone: Certificate Address > > \ !�Corporation �— Estimate Value ofWork: 0 Partnership Business Telephone "k -1 Mr- Nameof Licensed Plumber or Gas Fitter 0 Firm / Co. INSURANCECOVER E: I have a current li ility insurance policy or its substantial equivalent whi--h meets the requirements of MGL Ch. 142. Yes No CI If you have c eckedLes,, pleas indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity 0 Bond 0 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. Checkone: Owner O Agent'O Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the 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 TyrG cense: ber Signature Licensed Plumber or Gas Fitter Title fitterter license Number City/Town rneyman APPROVED (OFFICE USE ONLY) Pwmed 05,17100 ��moomouMEN noumono ��o�o��nn�oonn�oon ���o���0000mnoonn ONE Installing Company Name�ynw✓Ol'kone: Certificate Address > > \ !�Corporation �— Estimate Value ofWork: 0 Partnership Business Telephone "k -1 Mr- Nameof Licensed Plumber or Gas Fitter 0 Firm / Co. INSURANCECOVER E: I have a current li ility insurance policy or its substantial equivalent whi--h meets the requirements of MGL Ch. 142. Yes No CI If you have c eckedLes,, pleas indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity 0 Bond 0 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. Checkone: Owner O Agent'O Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the 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 TyrG cense: ber Signature Licensed Plumber or Gas Fitter Title fitterter license Number City/Town rneyman APPROVED (OFFICE USE ONLY) Pwmed 05,17100 Date.. /..�.. ? ... . A. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATIO 1 This certifies ................. has permission for gas installation ... ,,? !^.;,4 ,,-." : ......... in the buildings of .. i ". S. {A ..................... . at ...c) :. 4 4 r. .............. ...North- Andover, Mass. Fee.�.1 Lic. No.. l/ o G!... GA �..".......... INSPECTOR Check # �_ L � 6123 L3 } G (./ ! I� t,T �r }` TION`sFOR PERMIT TO DO GASFITTING' " MASSACHUSETTS UNIFORM APPLICA i 0 g C -2t -.-,Maas bate �'` ' .�' , pwnit Ic Builft Locadon ± t % 'A `paacr'2 Nam e/-�� QST ! OWW TeLI:Type of Oxttpaticy } New Renovado —�I// � G �r_t �;� � Flea Submitted:'Yes o ' No,' q,--- IXTU w. Installing Company Address / DaC,ETN r . I ! Business Telephone i9 7 g ) aa3 - /.30 ', i Name, of Ucensed Piumber or Gaa Fitter �1 c Check'one: Certificate O Corporation C3 Partnemhlp `(Firm/Co. 0 >J ;rr INSURANCE COVERAGE I have a ti rm t IlshWw lnm wsnm ponty or Ib itAstantlal equMknt whidt meets Oka of MGL Ch 142 I i YesV No D' �.w�� J If you have nt please hdleats the type caveraQ� MO the appropAate ltox. t A gabMty kMXanoe potty,Other type of hfdemnf4r D ,': �ottd d 6° I i i_ a ;Ila T '., a.`9. 't r i.; OWNERS INSURANCE WAIVER: I am swan IM a» AearMee tlttwraha ooverape roquked Dy Chapter 142 of rhe tM Masa. General L.&M and that my sipnshne on thb:peffrtn appACatlOh�� rr (f1h fegUkerhefl!`, 1 .. .. drr twig v, „ �w11er J o j Agent a Signature of Owner or Owners Agent I hereby certify that an of the detana and hrrormatlon 1 have rib—mit knowbdpe and that an p A*ft work and 'h taAatlona perMed hent pmvislons of the Masseftu tb State 'Oas Code and:0 T$le 4ea fitter • -Neater CAy/Town •-Ioumeyman APPROVED (OFFICE USE ONLY) of entma) aDovr! appAc�tlonaro. Ne and axurota to the Deet of my I. Kyay jMj�� pefmR tsatwd fo'fAb appft ! wtA artoe wdh aA I 8lpnaydro of LtW"d, Plumb atter Ucettas Number � Q'd � - �' i J I � L — � _ s n - y Noma M-1. Mul MT on _ pl w. Installing Company Address / DaC,ETN r . I ! Business Telephone i9 7 g ) aa3 - /.30 ', i Name, of Ucensed Piumber or Gaa Fitter �1 c Check'one: Certificate O Corporation C3 Partnemhlp `(Firm/Co. 0 >J ;rr INSURANCE COVERAGE I have a ti rm t IlshWw lnm wsnm ponty or Ib itAstantlal equMknt whidt meets Oka of MGL Ch 142 I i YesV No D' �.w�� J If you have nt please hdleats the type caveraQ� MO the appropAate ltox. t A gabMty kMXanoe potty,Other type of hfdemnf4r D ,': �ottd d 6° I i i_ a ;Ila T '., a.`9. 't r i.; OWNERS INSURANCE WAIVER: I am swan IM a» AearMee tlttwraha ooverape roquked Dy Chapter 142 of rhe tM Masa. General L.&M and that my sipnshne on thb:peffrtn appACatlOh�� rr (f1h fegUkerhefl!`, 1 .. .. drr twig v, „ �w11er J o j Agent a Signature of Owner or Owners Agent I hereby certify that an of the detana and hrrormatlon 1 have rib—mit knowbdpe and that an p A*ft work and 'h taAatlona perMed hent pmvislons of the Masseftu tb State 'Oas Code and:0 T$le 4ea fitter • -Neater CAy/Town •-Ioumeyman APPROVED (OFFICE USE ONLY) of entma) aDovr! appAc�tlonaro. Ne and axurota to the Deet of my I. Kyay jMj�� pefmR tsatwd fo'fAb appft ! wtA artoe wdh aA I 8lpnaydro of LtW"d, Plumb atter Ucettas Number � Q'd � - �' i J I � m;A' IN PLUM E� S%��`N �'r�4 fITTERS14" / LICE,NSED`J;OU �`MICHAEL BR016 NICHOLLYNN.,2-37.1 1 {I kit COMMOt�1N,$pTH �F MgSSACHUSETTS IN PLUMBE01t "A " ' 'FITTERS LICENSED AS ; AN:.i. •GAS INSTALL � 14ICHAEL A �B;kY L6 NICHOL'S I. Y N N ti �},� .,.Z'�rJ'2- 37 18 c to 933 0,0170T„ 259162 f ' 1 1 ' Iaaaraace ��� �� • ONLY AND,CONF(:RS NO RIGHTS UPON THE GL:KUtIL:A1 r i:p: C.taat St . H ER.T,H(S CERT.I WE DOES NOT AMEND, EXTEND OR ALM TN'CMWf AFF ORDED BY THE POLICIES BELOl11♦. tc:•erly, XA 01915 Scam Rabin INSURERS AFFORDING COVERAGE NAIL 0 !. ftsL*ED Kiciuml A. Iry"s ISIMtERk N enal "no Insummim Co. 147U Pl,At c/• TIS, lac. HOUKRsk 140 S. !rain St. c Vi/dltem, MA 01949 twLlletRo mums: COVERAGES THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWMWANDHO ANY REQUIREMENT, TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR mAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCEB DESCRIBED HERE" E SUBACT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAZCI:A* . 14ry 3R TYM OF NSURAM" POLICY NUMStR 11/Ol/t00! 11/01/t00 LMRS 04RIPAL UA AM iiD tACM OCCVRRENME is 1 Ofp Z COEtMERCMIOENERALLwEmDAIMM CLAMS MAN a occult TO NIMs A PtRSOK&L a MW H&W S 1000 O11,12M AOOMtOATE s' = p0 OEML AOOREDATE LMR APPUW ►ER: ►0.A ►Rp Lm PRODUCTS • COMPIO► AM s i 000 ---o-A LMASJTY AUTO tG� lhtR f OOml,MY ALL OWNED AVMG SCMEOUlEO AV1OS SOOLY INJURY s (Pw ��en) HREDAUTOS - �OWMEDAVMS LY INJURY (P�irioaldmq = E s +AALtrY AUTO ONLY • to ACCIDENT s ANYUTO OTHER THAN EA ACC s AUTO ONLY: AOQ s t'—Y DRRU UASLr" CIAMs MADE tACN OCCURRENER AOOREOATEcrou rfpll : s WOwRan COrM""TION AMD EMftxrfw • ENMITY A AM ►RO►RfElot TDMARTKFKXECVrWj O-CEMAEUSER DIQUDEW LL tACN ACCIDENT t LL 044E • M E s I rw d barba w do eiore e.a. 3PfCAoY+.E� E.LOMtASt•►OLICYIMR s E C ot"O" OF OPERATIONS i L.00ATTONt T VtMCLts / [XCLUEIONE ADDED SY INDORSEMtIR I tPlC1AL PROVItKm For Wentatisn Oa]J SHOULD ANY OR M AMM 019"" O POUe= St CAN=UAD Upon M t7..Dwwt A?M DAO 1TItRtOP, M Mum tq M %U tHDSAMOR TO MAL JR— MYS YTIM U NOrICt TOM CtRf1/I IA11 HOLM NA C TOM LM, DMT FALUN TO MAL SUCH NOTTOt SHALL WPM NO ODUOATM OR LMSRlry OFMYMD UPON M NSURtR, ITS AOtIfrS OR RlM "WATMi AV"IOMM X PRtMTRA?fn CORD 25 (2M=) DF created with pdfFactory Pro trial version www.DdfPaetorv,GOM GACORD CORPORATION 19a _fZ\_ The Commonwealth of Massachusetts Department of l�tdus�`rial Acc:dents _. . ` Office,of A"y.'id igahons 600 Washington Street i' Bosfoi+% wW{RmaSSgOv�dla : � ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ;; licant Information Please Print Legibly V Name (Business/Organization/Individual):�cr �.. Address: 1YQ egoy?/•� �% t N City/State/Zip:_ e �l�,�F%yrJ Il�f% .. 6� `�yq.,Phone*-.:. Are yo an em P to eV4 Ch1, .�' thwaPPropnateboa F, r} a k I Type 'of pro(requ i . 1. I am a employer wrth. S 4 ❑,:I am a general �o>mactor and I :;, a +� I 4 z 6:' ❑ New &6jffir6hbn employees (full and/o part-time).* : have hire I the,sub-co factors. ax 2. ❑ I am a sole proprietor or partner. listed on the>attached sheet t ? emode ' �$ , r ship and have no employees These: slbontractoish. 8:. ❑moht on . working for me in any capacity. workers, comp. insa ance,a 9. []Building addition [No workers' co k„ mp. insurance S. ❑ We area corporation.and its , ,�, ff, officers have ex$nrsed thea 0... ;Electrical ' required.] . ❑ repaiis.or oro i -41 3. ❑ I am a homeowner doing all work right of exemption per MGI; .. f 11. [l Pling repairs or addttibnis'� myself [No workers' comp. c. 152 '§1(4)` and we have no ...12.0; Roof repairs j . V insurance required.] t employees.'[No workers' comp. insurance required.] 13.❑ Other `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contiabtors must submit a new affidavit indicating sum'' " (Contractors that check this box must attached an additional sheet showing the.name of the.sub-contractors and their workers' comp. policy infoimatioa - F I am an employer that isproviding workers' compensation insurance for my employees Below is the o ,' and ob.ste. information. s P'. 3 -f Insurance Company Name: 15A) c�, 4 l� $ 3 �{� Expirati; F a Poli #. or Self -ms tic'. #: C i :, 5; _;; ' n• xt1 a << on Date /D fT O w 6 , Job Site Address. <r� I City, tatogip l' Attach a copy of the workers' compensation policy declaration page,(showing mbonepocynuerandeaPuh. Failure to secure coverage as required under, Section 2SAf 11%iG�I, c ;.152 can -lead to'.the impos7tion of criminal penalt<es fine up to S 1,500.00 and/or one-year imprisonment, as well as civil,,penalties in the form of a STOP WORK.ORDER of up to $250.00 a day against the violator. Be advised tbat a co of thrs; statement- P Investigations of the DIA for insurance �' may be forwarded". Office'of 1 ren p .t coverage verification r a 1 do hereby certify under the pains o and enaldes er• P fp fury that the information provided above is true and correct ::; .T..,_.... Signature. �✓jy� � n } ntl Phone #:�� Hi., r Offxid use only. Do not write.in this area, ,�, iR 5 y n• , to be completed by c`ttY or fawn o,%'reial City or Town:,.Peiniit/Licenie # } Issuing Authority (circle one): L Board of Health 2 Building Department 3. City/Town Clerk 4.°Electrical`Ilrspector 'S: Plumbing "" 6. Other .. I:_ �� ,, r.t ��or Contact Person:' I% " 1 Location No. % 8 Date —15�h9 19 I ,.ORT1y TOWN OF NORTH ANDOVER ••mow .�'�yQo� O?O: a _ Certificate of Occupancy $ Building/Frame Permit Fee $ s�cMusE Foundation Permit Fee $ Other Permit Fee(pooI) $ j -- Sewer Connection Fee $ Water Connection Fee $ TOTAL $Q ID � QQ ? Building Inspector 1311 b 05/27/99 11:28 104.06 PAID Div. Public Works d c� Z (i C s U O V C O G O Z a. t— Q r d Z (i C s c O V C O G O Z t— Q r � Z Y C Z V y0 O 'i < uj < -x m � Z n :1J N fi N V) N I f I 5 Z (i c I C Z Q � � Z Y Z V } O 6 < uj < m � Z � :1J N O C L < o w Z n — W X Z W y L c _ 1 C v z L < Cw Z < L d y f VO ? h J 0 z C C `1 w z Z ` r c 60 3 � F v t N `< z z z c C C Z z a. _ nW _ UJ Lu - SR tL L Z Z Z yJ < _ r v Z N Z z Z Z_ a Ln F•- _ :A A .: H J v v ( x Z U 3e CZE ;.+- U u ttJ LU W <n 7c T 7� ?, 7 X z Z '�[ Z Ln 0 VI W _- •L w f I 5 Z (i c I C Z Q � � Z Y Z V } 6 < uj < m � Z � z N O C L < o w — W X Z z c _ 1 C v z L < \ L d � y f VO ? h J 0 z C C `1 z r c 60 3 � F LLJz N `< z z z c Z z a. _ nW _ UJ O_ Z Z_ Z Z Z yJ f I 5 Z (i c I C Z � � Z Z V } N m � N O C < w W X Z z _ 1 C v < � L Z � y f I 5 (i ,.i C Z � Z V N m � m i, w z z a I z J y a i N Z z i z < y w Z LU Z i i D _ z :A _ L — V) — 4 — r , + FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT (�i a� EN S-'wo PHONE TTS- 26 LOCATION: Assessors Map Number g S� [_accv��u ��r PARCEL SUBDIVISION LOT (S) STREET L 0,LoIA i 0 C' "tela' ST. NUMBER �S S OFFICIAL USE ONLY'** R OMM DATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS 414 TOW PLANNER r 1� COMMENTS FOOD INS JS yPIC1N COMMENTS DATE APPROVED .D 11510 fl DATE- REJECTED 1 I .. wed Y DATE APPROVED DATE REJECTED. R -HEALTH DATE APPROVED r DATE REJECTED OR -HEALTH DATE APPROVED2_7-- DATE REJECTED �-T—T 44, PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE a ` A �J O z a N3 sl w � � o ww° v a O z ., Q ❑ a °�° U w O � � ° w O U �, W t c4° cn ro 44 OW w z �' /d►, 'O o 'ws w F z W Q W �' cn cn • f o CO O o o g C c :o R o ♦N vv R R E a A :m �v t:CD-ex o co O•��E�♦ r C C aN u . It h R oz�+M3 CO C43 y.+ 2 C R 0 3Em� CL v m N m acs 5 y H .Z eyv.5; o cm C � 0 CL Q m E CD .o = m :ago h o~ m :04 '.O z - CIO ,� Q :W Q r U CIO 7--1 0 U CO) uj Lij o id m ... o ,r .� •d " CLti 'O o 'ws • V _ A O p N =� O F- .0 0 L- a m to U 0 iCO CM c MnCD cn O 'E oo m i O fv CL co 3� CD o CL y e © Cc O J .� CO Z O CD V Cl) O C� CL Date.. �......��............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........0 R`J.lt............t.'�z c .... C..U.......................... has permission to perform ..... &0 0. wiring in the building of .......!.s}..>. ..!.......................................... at ...... .............,.` ,North /Andover,�+isfi: k- c. No44�'` .... . ELECTRICAL INSPECTOR 99 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer olFice Use only f The Commonwealth o Massachusetts Per.nh K2 No. ` J Occupancy & Fee Checked ' Department of Public Safety 3/90 (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR E ALL INFORMATION) Date 'W'057'41-1-7. 15795' City or Town of 14/1%&) y/ •--1P-C To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction With a building permit: Yes 14 No ❑ (Check Appropriate Box) Purpose of Building ���j//C� Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters t f V Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ��fj`jif`yfj�� tqpL No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- ❑ ❑ grnd. grnd. Generators KVA No. of Receptacle Outlets No. of Oil Burners - No. of Emergency Lighting Battery Units No. of Switch Outlets--- No. of Gas Burners __ FIRE ALARMS No. of Zones No. of Detection and No. of RangesNo. Air Cond, Total of tons Initiating Devices No. of Sounding Devices No. of Self Contained No. of Disposals No. of Heat Total Total Pum s Tons KW No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Local 11ConnectiMunnecti pal ❑ Other No. of Dryers Heating Devices KW on No. of Water Heaters KW No, No. of Signg LowVoltage nof Ballasts Wir No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Lia lity Insurance Policy including Completed Operations Coverage or it substantial equivalent. YES [Do" NO C]I have submitted valid proof of same to this office. YES [NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) Al t Estimated Value of Elec 4 W k $ Expiration Date tr or Work to Start Inspection Date Requested: Rough Sighed under the penalties of perjury: FIRM-NAME-- Licensee IRMNAME_, Licensee k Final LIC. N'1. Address -3 ` w,' C, OX `i2 ,/„1Ul 1,L/r t iw# B..72 As. Tel. No. (9-2?J '715P Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. Signature of Owner or Agent �� l PERMIT FEE S 5 GlJ U The Commonwealth of Massachusetts Department of Industrial Accidents Office 911110092 Dns 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Al licant mformatton Plea ePte�tb �. z. 7 name: t c)E' phone I am a homeowner performing all work myself. C] I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees workingonthis job. -fight Electric Co. Inc company m •tn name: " address: 1.111711011, i.,10 1 "']�-657-7195 city• shone #• ITT ",irtford. Ins. :0S-6',T"CCn067 insurance co. policy # .. .... . fir.;..."PtVw •,.,..iq+^ T'k:, "•J•, w^':i".•'T*•'R'1^�^?l!^Y L'y' '1T+.: __ .. .. : al..iiL......u:dJ..s's.trr�.f...a= p�.•r.+-;,. ... .. ,..w..... rer�.�;- I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address city: phone #: insurance co. policy # .,�" ,,.. 'f'T'$,_rP fix',.; .•'"'"n"»c. ...,..:.✓o!- .., ::: .:, .;..... ,....;...„7�"a"'+...:*sv*"�!�"rrr+!'.+• �fii�stS�` company name: address: city: tlhone #. insurance co. ” policd:# Attach additional sheet tfnecessary Failure to secure coverage as required under Section 25A of MGI. 152 can lead to the imposition of criminal penalties of a fide 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 S100.00 a day against me. I understand that a copy of this statement may be forwardedto the Office of Investigations of the DIA for coverage verification. / do hereby certify un t/ pains and pe alliesof jury that the information provided above is true and correct. Signature AMDate rol�ert 4, ,''ri :a Sr. 970-657-7195 Print name Phone # official use only do not write in this area to be completed by city or town official city or town: permit license # OBuilding Department check if immediate response is re [:]Licensing Board required ❑ P q - ❑Selectmen's Office ❑Health Department contact person: phone #; MOther (revised 3195 PJA) Town of North Andover HORTk « OFFICE OF a 3� ° �, • `•' �o COMMUNITY DEVELOPMENT AND SERVICES ° 27 Charles Street x North Andover, Massachusetts 01845 `"��,,;; �:•` �5 9SSACHUS WUILIAM J. SCOTT Director/_ % Cc (97 8) 688-9531 , Fax (978) 688-9542 SWIMMING POOL REGULATIIONS NOTE: PERNIIT�ARD—SHAi--L-BE"POST-r=DiN AViSIBLE AND ACOE'SStflLf 1:OC:AT10Nf4R OBTAINING THE VARIOUS INSPECTORS' SIGNATURES. ALL SWIMMING POOLS IN EXCESS OF 2 FEET IN DEPTH ARE REQUIRED TO HAVE A BUILDING PERMIT AND CONFORM TO THE FOLLOWING REGULATIONS: 1. ELECTRICAL: An electrical permit must be obtained prior to an application for a Building Permit to install a pool. 2. ZONING: Pools shall be located to the rear of the front building line of the house and no closer than 10 feet to the side of rear lot line. 3. HEALTH: a. Location from subsurface disposal system must be approved by the Board of Health. b. Semi-public and public pools must have plans approved by the Board of Health prior to construction and must also have an annual operating permit from the Board of Health. 4. SAFETY: Pools must be enclosed by a suitable wall and fence, at least 4 feet in height with self-closing and latching gate that meets the approval of the Building Inspector.* No water allowed in pool until fence is erected. Pool cannot be used Ami! 4nspected -and approved by the Electracaa Inspector and Building Inspector. *Fencing on comer lots must be erected-20ft. inside lot line. FEES: ELECTRICAL PERMIT $35.00 BUILDING PERMIT - 6.50 per thousand on estimated cost: $35:00 minimum permitfee rn iK BOARD OF APPEALS 688-9541 BURRING 688-9545 CONSERVATION 688-9530 D. Robert Nicetta, Building Commissioner HEALTH 688-9540 PLANNING 688-9535 /1/?— 57,1 Date ............7 N2 3919 TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING SACHUS This certifies that . ............... ........................ has permission to perform ...... ........ "I ...... plumbing in they buildings of .......... North,ndo,,er, Mass. Lic. No..l .. ..... . .... Ark. PLUMBING INSPECTOR 01/21/99 14:25 353.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer (Type or Print) NORTH ANDOVER ,Mass. Oate ; • ' /a-- 3,,,Building Location�G,�,�o�t/eQ �;rc le \ . �Permlt9/ Renovation Owners Name 1 4 Replacement Plans Sybmitted ri (Print or Type)': Check one: Certificate �ew'4 Installing Company Name 0"-'/'g ,, r' 3 Q Corp. Address Partner. Firm/Co. Business Telephone(9),%-) 'P -d.?a o Name of Licensed Plumber: ;% Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 0 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware -that the licensee of i this application does not have any one of the above three insurance coverages. Owner Agents. Signature of ownerlagent of property I I bemby eatifr that all of U.4c dclads and in(oimalion I lu•c submit lcd (or cnlncd) in atwnc apMicalios alae 14W asN�pyale to dw best ei w# k"wkdge mad "all plumbing walk and inslallatinns lop(nemcd undct resmil luucd (o/ this applintio4 will bo i• gylp(ja11p rj{11 W Fq&*W P1 l WO" of the Maawclwutll Slate Plumbing Cade and Cluplcl lit 9(111C Genual Laws, 1 44 ilk By Title City/Town: w ADD0r)VFr1 70FFICF USE ONLY) Signature of Licensed Plumber Type of Plumbing License License Number !_Master ❑ Journeyaa N2 2 14 7 Date .... /(....... ./r,9? TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....N.' S-A.........�.............. F.haspermisslon to perform .......... S ..... .................. wiring in the building of k.5.......... L. �. U �`?.'. C .......... ................................................ t S -C-c19 o ........................... .North Andover, Mass. Fee..: .v�.. Lic. No. ..... �f5 1......................................................... i ELECTRICAL INSPECTOR 1!/23/98 08:51 50.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 09WONWE4071OFMgSS CMU E77s Office Use only DEPARTAiNYTOFPUBLICSAFM Permit No. L 7 IBO,RDOFPWPREVElMONRWHA770AS527CMR 12:010 Occupancy &Fees Checked 9APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED 1N ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) & 5— La C o #1 t6� C(rd-e Owner or Tenant I_ Iriri L r� Owner's Address Is this permit in conjunction with a building permit: Yes ® No (Check Appropriate Box) Purpose of Building Res (deW«.( Utility Authorization No. FO S y -AD Existing Service Amps / Volts Overhead M Underground a No. of Meters New Service o a Amps J4 o 1,2yo Volts Overhead M Underground r"�" No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No of Transformers Total KVA No of Lighting Fixtures Swimming Pool Above Below Generators KVA and round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No of Ranges No. of Air Cond. Total Tons No. of Detection and No of Disposals No of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• instrarre Came. Fursuart tithe regtmarrals ofMassad' s Genaal Laws I have a wnw Liabtli y kmance Pbhcy mdudrg Canpiek Ca W or i s subs a givalaY YES ED NO 0 Ihawa bnai dvaaldptudofsarebtheoffimYEStNO a IfjculmedWodYES,plemeixkWthety)eofwmaWbyd—tgthe bcDL SURA CI CE M BOND r7 OTHER M ftaseSpe fy) D* Wak m Stant lr at Dai Rdgtxstad Signed under -Tr Penalties ofpclJW. FIRM NAME Ezri dd Valued'Elemical Wak $ Rough I Final LioatseNa Lie PLC(�C �Oc�� so�i�'eJ�e Sigr>awte � ,1� LioatseNo LG.7 5% �� V BusinessTeLNa Ad frrc o7 7 iT� �!�/ 5i4- Alt. Tet Na _fT d� G ?o � � 74 7/ OWNER'S INSURANCE WAIVER, Iamawarethat the U=wd thertmratneoaet aassub rtialei valatasrrjgtmedbyM C,erraa!Laws and that my sweat this perm6 apphcmw waits this m*wurtei t. �r (Please check one) Owner Agent a O�j Telephone No. PERMIT FEE $ U OF ELECTRICIANS AS A REG JO,UR,-M--Y.M°AN ELECTRIC IS UE$JHI L1 "FN TO NIC K H. KO DO{CR,IT m , 27 HOLLY S ° C 821=10BILLERI0 24584 E-x7/3101 „': 674006 t ' 4 Date ....:. �:.t'J........ NORTm TOWN OF NORTH ANDOVER PERMIT FOR WIRING qL This certifies that ........................ - ..... : P- ........................................... has permission to perform ............................................................................. wiring in the building of ............... Com:-��. 7!.-.�-�-...�<:'........................................ at ....... �.......................... .......... , North Andover, Mass. ry /� Fee s ,. . "......... Lic. No.!?.�,.'.............................................. \ � ELECTRICAL SPE s Check # 82.04. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.,/ BOARD OF FIRE PREVENTION REGULATIONS vc 1/07`y and Fee Checked w 1 lea 4'C htank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to he performed in accordance with the Massachusetts Electrical Code (EIEC), 527 CNIR 12,00 (PLEASE' PRINT IN INK OR TYPE ALL INFORMATION) Date: � — .2O —& k- --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) Owner or Tenant ,Q,' J g s Teo v+� ` Telephone No. !- Owner's Address �. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No, Existing Service 2�v A94 12d / zV,y V is Overhead ❑ Undgrd No, of Meters New Service Amps f Volts Overhead ❑ Undgrd ❑ No. of ;Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorkAl- X- /l/ 3 Z ! h �V IVV-- z � .duac:•h additional detail if desitett, oras required by the Irrspectorof Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: � `za —u r- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) 1 certify, under the pains and penalties of perjury, that the information an this application is true and completes FIRM NAME: ,%%e . LIC. NO.: jj y 3 3 Licensee: 4,, J Signature 7-I.LlC. NO.:9 9 3 3 t 11,rl,l,li edz/e. en r "e.eentpi !in the license netrnher tine.%y�-•- Address: "4 5 Bus. *Per M.G.I. C. 147,,, j -61, security work requires Departm of Public Safety "S" License: Alt. � el. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes Tutt hale the liability insurance coverage normally required by law. By my signature below, t hereby waive this requirement. I am the (check one) ❑ owner owner's -agent. tawilii/Apol signal"r@ _ � Telephone No. „r ,,,- r„bvn trig able may ne waived t, y tyre Ins eetor ol Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. ofTotal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool ove ❑ n-❑ o. o Emergency Lighting rnd, rnd. 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 InitiatingDevices No. of Ranges No. of Air Cond. Tans No. of Alerting Devices No. of Waste Disposers Heat Pump I Number ons No—.oTSelf-Containea Totals: JKW Detection/Afertinz Devices No, of Dishwashers Space/Area Heating KW Local ❑ t unrctpa ElOther Connection No. of Dryers Heating Appliances KW Security vstems: R o. o •iter No. of Devices or Equivalent Heaters KW o. o ! o. o Signs Ballasts Data Wirin No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP c ecornmuntcations Wiring: No. of Devices or Equivalent O'i'H ER: .duac:•h additional detail if desitett, oras required by the Irrspectorof Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: � `za —u r- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) 1 certify, under the pains and penalties of perjury, that the information an this application is true and completes FIRM NAME: ,%%e . LIC. NO.: jj y 3 3 Licensee: 4,, J Signature 7-I.LlC. NO.:9 9 3 3 t 11,rl,l,li edz/e. en r "e.eentpi !in the license netrnher tine.%y�-•- Address: "4 5 Bus. *Per M.G.I. C. 147,,, j -61, security work requires Departm of Public Safety "S" License: Alt. � el. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes Tutt hale the liability insurance coverage normally required by law. By my signature below, t hereby waive this requirement. I am the (check one) ❑ owner owner's -agent. tawilii/Apol signal"r@ _ � Telephone No. 2- A r� z li ;�4 O m c C N O C C3 v C. C :dw .16 : A m m C CD :Z O Q o CD Ea �CDo S S CD CD r0. C. E c �i c � � O V ~ o m � N *o N =m�� o �L)�V C o' aC� .: m N m cm • V' coQ � h 3 O �x C-111 CL c m C •O = v) CL 3p N COO Viz$ m r to c Ste_ =,- -N c «. H .y CLI Z W•E ca -o v .y o CS V� C. _ �oy•� O CL... m d z 0 4 w W v a� O E i O V Z p, O y 0 C as c, i o y O O �E m cc CD w �3 moo to O d o cc c Cc .v J 'o O C 0 0 CL C.3 co O C C CO2 OF U L OF U U W a aa U 0 _ •l ro U Q o a �_ °° �� \ a cd 0 U) w cn coo r� z li ;�4 O m c C N O C C3 v C. C :dw .16 : A m m C CD :Z O Q o CD Ea �CDo S S CD CD r0. C. E c �i c � � O V ~ o m � N *o N =m�� o �L)�V C o' aC� .: m N m cm • V' coQ � h 3 O �x C-111 CL c m C •O = v) CL 3p N COO Viz$ m r to c Ste_ =,- -N c «. H .y CLI Z W•E ca -o v .y o CS V� C. _ �oy•� O CL... m d z 0 4 w W v a� O E i O V Z p, O y 0 C as c, i o y O O �E m cc CD w �3 moo to O d o cc c Cc .v J 'o O C 0 0 CL C.3 co O C C CO2 306"9 Date..`-2�' �/' 4 NORTH TOWN OF NORTH ANDOVER g OFi.to ^,'t'O p PERMIT FOR GAS INSTALLATIONS This certifies that : .........4 + ...... • • ..�• has permission for gas installation..:k :� . .. ......... • • a in the buildings of.:. r'� ................. u at ..... .. .... . , North Andover, Mass. Fee. :. `/. Lic. No�!X5 ?.... . GAS INSPECTOR d i� WHITE: Applicant CANARY: Building Papt. PINK: Treasurer v 1<411 ✓IASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING or print) 1-4VxIH ANDOVER, MASSACHUSETTS Date / 01 1`> 19 9/ Building Locations a e o Nl�C- Permit # 2e)S7,�? Amount $ e'l Owner's Name New ---- Renovation ❑ Replacement ❑ Plans Submitted (Print or type) --- Check one: Certificate Installing Company Name / G �e,5' %1� Com,.; -1 /-111-) ❑ Corp. Address / h a ,/ c /, %y%E71tx-e •✓� 4 1.4 /) /eV4/ Business Telephone Name of Licensed Plumber or Gas Fitter U o -t t f ��, i -11111 ❑ Partner ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑''' No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ED I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett4te Gas Code and ChapterjA ofthefj.,eneral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) lSignature of Licensed Plumber Or Gas Fitter Plumber %,SSU ❑ Gas Fitter UcenV I -umber R—imo"t er 1:1urneyman rq � rn M N z c z C `z w L C w GCs] v, w z Q w a ,rYn„ z w � � w � _ v z � -t z z W .. F -C zz rl W r :� %" L �' C ;. z W C U w � W w w z 't C -t -� C C w C w r SUB-BASEM ENT BASEM ENT 1ST. FLOG R / 2ND. FLOGR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6 T H. F L O O R 7T If FLOG R 8TH. FLOOR (Print or type) --- Check one: Certificate Installing Company Name / G �e,5' %1� Com,.; -1 /-111-) ❑ Corp. Address / h a ,/ c /, %y%E71tx-e •✓� 4 1.4 /) /eV4/ Business Telephone Name of Licensed Plumber or Gas Fitter U o -t t f ��, i -11111 ❑ Partner ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑''' No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ED I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett4te Gas Code and ChapterjA ofthefj.,eneral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) lSignature of Licensed Plumber Or Gas Fitter Plumber %,SSU ❑ Gas Fitter UcenV I -umber R—imo"t er 1:1urneyman 3266 Date f NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION ,SSACH This certifies that ......... has permission for gas installation ll.......... 4? in the buildings of .................... at North Andover, Mass. 7:.. Lic. No..A-.'xK2-1. GAS INSPECTOR �j WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MAP 4ASSA CATON FOR PERNUT TO DO GAS FITTIlVG or print) iNuKIH ANDOVER, MASSACHUSETTS Date 17 1 or --S 19 71 - Building Locations _ FtS L.l� �� lre,4 Ct f- Permit # YA C C Amount S' j Owner's Name New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type)Q Name - -- I C-L1.Y-�rA W Check one: Certificate Installing Company ❑ Corp. ❑ Parmer. Firm/Co. Name of Licensed Plumber or Gas Fitter 1 \,^C i4t+rd Cv- %til A -e ke a INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes M No❑ If you have checked ves'please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Si_nature of Owner or Owner's Agent \ Owner ❑ Agent ❑ I hereby certify that all of the details and information I have suhmirred rnr PnrPrP,4) est 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 i'vtassachusetts State Gas Code and Chapter 142 of the General Laws. 10 Title City/Town PROVED (OFFICE USE ONLY) Signature of Licensed P ber Or Gas Fitter ❑Plumber. w- 1 ❑ Gas Fitter License N umner Master �✓�r�� � ��5. f Journeyman s' (Print or type)Q Name - -- I C-L1.Y-�rA W Check one: Certificate Installing Company ❑ Corp. ❑ Parmer. Firm/Co. Name of Licensed Plumber or Gas Fitter 1 \,^C i4t+rd Cv- %til A -e ke a INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes M No❑ If you have checked ves'please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Si_nature of Owner or Owner's Agent \ Owner ❑ Agent ❑ I hereby certify that all of the details and information I have suhmirred rnr PnrPrP,4) est 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 i'vtassachusetts State Gas Code and Chapter 142 of the General Laws. 10 Title City/Town PROVED (OFFICE USE ONLY) Signature of Licensed P ber Or Gas Fitter ❑Plumber. w- 1 ❑ Gas Fitter License N umner Master �✓�r�� � ��5. f Journeyman Location Nei.%'�r' Date MORTN TOWN OF NORTH ANDOVER O?O•,`,O '•,�O RVJ n Certificate of Occupancy $ * ; ; Building/Frame Permit Fee $� cNUSEt Foundation Permit Fee $ n; Other Permit Feel-,. ,$ s� ' a Sewer Connection Fee $ C207 Water Connection Fee $ 2, " TOTAL $ n C O 10/15/98`15:51 11� 1J.. 1,619.00 Pft Location � NO. Date A NaRTh TOWN OF NORTH ANDOVER; 0.1 �•, ..oma � n iI Certificate of Occupancy $ Building/Frame Permit Fee $" � s�CHU Foundation Permit Fee $ _. Other Permit Fee $ Sewer Connection Fee $ L; ° 1 % Water Connection Fee $ TOTAL $ Building Inspector c , , 10/4/98 15:51 1,619.00 PAID Div. Public Works C•, Q v a o u -\ a n z � uJ m � o }- � NN 7- � a w � 1 > G% r = cZ U z w E- � � v, w C O a o u -\ a n z � z m � o }- � NN � a w � r = cZ U (,j v ; w W W _ � C. z QLU w a- - w �i c G LLI �. J ¢ t = z Qj V� � ` z z o c o L Wuj L z C i — v Z h :n CJ =. C m C 1I w z V\ G) Z c C z— O 5 Gal C z LW W 0 r S( x > z _ u.. LU m r z¢ Ul 2 O z G z z C m© m ¢ Z a C ■r 2 V)z C Z z z 'r U u L, U Z �t��. z ¢ C C C ¢ zo W Z � w } a x " z •n z -n Ci z — = 1. m -- w w w :Y y u w C u iG z vi Z uz d z F_ s 4 U E w 0 Z C EZ m 0 w O C V) w z m c LLI J Ln U L n¢. w a o u -- , a n z � z m � � NN � a w � r = cZ U (,j v ; � C. z QLU w a- - c G LLI �. J ¢ t .� z Qj V� ` z z L Wuj L z C i — v Z h :n CJ v =. 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S• t'� - .,,, �4 71 w`.ry} F.'8y? � ��''• '' rd _k+'`}``-{'In�7,:E s^ 'r ��.: .µ r; �,z r £{ *• � � d� � ^k '�.n2 I��pwy, s''�jCil e'r.;ut�•i+'? °��3 .Qi + �`�" _ ° '�ti •Lr` °r s�,^f '.0 •��� r �. ' - .f It �r ?.< .t a�'+".•�yc �'2� `F%•{�. yz ��dy , yS vet lx ,�+ a� C�y� ,,,�VVV r y . A d^? h } $ttf .�. > " '� ry t . L± ,f.'� t,•r t It C i �, � { -n, �>t~* �, � : � k �•• a r �}�{� 1 ... Fj � Sr i " . L f .g � �<� _ a'i'1 ,i :S, '� �� n •"{ .r i i _ � t Y6."`.• k1 - _ �i'� i �� !t �• 6'S nr ��9 i� r'^r'"i 'u� � + f' 4 !^� � .. « .�;}f f7 "`'. 1 r�+. ' �� '1 2 } t a �.� ' � ,�t C � � u�s�?w q .b ►ter t"" r � � ' k '.+ _ � _ �.F� s r �. 3 x� � ;. ti>� +: '`d� ..s. „c• � �;oma, � �2> ,' "S7 � L _ -< �• t r .� .yam. �, �;, : ; � \ �e � i�� v r�. �` \�,.�[' .. • •. :i • 1 A" tr5l [J t•'l. J° i3 y,�x N '. ■A' Y� dt ,ts _. l ..,•-r" '' � �`}fir ;-^a- F'-�,•k y4 < �,'t a� t # � 4 �' Y . V r; :5. ., �. ._ f.3 ar '� .: �'^LS �r..., r+• . �,'b �- {����r�� �,�rn "�.C' ,.a� � r e fi.'. . , . ' .,, _ :�,: Fri , ..•• - r ' rry 1. \►t � Kn '� �is. � i � J'... }� I .. s'4 ri • ':� � E Y ..-" v O . t+ : ?- . _. _. � 1 yam, y ,gyp m'�: \IN The Commonwealth of Massachusetts Department of Industrial Accidents Ufflce 01I MS&YJA S 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit 4 � F m 0/f -E a. E O 1 am a -sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name, address: City' phone #- msarance co. yo`icf,. Failure to secure coverage as required under Section 25A of MG L 152 can lead to the imposition of criminal penalties of a fine 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 S100.00 a day against me. I understand that a copy of this statement ma forwarded to the Office of investigations of the DIA for coverage verification. I do hereby cerci u d the pain d allies of perj ry that the information provided above is true and correct Signature Date Print Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # r-18uilding Department OLicensing Board Cl check if immediate response is required C]Selectmen's Office C]Health Department contact person: phone #; -Other (rinsed 3195 PIA) FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION******* APPLICANT_ ��li`I£'� �V� 3 r PHONE LOCATION: Assessor's Map Number l®5 is Z PARCEL SUBDIVISION LOT (S) STREET �,4G'Oti14- &e1Z, ST. NUMBER ************** O F F I C IAL USE ONLY**`************* RE=,". TIONS OF TOWN AGENTS: /_ ` , COf&9kVATICFN ADMINIJTRATOk DATE APPROVED l DATE REJECTED COMMb.-U �: 11 , 1 TOWN'PLANNER _. DATE APPROVED DATE REJECTED COMMENTS i(vyvnr1r1 Av;ikfp 4>n( 1 �`�r'•a, �-->aVr/Y, FOOD INSPECTOR -HEALTH INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS D /FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Y PERMIT I-- � )11114 J Growth Management Bylaw Exemption Statement Town of North Andover Building Department This forth shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant an Bjuilding ermit (below) Address of Property for Permit (below) Cy Map and Parcel fDS S7- Purpose of Application (check below) hone Number of pplicant: _✓Single Family Two Family 1 the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any parry to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit irk issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement. restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Y This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a property executed and recorded deed restriction running with the land. For purposes of this Section "senior' shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building pernits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved forth U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate i ormation, or the checki off of an above item which does not comply, whether done to my knowlepgy� not, is groyj�ds for re sal by the Building Department to issue a Building Permit. ' ner r AutTionzed/AAebt who signed the Attached Building Permit Date must be attached to lye Building Permit upon application for such permit. I DEPAPTME!IT OF PURI IC SAFET CONSTRUCIAIi SUPERVISOP l ICENSE Nua6er Expires: CS 04BaD0. i2oll, SiT1date: D8999 Rests�cted�,� DD JOHN F ,OBR1Eli JR ' �B7 WHITTENORE ST TEWKSBURy, VA 01876 7 --_ HOME IMPROVEMENT CONTRACTOR ` Registration 103636 ' Type-- OBA - Ezpirati on 07/09/00 I O'BRIEN CONSTRUCTION John F. O'Brien i $1�dhit-temore St, j ADMINISTRATOR Tewksbury MA 01876 I f W a W am N` o a a o ` C y a O w ='�:•dc o :� .+.. = c CD � x q X a w w o FA w a w cn o a W am N` o ` C y O ='�:•dc a m Mc :� .+.. = c CD CD m *i o c. FA 7: `Om 0: f: c 2 d- cm 'o` E y .S ILO m m cd b- y = 3: *� w 0 CO •O � ' : O N m o m CD o c o, � CLmm � r�=o CM caw: CD's a 00 ?:mom m dew' C� O rn. v .' Z i m 0 O (/)* a o cm c a m :gym= CD :moo s H o y V3 W W =O -0v .h = GZ r.r .E Ems Z W ` 'D rl co_ y a m O:6 = tto J2 o O a�m� E CA y E co CD t C O co _Q CO2 0 CL y 0 V O — y 0 CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permitr+umm,/*/1/y oma s a 49 THIS CERTIFIES THAT THE BUILDING LOCATFD ON S V 4COM1 Z `I MCV, MAY BE OCCUPIED AS V l !R * IG 10401 ��/ /RPS IAT CY IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO A91 A Q 41P* 0'7 ....,00c ADDRESS BS ,C A ["I 4 60f, A& �CMUS Building Inspector v .v V m a ts ;c o L O N. cc t = C a `' ea C m O occ ` CD E � a r` m [ p o V :its 0 n E e 7`om P� O. •.~•a.. J1 a. E m m N w +- Ma c> O N �C m •O � : O � N R O �a E m mo 0 chc y o > cc yam= o cm � y dat m O • 0 yZ o is aoocm n 5 E N m c �c = m Cas o IV :n CD a W LU H .y C:s, C Z m •N O LU C3 •W CO) a �� o� Z tyv = � y'� O CL v W" 1 a� 0 0� ' L O V Z CD CL O H � G w, � W I O M O O m m h- �s CL �•+ CD G� 0 O O a IL Q1 Q y G O=� G CJ 9ev io ca G Z tjO L) CO) O G CL• G CO) 0 U � 'I M �lY Y r u y'�1 W3 [may ( , V �► 10 ���..Q...��� � �` W v Md W fd. a w ° z w w C a°' tu ° rA cn cn .v V m a ts ;c o L O N. cc t = C a `' ea C m O occ ` CD E � a r` m [ p o V :its 0 n E e 7`om P� O. •.~•a.. J1 a. E m m N w +- Ma c> O N �C m •O � : O � N R O �a E m mo 0 chc y o > cc yam= o cm � y dat m O • 0 yZ o is aoocm n 5 E N m c �c = m Cas o IV :n CD a W LU H .y C:s, C Z m •N O LU C3 •W CO) a �� o� Z tyv = � y'� O CL v W" 1 a� 0 0� ' L O V Z CD CL O H � G w, � W I O M O O m m h- �s CL �•+ CD G� 0 O O a IL Q1 Q y G O=� G CJ 9ev io ca G Z tjO L) CO) O G CL• G CO) 0 'I M �lY Y r u y'�1 W3 O ` 10 Q .v V m a ts ;c o L O N. cc t = C a `' ea C m O occ ` CD E � a r` m [ p o V :its 0 n E e 7`om P� O. •.~•a.. J1 a. E m m N w +- Ma c> O N �C m •O � : O � N R O �a E m mo 0 chc y o > cc yam= o cm � y dat m O • 0 yZ o is aoocm n 5 E N m c �c = m Cas o IV :n CD a W LU H .y C:s, C Z m •N O LU C3 •W CO) a �� o� Z tyv = � y'� O CL v W" 1 a� 0 0� ' L O V Z CD CL O H � G w, � W I O M O O m m h- �s CL �•+ CD G� 0 O O a IL Q1 Q y G O=� G CJ 9ev io ca G Z tjO L) CO) O G CL• G CO) 0 February 24, 1999 Mr. Michael McGuire Building Dept. Town of North Andover N. Andover, MA 01845 Dear Mike, Bill Engstrom and Linda Sabato take full responsibility for the front deck and on the back deck where there are no footings. The contractor will put them in as soon as the ground unfreezes. If there are any questions, please feel free to give us a call at 978-988 Sincerely, X /� ��- c— William Engstrom ANTOINETTE ZAI.AKET Notary Public My Commission Expires October 21, 2005 f N2 2191 Date.... 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ........... ................... has permission to perform .... A ....... Avn�t ........ )!. ' `j wiring in the building of ...... .. . ....... ............. )&W at4., ..... ey—� ....... .,;2,North Andover, Mass. AS�3.07-.O Lie. No..I��11( .............. . ................... 0, ............. ........ LECTRicAL INSPECTOR 01/04/99 13:30 307 An PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 7HE09ADIOANE4 THOFMAMMUSEM Office use only i DEPARTMFM'OFPUBLICSAFM Permit No. ( ` BOARD OFMEPREVLV70NRE M4T10AN 120 Occupancy &Fees Checked APPLICATION FOR 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) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) T-15- Z I* c e-501 1 4 lo Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building �eprMew 4Y Utility Authorization N .. � Existing Service' fes_ Amps aVolts OverheadM Underground ® No. of Meters L� New Service Amps /_Volts Overhead r-7 Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. 11-ighting Outlets No. of Rot Tubs No. of Transformers Total KVA No. of Lighting Fixtures ,+� Swimming Pool Above Below Generators KVA and1:1 ound No. of Receptacle Outlets No. of Oil Bumers No. ofEmergency Lighting Battery Units r No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges / No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW N No. of Self Contained Detection/Sounding Devices Local Municipal Other No. ofUryers Heating Devices KW Connections -No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER lrmrrwwCoraage Qmed Laws Iha\eaom tL bkyh>,swa=PobLyutdudogCcr Covagecrtsakswrgdegr,Wat YES F-1 NO IhmeWmitledMalidptoofofsatnetotheOfre YES M NO Ifyuha\ediedWYFS,plemmdc*theNxofw&aWbychad�gthe Wpoprilebcx INSURANCE ® BOND OTHER ft=Spm y) ' d n 4p; = Expitaa«tD* Estar>a�d Vahie ical Wcrk $ WodctuSW • � • 7t4 ._ InspecvrnDa$eRe4xsed Ragh Fatal Sigrted underlie R relfies ofptijtay. FIRMNAME LiotrneNa Lioal9ee Allt° r.4- Sigtmhae Li=W11,10 .�..�� Business Td Na Arm AiTel.Na `F -?'k — 1•740V OWM3Z'SINSURANCEWAIVER;Iammaredatthel-k= theittstr�toeoaetagetxAssubstar>tialt valetiastequaadbyMassac%tsdCsGeneralLaws and thatmysgri ttnanthispemtkapprtcWmwaiticsthisna* w-unenL (Please check one) Owner M Agent ® Telephone No. PERMIT FEE 1.0 106 Date ... 1� ... . ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ........ r. V. . .............................. has permission to perform ... ..........1// ......10.t:6 ,4 :: ........................ wiring in the building of .... I ......... ........................ at C ...... ............ ...... Zorth An ver, M 2,v L R Fee .............. Lic. f4o/l.f ..... .. . ......... �4 ELECTRICAL CM Check # 1 -o-117- F, 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code .00 (PLEI4SE PRINTIN.1NK OR �'EALL INFO (MEO)� s27 CMR 12.00 City or Town of: TI011� Daie: 2 �/ By this application the undersi ed'gives no ' e of his or her intentio perform the electrTo the ical work ) aiees.' Location (Street �& Number) �� /jot, A. I ,1i scribed below. Commonwealth of Massachusetts Official use Only Department ®f dire Services Permit No. —110106 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes 10 Purpose ofBuilding— zisting Service Amps _/ _Volts New_ Service Amps /_-volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �-V Telephone No. No ❑ BLDG PERMTT # Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters occturc of rnerouowing table,may be waived by the Inspector fWires.No. of Recessed Luminaires No. of Ceil.-Sus . (Paddle) Fans No. of NTotal. No. of Luminaire Outlets Transformers �rA O- of Hot Tubs Generators KVA, No. of Luminaires SyF,imming Pool Above rnd. ❑ In- ❑ o. o mergency ig tmg No. of Receptacle Outlets Lirrnd. Batte Units No. of Oil Burners No. of Switches FIRE FARMS No. of Zones No. of Gas Burners No. of Detection and No. of Ranges Total Initiatin Devices No. of Air Cond. No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons ns Totals: "'" """" .... No. of Self -Contained ......................................... No. of Dishwashers Detection/Alertin Devices jSpace/Area Heating KW Local ❑ Municipal No. of Dryers HeatingAppliances Connection ❑ Other PP KW Security Systems: * No. of Water KW No. of No. of Devices or Equivalent Heaters Ballasts Data Wiring: Si No. -Hydromassage BathtubsNo. of Devices or E uivalent No. of Motors Total HP Telecommunications Wiring: OTHER: No. of Devices or E uivalent ,m Estimated Value of Electrical Work: 0'v u 0 Attach additional detail if desired oras required by the Inspector of Wires. Work to Start: (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10, and upon completion. TNSURANCE COVERAGE; Unless waived by the owner, no permit for the performance of electrical work may issue the Licensee provides proof of liability insurance including "completed operation" coverage or its substantial e uivalent. T undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. y unless CHECK ONE: q he INSURANCE BOND [❑ OTHER d cert, under the pains and penalties o er'aa that the information on this application is trace and co FIRM NAME: fP ry, rrepleta Licensee: �+ e v (� � LIC. NO.: ez g (ZfaPPlicable, enter empt. in the lac nse number line.) Signature Address: ;2 LIC. NO.: g� *Per M.G.L. c.I47, s. 57-61, security work requires Dep R 14 Bus. Tel. l�To.; r-> c�c'— OVVNER'SINS ent ofP lic Safety ``S'� Licen Alt. Tel. No"'- � =3 s, - 7p INSURANCE WAIVER: I am aware that .the Licensee does not have the liabilityLIC. NO.: required by law. By my signature below, I hereby waive this requirement. I am the (check one insurance coverage normally Owner/Agent ) ❑ owner ❑ owner's agent. Telephone No. p RMIT FEE. $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR -]DOUG SMALL 1. ROUGH INSPECTION: Passed — Failed— [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: ature - no initials) Date if fz.', Inspectors' comments: 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) Inspectors' comments: 'Signature - no initials Date 5.1NSPECTION - OTHER: Passed — [ ] Failed — Inspectors' comments: ection (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE. FILLED OUT AND LEFT ON SITE IF THE .AREA, TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. 1 The Commonwealth of Massachusetts Depairtment oflnrlustrial.flccidents Office of Investigations 600 Washington Street Boston, MM 02111 1UT vww.Yzass gov1dia Workers' Compensation Insurance davit: Builders/Contractors)Elecilricians/. lumbers Applicant Information Please Print Legibly Naive (Business/Organization/.individual): Address: v2 i (fL 271�4 City/State/Zip: IJLIJg LJ &q AQ K f Phone #:__2 7�— 3_ j %O Z� Are you an employer? Check the appropriate box: Type of project (required): I. ❑ I am a employer with 4. 111 am a general contractor and 1[6. employees (full and/or part-time).* have hired the sub -contractors [( New construction 2. I am a sole proprietor or partner- listed on the attached sheet. s . ❑ Remodeling . ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g. ❑ Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.E1. I am a homeowner doing all work right of exemption per MGL 1111 Plumbing- repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12TIRoofrepairs insurance required.] T employees. [No workers' 13. ❑ Other comp. insurance required.] *Ana 1' h y pp ?cant t at checks box#1 must also flu l out me 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 subunit a new•affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and joh site information. Insurance Company Policy ## or Self -ins. Lic. #: Expiration Date: rob Site Address: City/State/Zip- Attach a copy of the workerscompensation 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 flue ofup to $250.00 a day agaiustthe violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenaxes of perjury that the information provided above is true and correct. Sig -nature- Date• ®fficial use only. Do not write in this area, to be completed by city or town official City or Town: Perm!tUcense 0 Issuing Authority (circle one): x. Board of]3ealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contactrerson: Phone