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HomeMy WebLinkAboutMiscellaneous - 922 DALE STREET 4/30/2018 (3)Phone. 978-632-2660 JAMES A. TRUDEAU Fax. 978-632-2662 Adjustment Service Inc. - P. O. Box 7 Gardner, MA 01440 claims()trudeauadi &M Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B September 1.0, 2014 Building Inspector 120 Main Street North Andover, MA 01845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Joseph McCarthy Loss Location: 922 Dale Street, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100597993 Date of Loss: September 8, 2014 File Number: 14-12291 Claim Number: 14119650 Type of Loss: Property Damage Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause "Mass. Gen. Laws, Chapter 143, Section 6" to be applicable. If any notice under "Mass. Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Joshua M. Trudeau Claims Adjuster Location? .i �^-�-� Z No. `l '15-7 Date 1�- TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 07/25/95 13:28 M96 25°00 PAB%uilding Inspector Div. Public Works 14 w a W a Y rc 0 0 m W l�� z O N W N U) is J I� J im W z 0 K Z W m 0 < F J f W m0 m 0 0 0 0 0 I-- 0 4 W d O W WO Ix m W N N n z m m l ItJ Z Q a Cl - o z > O j C-6 F W F mF W o J W < Z 0 0 Z 0 < Z m O < IA m j W r a i W N <W 0 W 0 F u 7 i l"m t 0 N m W z Y u I r m Z K 0 O r O z l7 > Z U. 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O y C C co pm I p C e O C �E m m CD 0 co co O Oca i C O Cc vCID J •fl .yCD Z V O y V C cc C to H bgBiO VN N3(1 IR � 1S 83NNn 80lV8iSirmwrn> AbM011tl9 '3 AH10NI1 9NI13db1NO3 AdM011b9 f f 86/IZ/90 uorleatdx3 1b110IAIONI - adAl o 666911 uoTlealst6ad (. d013bd1NO3 1N3N3AOddNI 3NOH j 66810 HN `N30N13N T^ _ V 1S Buns OZ r AOA011a9 3 AH10NI1 00 :01 Pa}ar�asad BSbi/EZ/II 1661/EZ/II 6S6(p0 S3 .:a1ePq#1i8 :Saltdx3 :IaginN 3SN33I1 dOSIAd3dOS NOI130d1SN03 AIMS 3I180d 10 1N3NIM30 11 "Y' I i M 4282 P Date................................. t TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that�......... — .......................................:............................................ has permission to perform ... ................. ......�1................................................. wiring in the building of ..?....:....... A......,� at . Z........................................................................... , North Andover, Mass. ,> is 7 Fee .................. Lic. No....... i.7..L P -..........................................� ..... . ELECTRICAL INSPECTOR Check # �� THECOMMONWFALTHOFMASS4MUSETTS Office Use only DEPAR A1EW0FPUBL[CSAFETY Permit No. 2/ D c1 RD BOAOFFIREPREV"HONREGUTAHONS527CM 12:bn -- o Occupancy & Fees Checked APPLICAHONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 q (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date nl '— 3 Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street � Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes m No (Check Appropriate Box) Purpose of Building Utility Authorization No. _ Existing Service — _ -� Amps /Zi/ ?— Q/ 0 is Overhead UndergroundED No. of Meters New Service Amps / Volts Overhead Underground r-1 No. of Meters A 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 M Below Generators KVA ground ground 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 OtherEl -! 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 N OTHER• r Inauawecomng.- Pt16tla 1Ddrietp kmff%ofMassadK&fls Ibaw awnuntLiabhtyhnivaz=Fbbcynxix mgCompkt� OPFO IhawabffiWdvaiidproofof tothe0ffiM YES a bstarm ivabt YES " NO M If)mhavedme edYES,pleas udcwthctypeofcovesby NSURANCE BOND r-1- - OR TUR 0- ( ;) l _ _C b 1J TVOL D 0 MoiktoSW J � � nVXdMML)Me litspectim NeReWested 1 ?— 02! ah eofF7earFir" tk $ >igrtedundert& ofpajtuy // 7RMNAW O t^ 1. No. 2,17 7 icensee �© IJP.i� l��[ill/1 `l Si, -Uxt-l� a"zF=,No 2 77 7�- �nnBusmessTel NO �' 7 Y ) 7 — J//Z �rlrt�Pcr 7 7�yl ( _ Jq / ��'I�l V " ° l �, ©�_ � I __ AIC Tel. No. )M/P,'SINSURANCEWAIVER;Iamawaredial thclio=doesnothavetheinsurar=oovaageoritssubs talgivakTtasregmcdbyMassacht]settsGmcralLam ndtbatmysignatureonthispeuritapphcationwaives this requmnu t. Please check one) Owner Agent Telephone No. PERMIT FEE $ Signature ot Uwner or Agent Name Name: Location: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Affidavit Please Print City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance. Co. Policv # Company name: Address CiM. Phone #.- Insurance : Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of crgriinal penalties of.a fine up to $1,500.00 and/or one years' imprisonment_as_vre_as_civil.penattiesin-their m-daSTOP.MPX_ORD.ER.aW_a.fine-cf.(51120.DD)-ashy againsi.me. 1 understated that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verftation. l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town offiaar City or Town Permit/lxensinq D Building Dept ❑Check if immediate response is required .0 Licensing Board 0 Selectman's Office Contact person: Phone A Q Health Department 0 Other �. 495 Date .. -1-3 .... ::.�....... f NOR7M 1 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 'LOW SS�{CHUSE'� ` This certifies that' / has permission to perform....:.................................................... wiring in the building of../,-,... .........� -�' ............................................................. at ..... �f . i_. —� .......................... . North Andover, Mass. .......... ............. ..j:.......... Lic. No .............. ................................................................ % L'" -- Fee..-6 ELECTRICAL INSPECTOR Check # I Commontvaallfi of Majeacltuaalls 2eparlmenl o`,}ire servicad BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. q Z f`S — Occupancy and Fee Checked"' [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All wurk to be performed in accordance with the Massachusetts Electrical Code (N,IEC), 527 CNIR 12 00 WORK. (PLE,ISE PRINT IN INK OR TYPE ALL INFORM f710N) Date: City or'TOrvn of: Al0AV4 4w aovm To the Inspector of i+Yires: [3y this application the undersigned gives notice of his or her intention to perform the electrical work described below Location (Street & Nutnbcr) 9� Ijyq LE— S 7` Owner or Tenat,tt A • M Telephone No, Owner's Address _ I� 0 13 a y Pt-* l,v u 1 L ( F let xF 0;-76 .z Is this permit in conjunction with n buildinb perntil' Yes ❑ No ❑ (Check AppropriateBox) of Building Utility Authorization No. I� 3 k -7 3 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters New Service Amps / Volts Overhead ❑ Undgrd F-1No. of Nleters Number of Feeders and Anipacity Location and Nature of Proposed Electrical Work: /e -O /1 0.4- i"e- -1 t > S FxrJ Fo n ry D 77t r L &-X_ comnletioll of the fllln villa 1,A], No. of Recessed Fixtures -. _ _....� No. of Ccil.-Bush. (Paddle) Fans ---.1 -1 ...., .cu vv urc n� cctyryl n IrC3. °' ° Total Cransformers KVA No. of Lihhting Outlets No. of ilut Tubs Generators KN'A No. of Lighting Fixtures Swimming Pool Above ❑ Ill- ❑ rnd. grad. t o. o tnergency tg tang Units No. of Receptacle Outlets No. of Oil Burners -Battery FIRE ALARI•IS No. oC Zoites No, of Switches No. of Gas Burners No. o etection and Initiating Dcviccs No. of Ranges Total No. of Air Cond. Tons No—of Alerting Devices No. of Waste Disposers Heat Pump,•,•••,,,.,, Totals: Eons,_,•••-� •,,, e - o. of ontained Detection/Alertino Devices No. of Dishwashers Space/Area Heating KW Local ❑ Co me Uon ❑ Other No. of Dryers Heating Appliances IM Security ystems: No. of Devices or Equivalent No. of N KW hleaters Hen o. o t o• o! Signs Ballasts Data WRriug: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP1'e ecommunica(ions W'11111g: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the /nspector of Wires. INSUR.A.i`ICE COVEILIGE: Unless Nvaived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "conipleted operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy) (Expiration Dole) Work to Start: Inspections to be requested ur accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjnr7•, that the informatio on this applicati trite acrd complete. V1RL)I NAfNIL: • ty ry ri F E'Z (7--e TYt t c / LIC. NO.: t_iecnscc: l�T l+G,,v y A"- i r t (= Siare i LIC. NO.: ,9 /';-1 7 S (If opplic•able, enter "art alpt " in the license number line.) flus. Tel. No.: 7S' - 7y- " 72 Address: VO0 7. 1,,u v. i' r? ,t. lir ( M7q t ; S� Alt. Tel. No,: ONVNER'S INSURANCE NVAIVER: f am aware that the Licensee does n t have the liability insurance coveravc normally required by law. t3\• :ny signature below, I hereby waive this requirenient. I am the (check one) ❑owner ❑ o�•ner's a,rnt. Owner/A�cnt Si"miture Telephone No. Pi:Ri1fIT FL•F:•: S Location No. 3 S Date 12- 7 v Z NORTH TOWN OF NORTH ANDOVER r ' OL Certificate of Occupancy $ �' b'•"°•'<� CHust Building/Frame Permit Fee $ %U� a Foundation Permit Fee $ e Other Permit Fee $ TOTAL $ Check # rA S W 16082 Building Inspector 9 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . S" S Z" 3 �.,k y..C,"". '%3•+'uL }.�.,. iVi til{IaT.,Vlli ..., '� ,i'. fin..: z 77777 BUILDING PERMIT NUMBER:,-- DATE ISSUED:�— SIGNATURE: Building Commissioner/12EMtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: % ;)- d -)/e S 1.2 Assessors Map and Parcel Number: A9 'ell Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'red Provided Required Provided 1.7 Water Supply M.G.L.C.4o. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record .( "/ Name (Print) Address for Service Sign t re Aelephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone v m lv (`J C� Q N O Z M 90 O mn ic r 0 M r r Z Y♦ SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check auapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit ap2licant OFFICIAL USE ONLY . .. 1. Building_ D G G a (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X (b) J/_4 l e2 0---- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SE TION 7b OWNER/AUTHORIZED AGENT DECLARATION A wner/ uthorized Agent of subject y Tecarethat the statements and information on the foregoing application are true and accurate, to the best of my knowledge 4er and belief Print Name Signature of Owner/Agent Date OWN NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS 1ST 2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DUAENSIONS OF GIRDERS 1ILIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUU DING CONNECTED TO NATURAL GAS LINE f " Tel: 978-688-9545 Please print. DATE /,2.. X0 2 JOB LOCATION Number Town of North Andover Building Department 27 Charles Street North Andover MA 01845 HOMEOWNER LICENSE EXEMPTION Street Section of Town "HOMEOWNER f _--) P Number Home Phone Work Phone PRESENT MAILING ADDRESS J- a--i»ef City Town State The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) Zip Code DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATUR APPROVAL OF BUILDING Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. Cl) M m cnm cn 0 m L� CO) .p � z CD O ar 0 0 n� -v o p CL cr CCD O COO) 'v CD 0 v d d O y c 0 c CA d CD O CD CSD y� CD CA 0 CD a 0 CD C c = O � S r0r �•CA Q N n aC C m CO) =m 0 ® n to CA T Z y O .* c R =r= N m H T CL .-r d O CD -4CD O H p CO) N o CD 2 > >CD o n nq O G H. CC9 . o0 0 CA r � Z a //��� c O = VJ m H ; ;S Cn m n lJ m ' y D. r z o0�=�a j//�`• to (/1J m CD -ft � o o CDR� cB cn �y oq tz _ d CD r CLW _ O = c, d C " b y o = O gym: m �q O PT, ~ R� Z ' CD y w 91 r rn z H � w n G 00 � O w G x rr c, � O phi w 0 � r c O O F 0 a " 0 r� o x 9 M NO Ll 4 s 0 H 0 9 0 c 4,1,1 Mw TOWN OF NORTH ANDOVER �} APPLICATION FOR PLAN EXAMINATION Permit NO: 0 '- Date Received Date Issued: 1 27 IMPORTANT: A licant must com Tete all items on this base LOCATION at - 1 S7 -. Print PROPERTY OWNER W 4 k U G-1M,1� Unit # Print MAP NO:_PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT ❑ New Building ❑A teratin teration ❑ Repair, replacement ❑ Demolition Well PROPOSED USE Residential ne family ❑ Two or more family No. of units: ❑ Assessory Bldg ❑ Other F1 Flon.I„i Ail1 .I � DESC PTI N OF WORK TO BE PERFORM OWNER: Name: J d Please Type or Print Clearly) Non- Residential ❑ Industrial ❑ Commercial ❑ Others: 1-Ii,trirt s� -045, CONTRACTOR Name: ��.^ c, Icvbn Phone: 22S' 7//W - Address: Supervisor's Construction License: _ g” 7 9 '7 —7 Exp. Date: Home Improvement License: / tl ZD g" Exp. Date: ARCHITECT/ENGINEER Phone: R- 1, Address: Reg. No. FEE SCHEDULE: BULDING PERMIT.$12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ?&MFEE: $ Check No.: Receipt No.: I� 7 ,. NOTE: Persons contracting w' h unregiste4zigp8f1q"re_o...f ractors do not have access to a guaran . f Siod gnature of Agent/Owner ,el contactor a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑1 Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pe rnanent Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORAM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS NLiI=ic .i.-i:i cVil `tYl:.i.i ilii &uioai COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS - fx ,�'Not no Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total lana area sq. ft.: ELECTRICAL: Movement of dieter location, rust or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes N® MGL Chapter 166 Section 21A —F and G min.$1o0-$1000 fine Doc: -Building Permit Revised 2011 June/mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Mterior Rehabilitation Permits ® Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pert 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 Coni: ac'� C, o-looi-iCi-ossectioii/-Eleva`Lioti Fian tai- Proposea vvol'i1 vvan bprif'1mer man Ana Hydraulic Calculations (If Applicable) o 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 Permi- 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 .Permii 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 Location C12 2— �Oe No. ` t b -2 rill Date r om'->^ Check #t -`30 54 48% lu TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �(,::,"' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ , f v ` Building Inspector v C O 0 Z N CD 010 =r 0 � O � 0 CD �D O Q � � � = C CD 0 CD W C _.vU) O y CC C ' � v 0 a Z 0 �- 0 70 71 CD O CD V Ln (D rt o C T m M T O D) O C �- H H m T S. Dl N (D < ;O O C S r, m ;:o O C S3 V r C W c� Z H m 0 �' DL S O C ? O G 0 � m ;a O O n s m 3 W O S D m x o M Z cn --i m cn 0— Z 0 O h Ci) z O o " o w x �-<CD -0 En M 0 CD n 0 O Q- 0 � M o 2 -0= rt cDm 0 0 •-• CL m WCD � 0 � CD C x Q W N CCD O O O 0 co Q O O O W —0 .+S( OD -0 daftib CD -0 0 o to V rt O 0 co),. m CD A 0 0, s . s m Cn rt Q Ds O 0 O CC 0 o CO) Q_. - = : O CD < IL CL 00 <D =d. � N r� CD 00 O 5.0 0 EF E 0 C =r CD CD mo N .` -n ID B a w n cn re CD DW cD •0 0 � rt � O Q O Vf O (D 0 r+ Ln (D rt o 00 C (D T m M T O D) O C �- H H m T S. Dl N (D < ;O O C S m m C A n Z N m 0 T j v ;:o O C S3 V r C W c� Z H m 0 �' DL S O C ? O G 0 � p Z Z N m O (D "O < 3 O O n s m 3 W O S D m x O 0 c Massachusetts Department of Public Safety l�.IT - Board of Building Regulations and Standards License: CS -087977 Construction Supervisor R�L. ERIC W PALM 3 HILTON ST SALEM MA 01970 Construction Supervisor Restricted to: Unrestri6ted - Buildings of any use group which contain less than 35,000 cubic feet (991 cubic meters) Of . enclosed space. (' t Failure to possess a'current edition ofthe Massachusetts Expiration: S'Eate Building Code is cause for revocation offts (cense. Commissioner 04/23/2018 DPS Licensing information visit: W W W.MASS GOVMPS �. n,„ux+nrw rrl rJ�,.crrr./rrgfr License or registration valid for individnt use only Office of Consumer Affairs & Business Regulation before the expiration date. If found return to:_ 1 Q ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Itegdatiou egrstration: 142089 Type: 10 Park Plaza - Suite 5170 t acpiratlon: w12120W Ltd liability Corpor Boston, MA 02116 ATLANTIC WEATHERIZATtQfV:Li. C. ERIC PALM 61 R JEFFERSON AVE �Q��� Not vaUd without signature SALEM, MA 01870 Underseeret nry ACV RO° f CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDD/YYY1� 3/9/2016 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 i Eastern Insurance Group LLCI 233 West Central St j t Natick NA 01760 CO TACT ConstructionNA E: COri3trCt10ri PHONE (800) 333-7234 Fax A1C No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER AArbella Protection Ins. Co. 41360 INSURED Atlantic Weatherization 1 61 Rear Jefferson Avenue Salem HA 01970 INSURER B'Xa11tilUS Insurance Co INSURERC: INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER14aster 2016 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. tNSR LTR TYPEOFINSURANCE B NUMBER POLICY EFF MMID POLICY EXP MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE LJ OCCUR t. I 500042816 /20/2016 /20/2017 DAMENTET— PREM SES EGE TO R ocwnence $ 50,000 MEDEXP(Anyoneperson) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 X CONTRACTUAL LIABILITY X CG0001 10/01 FORM GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 i POLICY X PRO LOC S AUTOMOBILE LIABILITY j COMBINED SINGLE LIMIT Ea accident S 11000,000 BODILY INJURY (Par person) S A ANY AUTO ALLOWNED X SCHEDULED AUTOS AUTOS $ ` I 1020015871 /20/2016 /20/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident S NON -OWNED X HIRED AUTOS X AUTOS PIP -Basic S } X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 AGGREGATE S 1,000,000 A EXCESS LIAB CLAIMS -MADE DED RETENTIONS 10,00 S ( 600058654 /20/2016 /20/2017 WORKERS COMPENSATION WC STATU- OTH- Y "M ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTPJEEL. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? � N I'A (Mandatory in NH) f E.L. DISEASE - EA EMPLOYEE S If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S B POLLUTION PL200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 I GENERAL AGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES`' (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) t i i i 1 r TOWN OF NORTH ANDOVER 1600 OSGOOD STREET i NORTH ANDOVER, MA 01845 ACORD 25 (201 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 John Koegel/SME — ©1988-2010 ACORD CORPORATION. All rights reserved. INS02517mnnat m Tha annpn norma anri Innn ara ranietnrari marira of ar`.npn •�� �� + �r C.JI &VJ.0 0. JY . Z. *1 MVI rt%%Jz 6/ VU6 raA DCL vtir I _, DATE r TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER A TV 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 1S WAIVED, subject to he 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 endorsemen s . PRODUCER CONTACT j NAME: PHONE FAX EASTERN INS GROUP LLC 233 W CENTRAL STREET t (A/C. No, Ext): (AIC, No): i NATICK, MA 01760 I EMAIL ADDRESS: 22MLW i INSURER(S) AFFORDING COVERAGE NAIC # INSURED ATLANTIC WEATHERIZATION LLC INSURER A: AMERICAN ZURICH INSURANCE COMPANY INSURERS: 1 INSURER C: 61 REAR JEFFERSON AVE SALEM, MA 01970 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HAMIM ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ARYCONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 PAD CLAIMS. NSR LTR ' TYPE OF INSURANCE ( AOD L SUB R POLICY NUMBER POLICY EFF DATE IM WMD1YYYY) POLICY EXP DATE (WMDD\YYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE $ CLAIMS MADE OCCUR- AMAGE TO RENTED $ REMISES (Ea occurrence) MED EXP (Any one person) $ ERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER_; POLICY ID PROJECT ❑ LOG ENERAL AGGREGATE S RODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COWiBWED SINGLE $ LIMIT (Ea accidert) ALL OWNED AUTOS I BODILY INJURY $ SCHEDULE AUTOS ? (Per person) BODILY INJURY $ HIRED AUTOS i NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND ? EMPLOYER'S LIABILITY YIN UB -58270121-16 03/20/2016 03/2012017 X wC STATUTORY oTIR LIMI75 ANY PROFERITORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? r. N/A E. L EACH ACCIDENT $ 500,000 (Mandatory In NH► I If yes, describe under E.L_ DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below i DESCRIPTION OF OPERATIONS/LOCATIONS/ViMICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. F CERTIFICATE HOLDER CANCELLATION 6 Iv wIN yr INUIC1n AIV SJU VIrIC 1600 OSGOOD ST N. ANDOVER, MA 01845 'JHUVLLJ ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR TA VE F. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 19SB=20110 ACORD CORPORATION. All tights The Commonwealth of Massaclaasselts Departinellt of indiatricalAccidents ' Office of Investigations `s 1 Congress Street, Waite dap o° Boston, MA 02114-2017 www Dnass govldia Workers' Compensation Insurance Affidavit: Builders/Contr2ctors/Eiectricians/Plumbers licant In for>matiinn Name (Business/Organization/Individual):` Afiati$lc LK Address: vB K Jellersoll Avenue Phone #:-- Are yo an employer? Check the appropriate box: Zama 1: a employer with �_ 4. f ] I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor have hired the sub -contractors listed or partner- 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.z required.] 3. ❑ 1 am a homeowner doing 5. 0 We are a corporation and its 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 re d Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. Q Demolition 9. [3 Building addition 10.[x: Electrical repairs or additions 11.[] Plumbing repairs or additions 12•[. Roo repairs 13. they___ __i t,,t rz quire .] I *Any applicant that checks box #] 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 silt alt ettipleyer that is provitling workers' competlsatiott insurance for my emplovees. Below is the policy and job site informatiotr. Insurance Company Name: Lt rt` Policy # or Self -ins. Lie. #: 5 Expiration Date;_ij �2 p�i7 Job Site Address:— 0n 02 City/State/Zip: Attach a copy of the workers' compensationpolicy 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. 1 do hereby certify der the pants alt enalties of perjury 11, at the information provided above is true and correct m Si nature: Date: -1130 Phone #: CI 7 �' 76fki- 1-t 'z Official Ilse only. Do not write itz 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 #: page 3 of 4 �,.Aceeu�!!ffifl+allll�f s t.y L- Cmquiaem 1'agttafaprafr home,�sofihestate's33ameImoiorameatCoatractmia�v n soh0setsCoaslmrerGtdds s5azc�advi�i a„r�(e4ifz�,chapteci$2A}.Ir2tdsesaot�y�_y-�dorl C�ceofC � andBQsintsz FmE2me be;ott iia gomYkm ghame ,rmeoLs tauldfu` ohtaivaco- gf°A 110MGt1Fi metro;l'sCa � ion$otiincatbil-5�?3 ?8ia I'"Y°btrinaftzecmbyVaI&Stb, �s3ert�:ioaf1" .i,3 375? oroa ot:i r-rrosae Vane CDDC$iDF¢OFa"t ?�it)P ^� -•• cLat ur:a¢si�ii¢gcont:-a.<;•(aatice:,ce=d113. 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Lierss~i�.rf ntethsb^^ aad_slaty_ iFnlcssotiterinsenot ittg uis canfr..,,L aPJ<rzd an therde tc? itbin Lhis docnaeat; the e Reci�itlieFollasingcmttinnsandnotices sw�Lnn'tL �- i?;ai:enLrL'y^e. 0 stfiecatitrum II:ctiesto_,;�.ii etc: na; z 2Jid and fully u^_d d i 4� "�tr`ciom10he.vgfstaradtitbt3e�i nsatCantr�ta-??e3str aa� e L�lcaesnonsifsometningisnnc[e�r tiaaby;�;;�g,o e7iran, t orofi3o�etmpa: �tConLzetOr !� r mostbemcim1,rsrementcantr r De s the coats or lO Rem as v c.a wand se -a co,;,o^ arr�;amsun�ic? tie^ 'Fw3aSi7t�,Fo:0h,n=3x02i1Gerb. �� mS abnutcon actor Copy z vrcaa 0f.zaS,en � cacumn t cUr `0rfa. itisfas?ma¢ aaaaa =' y '= 6;7 9i3�^7oi or83d 3;� 3737. 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