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HomeMy WebLinkAboutMiscellaneous - 9 BEECH STREET 4/30/2018N O O W W N O O O O O Date ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........ -\16 -S'f ai'. .................................... has permission for gas installatio�n .......... . ... '4r -I . . ........................ 70 - inthe buildings of .......... ............................................................ at ......../ . ......../<<, ,,............... I North Andover, Mass. FeeCJ-b:n ..... Lic. No. .. ..................................................................... GASINSPECTOR Check # --7-1 Iz_ V I- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY r�." c .--� MA DATE �� - 'S'- i �i PERMIT # - -z f JOBSITE ADDRESS 0WNER'S NAMETb, +I,� : ��� �t�•�- S GOWNER ADDRESS _ - _ _. JIT _ - FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: D RENOVATION: ® REPLACEMENT: ( PLANS SUBMITTED: YES NO ©1 APPLIANCES 7 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 _ .(� -_ r ! L-_ . I _ .. .__. .1 . _ __ i _ -h:- �-. DRYER FIREPLACE J ... - 1 L FRYOLATOR __. FURNACE - - L _( GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT_. OVEN -- C� �_ -_.. �_ _ -- L_ POOL HEATER ROOM /SPACE HEATER ROOFTOP UNIT _FJ' TEST -- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER -- ......... ......................-...... ....... ... ... ........ .... ........... INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IJ&NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY A OTHER TYPE INDEMNITY E] BOND �[] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 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 incoa/elha�,Pentprovillonofthe s Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ �, L w� � »%J _ LICENSE # - ( IGNATURE MP D MGF Ejl JP 5g JGFj LPG] 0 CORPORATION E]# PARTNERSHIP# LLC D# COMPANY NAME: .-.-- � u—j ADDRESS CITY � '-�%_ ( STATE� f� ZIP i� � ]TEL FAX --S-7t*A11 CELL _� i?_' EMAIL V I- `�s The Commonwealth of Massachusetts F Department ofIndustrial Accidents 1 Congress Street, Suite 100 Boston, MA. 02114-2017 9` www mass.gov/dia Wel kers' Compensation Insurance Affidavit- Builders/Cont:tactors/Electricians/PlWbers. TO BE FILED WITH TBE PERMITTING AUTHORITY. Applicant Information Please dnt Le ibiV Name (Business/OrgaAization/individual):_ ' `^�� 4J-- Address: 1777 City/State/Zip: ,v Are you an employer? Check the approprlate box: Phone #: tot I >-'5 77 1.Q I am a employer with employees (full and/or part time).* 2.[N 1 am a sole proprietor or partnership and have no employees working for me m any capacity. [No workers' comp. insurance required.] 3. Q lam a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c- 152, §1(4), and'we have no empldydes: [No workers' comp. insurance required.] Type of project (1•equired): 7. ❑ Ne'donstriiction 8. [] R.emodellhg 9. ❑ Demolition 10 ❑ Building addition l l.❑ Electricalpopqirs or additions 1Z,[}Piumbing repairs or additions 11E] R66f repairs 14.[] Other *Any applicant that checks box#] wrist also fill out the section below showing their workers' compensation policy information. Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached' n additional sheet showing the name of the sub -contractors and state whether or not (hose, entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #:, Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers, compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a firie up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA. for insurance coverage verification. s and c v Hereby certi under tli ainenalties ofperjury that the information provided above is true and correct. pp Tlata• 6 l '� ti ^ 1 r Phone #: ; - official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: N 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' defried as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver'or, trustee cif 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 b6 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 intp any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for the permit or license is being requested, not the Department of IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a •workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write •"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia , ^^ / / ' / / / IMONWEALTH OF MA R'L.Af STOW.. 03865-254:3 / / ' / / / / ' / / / IMONWEALTH OF MA R'L.Af STOW.. 03865-254:3 A 11360 Date.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .................................................. This certifies that.fi-4itw ..... has permission to perform ...........10.......% !:;kj ................................................... plumbing in the buildinsf ............. Zj., .. ....................................... lei at &C-CAl ..... .. .......................... ....... ..... . 4orth Andover, Mass. Fee.4 .... 6V. Lic. NoSd.,�.346... ................... PL Check # Vo POWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ✓ ( MA DATE jl]` PERMIT JOBSITE ADDRESS OWNER'S NAME ::=-j ADDRESS 1 _ @f' TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL NEW: Mf RENOVATION: Er REPLACEMENT: Q PLANS SUBMITTED: YES © NO FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES dNO M CROSS CONNECTION DEVICE LIABILITY INSURANCE POLICYOTHER TYPE OF INDEMNITY i BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the DEDICATED SPECIAL WASTE SYSTEM CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM and that all plumbing work and installations performed under the permit issued for this application will be in con2pliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. DEDICATED GRAY WATER SYSTEM MP D1 JP CORPORATION Fj]#PARTNERSHIP 0# _ _ ; LLC COMPANY NAME �, _ S_ -� ; ADDRESS ___._ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN l ._-__--_{ _---__i -____► _W ._{ _ ; ---__..__I __._..___I .____. .._....__1 .___..-1 ___ .__t __....__I _f _..___! FOOD DISPOSER FLOOR IAREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK _I 1 _._ (J ---___i i j .__..__[ I t .__.._.6 .. j =1 i LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET -- -.. ( � _ _f L.–DE—J, �1 I .__._.._ URINAL WASHING MACHINE CONNECTION 'F� <IWF�-FMFMrM-FMQl-�FMFMFMFMIM- WATER HEATER ALL TYPES WATER PIPING ( i __-..� I _ t _... I ..__j _ _ j OTHER IL INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES dNO M IF YOU CHECKED YES, PLEASE INDICAT7TPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE OF INDEMNITY i BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 con2pliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ,. a u LICENSE # _ Z �b I SIGNATURE MP D1 JP CORPORATION Fj]#PARTNERSHIP 0# _ _ ; LLC COMPANY NAME �, _ S_ -� ; ADDRESS CITY �1�- i _. __..._. t STATE ZIP ( TEL FAX g CELLEMAIL - - -' -' - - -- __.-t- �.._�...._i o El z iui w LL 7 aRM SJ' V` Korkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers. TO BE FILED WITH THE PERMITTJNG AUTAORITY. Name (Business/Organizationgndividual): Address: Phone #: City/State/Zip: }� . �.. ,... , Are you an employer? Check the appropriate box: Type of project (fequired): l.[] I am a employer with ( em to frill and/or part-time).* 7. ❑ N&W'donstt'udtlon � � P y ees 2.�am a sole proprietor or partnership and have no employees working for me in 8, v Remo deli]lg any capacity. [No workers' comp. insurance required.] 9, ❑ Demolition 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 [1 Building addition 4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑ Electrical repairs or additions ensure that all contractors either have workers' compensation insurance or are sole bin airs Or additions proprietors with no ei3wb.yees. 12� [f Plum. g repairs 5.❑I am a general contractor and l have hired the sub -contractors listed on the attached sheet. 13., ] RbOf repairs These sub -contractors have employees and have workers' comp. insurance.t 14. Q Other 6.Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 91(4) and've have no employees. [No workers' comp. insurance required] *Any applicant that check's box 41 must also fill out the section below showing their workers' compensation policy information: Homeowners who submit•tlus affidavit indicating they aze doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities, have employees. If the sub contractors have employees, they must provide their workers' comp. policy number. workers' compensation insurance for my employees. Below is the policy and job site X am an employer that is providing information. Insurance Company Policy # or Self -ins. Lic. #:, Expiration Date,. City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratio�a date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil p be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement may coverage verification. XdO hereby CBYLL er tliepazns a enalties_ofperjury tit at the information provided above is true and correct. N Official use only. Do not write in this area, to be completed by city or town offzciaL City or Town: PermitJLicense # 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 #: The Commonwealth of Massachusetts Department oflndustr"ialAccidents F 1 Congress Street, Suite 100 Boston, MA. 02114-2017 w www mass.gov/dia 7 aRM SJ' V` Korkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers. TO BE FILED WITH THE PERMITTJNG AUTAORITY. Name (Business/Organizationgndividual): Address: Phone #: City/State/Zip: }� . �.. ,... , Are you an employer? Check the appropriate box: Type of project (fequired): l.[] I am a employer with ( em to frill and/or part-time).* 7. ❑ N&W'donstt'udtlon � � P y ees 2.�am a sole proprietor or partnership and have no employees working for me in 8, v Remo deli]lg any capacity. [No workers' comp. insurance required.] 9, ❑ Demolition 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 [1 Building addition 4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑ Electrical repairs or additions ensure that all contractors either have workers' compensation insurance or are sole bin airs Or additions proprietors with no ei3wb.yees. 12� [f Plum. g repairs 5.❑I am a general contractor and l have hired the sub -contractors listed on the attached sheet. 13., ] RbOf repairs These sub -contractors have employees and have workers' comp. insurance.t 14. Q Other 6.Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 91(4) and've have no employees. [No workers' comp. insurance required] *Any applicant that check's box 41 must also fill out the section below showing their workers' compensation policy information: Homeowners who submit•tlus affidavit indicating they aze doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities, have employees. If the sub contractors have employees, they must provide their workers' comp. policy number. workers' compensation insurance for my employees. Below is the policy and job site X am an employer that is providing information. Insurance Company Policy # or Self -ins. Lic. #:, Expiration Date,. City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratio�a date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil p be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement may coverage verification. XdO hereby CBYLL er tliepazns a enalties_ofperjury tit at the information provided above is true and correct. N Official use only. Do not write in this area, to be completed by city or town offzciaL City or Town: PermitJLicense # 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 hli l express or implied, oral or written." An employer is' deffned as "an individual', partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver'or trustee ofan 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 xequired." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of IndustrialAccidents. 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial. Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SS.AFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia .4 �-d ZWZ9LZ9L6 !JIOPue-1 welll!M Location if No. 7� a " �� Date Z �� NORTq TOWN OF NORTH ANDOVER F w • �e Certificate of Occupancy $ wu5 t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # d O 24 i 52 Building Inspector A TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit M76577-11 Date Received Date Issued: �_/2- IMPORTANT: Applicant must complete all items on this page LOCATION &eec� Y9L e - AJ, /9nd avP / / Print r C E/f T� e l�, s - Print MAP NO: 3.o PARCEL: 0o 41ZONINCY DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial 19 -Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other We ±Floodplain®tWetlands;. 1Wafershe D strict; T DESCI '13TION E WORD TO BE PERFORMED: eJ4q fcUrip a„a( -Aew U. f.,#e (Identification Please Type or Print Clearly) OWNER: Name: Mo, Tg e k s Phone• 781 L q 8 11 4 Address: &e-ee-4 4.ve CONTRACTOR Name: oa n i c f G 1, vQ ; ✓ G Phone: `t 78-6 d y -,S-6 33 Address: P, 0 Sox 15- t14c, Supervisor's Construction License: Exp. Date: 2 Z -)Z. Home Improvement License: 2 3,T S Z Exp. Date: A- l r- 13 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cosi: $ X2,00 o FEE: $ Check No.: 5 90, � Receipt No.: ;/l NOTE: Persons contract' g wit�unre�gister ntractors do not have access�o the guaranty fiund 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 (VOTE: 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/Crossection/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 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 ❑ 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.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Pians ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales 'El Food Packaging/Sales 11Private (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 Sianature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Comm -N Conservation Decision: Comments Water & Sewer Connection/Sianature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. fit.: 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 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008mi tA w c c O as c L U v o Z w . y C � o ca 0.— D 'O w. O 'O 'E m m :.c h o -n °o w �, � v) a Or. o co o w o C2 .� U G w CD o rs: a w w W °° o w a cn � V. c °° o w � w a- w cuG 00 z 8o cn v Q cn tA w U) a I O c c as c L O v o Z 0. O � y C � w+ W V/ ca 0.— D 'O ots O 'O 'E m m :.c h o c CD 0 cc o a �o v c CD ccc v CLC c Z c O R cj V� O C C ;= O CL H r � Cc to L _ : CD C _ •+ \ A: *C; c .ca EE :.o - o 00 u as m c E N m m m a. N cm •+ Cc = C N C t O O U mocm O OI c c a :o m o ccc o c o c H : y O C C = o :'tc3 N 0N CL O O a� COD Co �__ 'd! D !O 'C= O ac C43 e 4.a'C Z E `m 0 � N c o La ®®e COD O. 'D .5 0;5 _ 0 .0 cm= O CL 0- m U) a I O O O L O v o Z 0. O � y C � w+ W V/ ca 0.— D 'O M O 'O 'E m m CD 0 cc o a c CD ccc v c Z c cj V� O C C cc CL H r � The Commonwealth of Massachusetts r w Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govklia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` Please Print Legibly_ Name (Business/Organization/Tndividual): Address:. C 1,)( ! • -(o City/State/Zip: N eaoQl y /Yj, O( 8-( Y Phone #: 4 7g- 6 d y S-( 33 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. # 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.] 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. [g-f,00f 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 acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. j Insurance Company Name: U4 14 c�� "�� —1 CY/ Policy # or Self -ins. Lic. #:-() d - 7 6 0 0 4 0 3 K- 10 Expiration Date: 7-2-3-// Job Site Address: C( 6,t e c4 Ave City/State/Zip: AA 1' `X -(OP / 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 fonn 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 maybe forwarded to the Office of Investigations of the DIA for insurance' coverage verification. I do hereby certify underAhe pains and penalties ofpefjury that the information provided above is true and correct.' Phone#• 17 -- 6&L/S-633 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 joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or -on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) naine(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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 confinnation 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 ifyou 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 pen-nit/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 pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-M.ASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER HUB INTERNATIONALNE 600 LONGWATER DR NORWELL, MA 02061 278WS INSURED OLIVEIRA DANIEL JR DBA OLIVEIRA CONSTRUCTION CONTACT EACH OCCURRENCE $ NAME: AGGREGATE $ PHONE FAX (A/C, No, Ext): FAX WORKER'S COMPENSATION AND (A/C, No): E-MAIL ADDRESS: PRODUCER CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE INSURER A: HARTFORD GROUP INSURER B: INSURER C: INSURER D: P 0 BOX 156 INSURER E: NORTH READING, MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 TYPE O.FINSURANCE LTR GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULE AUTOS HIRED AUTOS NON -OWNED AUTOS ADDLSUBR POLICY EFF DATE POLICY EXP DATE POLICY NUMBER (MM\DD\YYYY) (MM\DD\YYYY) LIMITS INSR WVD EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL&& ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGO $ COMBINED SINGLE $ LIMIT (Ea accident) BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKER'S COMPENSATION AND W C STATUTORY LIMITS OTHER EMPLOYER'S LIABILITY YIN UB-760OA034-10 07/23/2010 07/23/2011 E. L. EACH ACCIDENT $ ANY PROPERITORIPARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) II de 'b E.L. DISEASE - POLICY LIMIT $ yes. scri a under DESCRIPTION OF OPERATIONS below )ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFTECTING WORKERS COMP COVERAGE. ;ERTIFICATE HOLDER EVIDENCE OF INSURANCE N READING, MA 01864 %CORD 25 (2009/09) 08/03/2010 NAIC # 500,000 500,000 500,000 CANCELLATION 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 Ramani Ayer 1988-2009 ACORD CORPORATION. All rights reserved. Client#: 16107 OLIVEIRACO ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIOD 10/18/2010) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB Int'I New England (WILSB) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 299 Ballardvale St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington, MA 01887 INSURED Oliveira Construction Daniel Oliveira, Jr. P.O. Box 156 North Reading, MA 01864 CnVFRAnFR INSURERS AFFORDING COVERAGE NAIC # INSURER A: Travelers Property Casualty Co 25674 INSURER B: INSURER C: INSURER D: INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DA ECMMFDDCT/YYYY EXPIRATION ATEYMM DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY I6801917N278 N- IS- 1I Iu 1 s I EACH OCCURRENCE S1,000,000 DAMAGE MISE TO RES (EaENTED $300UOO CLAIMS MADE N OCCUR MED EXP (Any one person) s5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 POLICY PROT LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY $ (Per person) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-1 6LAIMSMADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU• IF... LIABILITY "� E.L. EACH ACCIDENT $ ANY CCPROPRIETOEER/PARTNER/EXECUTIVE OFanldatory ", NH) EXCLUDED? n E.L. DISEASE - EA EMPLOYEE $ If es, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS FyY"r:.[6146]A 7 CANCELLATION 1U Ua S for Nonwa mens SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHOR�RESENTATIV� ACORD 25 (2009101) 1 of 2 #S445855/M369684 © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WR001 Massachusetts - Department of Public SafetN.. Board of Building Relaulations and Standards Construction Supervisor License License: CS 68413 Restricted to: 00 DANIEL OLIVEIRA JR ! 10 MILL ST N READING, MA 01864 Expiration: 6/27/2012 Commissioner Tr#: 27770. ✓lze 6" a). /�iaaoacii.�aeaa Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Type: Registration: •,,x'123852 Expiration_.: ;411512013 DBA a Oliveira Constructions -; �� i 'Daniel Oliveira, Jr`, 10 Mill street , r•;` /;1 ga f N. Reading, MA 01864 + _a` "' Undersecretary � I .4 o�n�yy /14d � j c ti e C' �c 9f��els _oltJIVE Roofing a cutters j AR dr COLLECTI B CONSTRUCTION CertainTeedM P. O. Box 156 North Reading, MA 01864 (978) 664-5633 Fully Insured Lic. #068413 Reg. #123852 PROPOSAL SUBMITTED TO ( r j 7- e lT t PHONE91r2 .. "S DATE STREET f r P� V r JOB NAME !�STAT, ZIP JOB LOCATION MYN, cl a ve f i G We hereby submit specifications and estimates for / � a ,, /r" �( r c t i. t � u : � (a ,, � , ,. !�/ r" r ! � c�Pr• S' � � �� � /? � ' �r �� , . •. � / f i r t T (,,. T jf 'J (` r '� � f � .( r i r ("1 C T f t . /^ r i ( ) f �!J rt ... . ' Cr' .,. .r l (� - ) r r pr, itl 30 ins -loll �tw sea•w�cjr c1��'�a�.� 9('Ntr' a��( cQo,,.�s�v„%r j�o � 6UfIP� CbeG k v u me,, Price Includes removal of all job related debris. ' 7 ba1/7 V P I s I AS4� 'Please note: All items in attic should be covered during roof tear -off. We Propose hereby to furnish material and labor -- complete in accordance with above specifications, for the sum of: dollars ($ IZ7 0 r C`, P rl Payment to be made as follows:OWN* Note: This proposal may be withdrawn by us if not accepted within days. r e Acceptance of Proposal: The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to J� do work as specified. Payment will be made as outlined above. jJ��,., / Signature �"L2f.i Signature Note: Unpaid bills over 30 days subject to 1-1/2% finance charge per month (18% annual). Date. F— S'—.....eq,5 . .......... NORTH TOW OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............ .................. has permission for gas installation ......... in the buildings of I . .......................... i atI .............. North Andover, Mass. Re-3?.�� . Lic. No4!� ..... Check # 11�s 151 5228 t.... Ir 11 ASSACHUSETTS UNIFORM APPUCATioNz--FOR PERMIT -TO DO GASFiTTING (Print or Type) NORTH AIJDOVC`iZ. Mass. Date 9 . i ao Permit # Building Location _ Q BELCH L/ _- Owner's Name DEBJ2f1 � A KI)OVER HA Ol R 4�S Type of Occupancy_ F—ESI Q E K)T I A L- New ❑ Renovation ❑ Replacement Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone 9 T 8 - 6.8,7 =110 5 %X #306 _ 6,2EM0A Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: XJ Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. .I IYes K No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 18( 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 ❑ hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accurate to.the best of my knowledge and that all plumbing work and installations performed under the permit iss i r this application wil n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s.. By TvDe of Ucense: Plumber Signature o cen lum er or Gas am True . Gasfitter Master License Number Z74-5 City/Town . Journeyman APPitOVEU (OFFICE U NONNI moson son Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone 9 T 8 - 6.8,7 =110 5 %X #306 _ 6,2EM0A Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: XJ Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. .I IYes K No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 18( 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 ❑ hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accurate to.the best of my knowledge and that all plumbing work and installations performed under the permit iss i r this application wil n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s.. By TvDe of Ucense: Plumber Signature o cen lum er or Gas am True . Gasfitter Master License Number Z74-5 City/Town . Journeyman APPitOVEU (OFFICE U Zi0 ''. .., . . . I a Z I -- t7 CL IL 0 9L LL C; a ui 0 , Z CL cc cc 0 0 U. U. .%: z 0 w w 6.1 LL I J a: 0 w z fA CL J a: 0 w z fA Location 12-P P c h �� No. 7 Date ,All f I`2 1093 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ d� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ �r Building Inspector Div. Public Works O O n 4 z Z m > r r 4 Q t A n A A 1 n O n m 7 N - 01 n o" c 1 0 z '1 r p • A i > > m � 2 Y A n A A 1 n O n m 7 N - 01 n o" c 1 0 z 1 ! Ir' r mO _w 0 O A C C 0 c o g 0 ! MO Im=I 2 n A r i i Q 0 m 0 z 0 z I A w • I O - - Z i Z /A 0 iZ > C N I 0 Z r o m z z z A I A z� > I O I o A> n Z -i 70 O c 0 iIn A � c A m z i -1 A 2 1 C f) Ij 0 2 N p • A i A i A i � 2 Y o n m> r= r R O a O n r X 3 o n o" c 0 0 z i > i > 0 O O A x" a 0 c o g S n o n A 2 n A m t s q• Q 0 'I v r 2 O 2 O 3 r 0 A m O i Z /A O> iZ A 0 Z m f H m H> of o o m> r= 0 z o z r N 3 m � c c c> i > i > 1 > O A A n z PI 0 c o _o o_ n o n A n A n A m m n s q• m 'I v r 2 O 2 O Z O r 0 A m O i Z /A O> iZ A Z 0 r o m z z z A i z� > A> n Z -i 70 O 0 iIn A A m -1 A > 0 i Z A i A C C Z Z • N' +� 30. 0 m r 0 O C C r C C < NA A n z m > �, > n A I I A Q I it in m w!• S o• 1 w s z G T p 7Co z1 i z z i1 O 0 n r Z w r 0 1-4 0 0 0 1 n O z z z x 0 Z= w w a'mc O Z A z A z A w o r z z > A o 0 m r 0 0 i nl --1 O < .. 0 o A m m m m• A Q p '� 0 O O 0 2 m I • 0 0 0 IT m z-4 i r .1 A sz z r 9 > r m f i > ZO N > • A A r r x -1 z 0 > -i AIn= N x o a I W 0 A 3. + < O l7 11t r JL Ul c O00 WW ux< z° z K O O Of O N ��Ot alr x "{ w W . •� �� <; N t� Oma 'z t7 JOh v._Z 0 WZ OJa \ :t D Z 'm W O h Om(u N f O cc IL WS • J IL OO I (fl W Ii FQF_O_m umI s �N:E 2 <zr V W Z V a WIO 3cvWOLO, 'I N< ^ ulUf Y Z a i mWw W .y �O Z<m ` emu VW�j WZ W 1 I N i0< z .r < 11t c O00 z° z K O O Of +p t N ��Ot z cb �Q -0 •� �� N N Y Z z W W _ WZ \ :t r V N W O h z N f O cc < • L OO O W O Ii t2' s �N:E 2 C O V W Z V a a' N< ^ Y Z a i I I V O ZT O _ u z .r 5 < 11t c O00 z° z K O O Of +p t N ��Ot z Y. �Q -0 •� �� N N Y Z W= 3xp�4 W _ WZ Oe W X " C p V e: N f W S =i Z- O N u O W O = ee�W W r a s �N:E W C O V W Z V a < N< ^ Y Z a i 5 < 11t O00 mm�' 3 p W W Q Z O O Of +p t W W ��Ot �Q rr� OCOSN _`000 0ZZ 00 IN SI 5 WILLL4M J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY D�,VELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 O 76 F M gmt Z Al C s s I ? O d = Ma aya: m m0 Q�Q ti C Ei aC G—• � W CO) C7 CD � m y St Z O H �■ ro C36 C CZ =;* C y m a m 0 o v CD CD O C Q .� - . CD i CD Ow CD CO C CD y� a. v —• O co) co CD o C o CL 1 o ' CO) C2 O ° CD CD Z O CD CD EL m .0 SE o CD O 76 F M gmt Z Al C s s I ? O d = Ma aya: m m0 Q�Q ti C Ei aC 10 r � �"2 Od�m N y T o aid � m y n• \ ro -i000 o IEm� m a m ZS.n H!�� - . i �► O 0 0.C C -r..«; o o C o CL 1 o ' ° d C CL CD EL m .0 SE o H H ^ O o m 1 01 � ^ :� 6 M CD _: . O 00 Vb :G 0= 0 H CD oma xv CA _ ! (A ° A " IB OS 0 -x �'. Q�Q ro Ei f�D 10 r � 1 �' �• Q. M n• \ ro tri ° ° v N° 2 i u J Date...,l...�� ............. t E NORTH O au H P ,SSAC14US� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.�c.......�.7-..4.:e0k 4 C. ...........{.- ............................. has permission to perform ... `P, .1.4^,...1 ............................. wiring in the building of ......�.. �al.!?..2.................................................. at .... ..C. { ...... zt :� k. .'+ U ...'"........................ . North Andover, Mass. a �q Fee . .`. v�.... Lic. No / �� 7v ............................................................. ELECTRICAL INSPECTOR N6 r -c e-, WHITE: Applicant CANARY: Building Dept. PINK: Treasurer (4"1\ office Use only �„ L(?2 u�1P LIIiYIiIiIIIIlUEII I of 905#1mitt Permit Na. 3 3e�i rtmrin of 11uhUt �fzt9 ccupancy & Fee Checked /50 �+ (leave blank) BOARD OF "FIRE PREVENTION REGULATIONS 527 C'JR 12:00 APPLICATION FOR PERMIT TO PERFOR -ELECTRICAL WORK All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CMR 2:0 (PLEASE PRINT IN INK ICR_, INFORMATION) Date (XX or Town of To the Inspector of wires: The udersigned applies for a permit to perform the e�ectripi work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in ccnjurction with a building permit Furecse of Suiidirc Existing Service Amps New Service Amos Numcer of Feecers arc Arr.cac:ty Yes _ Na (Check Aporaerate Sax) Utility Authorization No. VCits Over^eae _ Unccrna No. of Meters Vcits Overheac _ Uncgrna I— No. of Meters _ccattcr, arc Nature cf ?rcccsec Eiec:r:cai '-'Icrx S� _ Totai Na. at _:g^ting Cutlets i No..-., .. .,:=s No. cf'ranstormers K„A i Aoove.— tis- No. of Lignt:ng = xtures Swimming Pco' grna. — crnc. No. a=ecectar-:e Cutlets No. of Cit Eumers No. at Switcn Cutlets No. or Cas =_risers Total No. of Ranges No. cf Air _ r.c. tons -I year Total Totai No. of Oiscosais No.ot PL-cs Tons "'•J No. it Disnwasners - i ScacerArea Heating K%V p Ne. of Driers Heat:. -.c Cevices c•v No.. of NG. vt No. of '.Vater Heaters KN Sons 3adasis ` Nn_ 'jvcrn Massace Tu c s � I No. at !.Maters Totai HP CTtiE Generators KVA No. of Emergency Lighting Battery Units FIRE ALARMS No. of 7 -ones No. of C etec::on anc initiating Cavices No. of Scuncing Devices No. of Sed Contained OetecnanrSouneing Devices I Municicai Other Local Connec.:on Lcw Voltage winnc INSURANCE COVE=AGE: Pursuant :o the recuirements zt MassaCn"aV's ;ererat Laws _ _ I have a current Liaetiity Insurance Pcticy inc:acing C:,rnc:eree Ocerattens C:;verage or is suastanual ecuivatent. YES _ NO nave suzmatea vallC Arcot at same to :he Office. YEB _ NO _ if 'iau nave c.^.ecxea `.'ES. please ineicate :rie tyce at -^verage Cy cnecKtng :ne aocr riate oox. INSURANCE )BONO = OTHER = tP'ease SceF y) (Excitation Oatei Esarnatec Value of E!ectncai Worx 5 werx :a Start Inscec::on Oate Racuestec: Roug• Signee .;neer :rie Penalties of perjury-. s NAME /f � /C C _ uC. NO. F.RM f X Lt NO. S �l 7 5 Licensee; ���Ti� Signature 7� Bus. Tat. No. Actress �� (,�L/C/C�ilf/� Alt. 741. No. OWNER'S INSURANCE',VAIVER: I am aware that the ! :censee aces not nave me assurance coverage or its suostantiat eaurvate� es te- auveo ov Massacnusetts General Laws. and trial my signature an =s cerrnir aeolicatwon waives triis reeuirement. Owner 9 (Please cnecx anew eieenene No. PERMIT FS: iSicrature or C•Nner ar Agenn