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Miscellaneous - 93 BONNY LANE 4/30/2018 (2)
Location 7 3 x, -c- No. Date TOWN OF NORTH ANDOVEP Certificate of Occupancy $ 41 $ 130, Building/Frame Permit Fee ..... . Foundation Permit Fee $ Mu uj Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ CU TOTAL $ V 4�- G S /� ll Building Inspector 12.11)22 Div. Public Works I y. N N "N ^t7 C` cr n ) Z N N — L CA U v t4 D rS tG� 1 w 7 V� _= C m F, L X Z v. I y. N N "N ^t7 C` cr n ) Z N N — L CA U v t4 D rS tG� 1 w I y. N N "N ^t7 C` cr ) Z N N — m U v t4 D Lnx w ni 71 rr z r V: � m I y. N N "N ^t7 C` cr ) Z N N — m U v t4 D Lnx w ni rr z r V: � m I y. N N "N ^t7 C` cr v, y C � S 'O O coo CD n Z y CSD O 'O CL r �� C CZ S. y nco -v 0 cm 0 CD CD o s d CD CCD O CSD C CD CA CD 0: O y I co CD C3 CO) O 'O Z CD oCD CD0 I I CCn n O z C c c=fig --4O • H 0 Q N O y CZ o O Cl) 9 N Cd C. T Z 5 cgo go's a o� 5_::O H a T a � W1 m m 0 G m H O w N it m = > >� co p� Oo y C. O O 'NO C S H m: A m m N C d 9DO' CD C. d N , N _ C H 9 m5 IE SD 5 :O o U4 3 Wim: ��� 00N 1 l a CD o H � � Al 4 CD m i =: H �m ft Sip - d m �m 9- 7r A o + w oa 9 z7Wg a= n. to 010 til z� E. GQ .d r °= ��� OQ ? � rL w C/) �^ y al Q. \ x 0 ro C) ~ M rD O H 0 9 m CL 0 c m r. UO z - z z a a - f`✓ ar t( 1 ` y V vicm z V. z m N c, W — L v, '� ra r fes` tz m r. UO z - z V' a - f`✓ k• y V vicm z V. z m N W — '� ra N ..• 7 Z ,-, �. 7 X N N y N in 7:z Z Wrr. N z w n m ? zi Z z n � m l 9. m r. UO z - z V' a - f`✓ k• y V vicm z z z m N W — '� ra N ..• 7 Z ,-, �. 7 X N N y N Z n m r. UO N V' a - f`✓ k• N maa vicm JJe�al N m N W — '� ra N ..• 7 Z ,-, �. 7 X N Z m r. UO N V' a - f`✓ k• N maa vicm JJe�al N m N W — '� ra a - k• r>. -t maa y -y W '� ra >'. N N v, m m m f.d n, ` y 21 1y m. Vi G .t` ir. ✓. V- r) m t. x X X 7X zt � tF U - — ^. v T ro.n9 s � ( s z E � _ z I'M x C J z z V� y - r LIN L6 COJ 71 �C'i y Vi •.. 71 L i >'. N N v, m m m f.d n, ` y 21 1y m. Vi Yn r a z x Let y r) m t. x X X 7X zt � tF U - — ^. v T ro.n9 s � ( s z E � _ z I'M x C J z z V� COJ >'. -.a N V. f.d 21 1y m. Vi Yn y z t. r Z r) Z N 7X � tF U - — ^. v T ro.n9 s s z E � _ z I'M x >'. I -.a N V. f.d 21 1y m. Vi Yn t. G ro.n9 I -.a r. a- x- 21 t. G Date........ . ...... .. ... ... .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING -7 This certifies that .. r- , 4 - t:z: ............................................................... : ........................... I -.� /:—! -r, , At, / has permission to perform ....... t� ................................... ................................ wiring in the building of ......... K!. ........................... at ..... .... North ZAnd, ........... Lic. Not:.A�.- ......... ....... .... ............ . ........... ........ c�L 4i�i TR > E CAL INS R 01/12/99 14:44 75.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TRF0OMMONWEALTHOFAL4YS4CHUS = Office Use only DEPARTAfENT0FPUXJC&4FM Permit No. BOARD 0FMEPREVEM70NRD9JTA770AN5r0 R I20 VJ4 Occupancy &Fees CheckedPPLICATION FORPERAff TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL E, 527 CMR 12:00 / PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 'own of North Andover To the Inspector of Wires: ie undersigned applies for a permit to perform the electrical work described below. ration (Street & Number) g 3 4w .e_ ner or Tenant ,l to 130V o e -s G er's Address ':5, — hermit in conjunction with a building permit: Yes LM No (Check Appropriate Box) of Building Utility Authorization No. iervice Amps / Volts Overhead r7 Underground r7 No. of Meters vice Amps I Volts Overhead M Underground M No. of Meters Ni of Feeders and Ampacity Loci ,ton and Nature of Proposed Electrical Work /W SQL /.fir ax-e--e— No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA groundg1:1round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets it G/ 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 Pum s 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 1`• of Dryers Heating Devices KW `t. Connections of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs / No. of Motors Total HP 7 ej1_— 1-e"r - • • :r. • • i • r :. u: . r .�.:i: - • ..r �, iY: • • • i . o • :.:r •:..�.••. • • ,t • n� . :jai :.. i .1• � � OCR. 29341 Etm&d ValuedUecftxal Wait $ Wak�Sta�t hgxMmL*Rigxsted Rough Final Sigtteduttr$�iePertalti� uty._ - FMMNAME �Z9t► G� j C-' + Li=WNn 0 OWNER'S WAIVER;tans+nateb tthL,Lx=do�_nutha' and@?,atmysigttatueontttispetma#appL�riaiwai�esdris ted. (Please check one) Owner Agent Telephone No. PERMIT FEE $ lu W 104-1 --glob, Ulm* Date.e.i..2-/.- 7�: ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ............. . ....................................... ... . . .. ... .... ... .. ......... has permission to perform ...... ........ e ........................................ ....... .................................... wiring in the building of ........... .................... at..Z ............ x ... . ........... ............ . North Andover, Mass. .......... �-/ ic. NoE.S--?Z'�V/ ............ � . .............. Fe�-v . .............. L �/ tLEcrRICAL INSPECrOR 08/26/99 12:28 25-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ` TAE C0AW0AWl�i LTH OFAUMMUSMS Permit No. OfficeUse �only Z�i�OFPUI3LIC�9FElY BOARD OFFMEPREVEYHONREGU AHOAS527CM12-iYl 7_ Occupancy &Fees Checked APPLICATIONFORPERt7IT TOPERFORMELE=CAL 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. 0 6, 7 PARCEL Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with building permit: Purpose of Building & n c k f d Vr✓ in Existing Service `' Amps 11 d / 2 2-- Volts New Service Amps / Volts I W:01 Number of Feeders and Ampacity qV o &, P Low Loca' 4bn and Nature of Proposed Electrical Work sWe Utility Authorization No. Overhead ®underground M Overhead [= Underground No. of Meters f No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures�O Swunming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets 3. 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 LocalMunicipal ® Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis Jlo. Hydro Massage Tubs No. of Motors Total HP OTHER - J :. •:I -, I " FA •" i Ilw • .: IN 05 1 ilk W I .I :1. :•1 : 1 • -. (age y) q �,-V\ `\ Est mr VakrdE1ecbcal Wcxk $ Find F'o3/C/L// fui±ur, -2L1 a)ur.,,+-.s,/ Lowe I ^ A4 -t. a t�sU Alt Tel Na N9 ` 45-0-0040 OWNER'SINK RANCE WAIVER, Iamawatet iatthe Licawdmnot haw the mr&=oo�crits suttnvialegivalilaswg=dbyNlassadmsells GmualLaws arlthatmysigrahueonthispermitapplimbm"ailcsthisregian i (Please check one) Owner 71 Agent Telephone No. PERMIT FEE $ 6igna7ue of Owner or Agent Is Date ... .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION . . ....... This certifies that ........ .................................................................................... t 11 has permission for g ns a ati ... .. ....... in the buildings of .... S.,K- - ..... .. ..... ........... ... .................................................................... , I at ........ ........ ............................. . North Andover, Mass. Fee.,.7.4D.7.... Lic. No.....�nj ....... ..................................................................... GASINSPECTOR Check OiAg I u 2,a- � M�� ,1� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE 10-22 - /.- PERMIT # W-ro JOBSITE ADDRESS 9'3 &�%9k1, OWNER'S NAME A�K/1 /,I-dMe' OWNER ADDRESS G TEL FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES El No APPLIANCES Z FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER -GAS tl 1(' �G INSURANCE COVERAGE 1 have liability insurance its the MGL. Ch. 142 YES NO ❑ a current policy or substantial equivalent which meets requirements of I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OFCOVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIOTHER TYPE INDEMNITY ❑ BOND ❑ CY 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 ❑ AGENT ❑ 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 t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com nce 'th nen ovision of the Massachusetts State Plumbing Code and Chapter 1422 of the General Laws. PLUMBER-GASFITTER NAME &� #Arl-e /01 LICENSE # JS�S 11 SIGNAT E MID GF ElJP ❑ JGF EILPGl [I CORPORATI01# '3-77/(— PARTNERSHIP [I# LLC El# COMPANY NAME Cfeemc a Q d W , . l/l't- ADDRESS S LU W ems' Si(4 t CITY MgAu P vl _ STATE ZIP 01W TEL C% 7l— FAX CE9 EMAIL ,1� W O Z z 0 H w a z a d � w D '❑ a Z �a >- w W a � F UA ftZ z N W s a W CO) oG � O4 O W w N a d00 ss, a a J F a CL �► '3 w = W H LL W F °z 0 F U a CA r CQ7 V O O a OF MASSACHLSEl The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 1 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORI'T'Y. NaMe (Business/Organization/Individual): Address: // // ,�/� olry r City/State/Zip : /Vt 4 i) e Pg / / / G, Phone Are you an employer? Check the appropriate box: ig 91E- 66e- 000V 1. Vq I am.a. employer with D ..: employees (full and/or part-time).* 2. 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.. Q I am 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. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have nq employees. [No workers' comp. insurance required.] Type of project (required): 7. [f New construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. E] Electrical repairs or additions 12. n Plumbing repairs or additions 13. E] Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submif Ns 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 an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-conlraci6rs have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees.' Below is thepolicy and job site information. Insurance Company Name:�C Policy # or Self -ins, Lic. #: 9 Y49 ! 9' /a &, / Expiration Date:: Job Site Address: OY% 4/v e City/State/Zip: A/ Attach a copy of the workers' comp , sation 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 fine up to $1,500.00 and/or one-year mprisonment, 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 DIA for insurance coverage verification. I do hereby certi undE� t e pains and penalties of perjury that the information provided above is true and correct. • :.` / Phone/ Official use only. Do not write in this area, to be completed by city or town official.. City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical 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 6f lure, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth, for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), 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 maybe submitted to the Department of Industrial Accidents foi• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you. are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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 www.mass.gov/dia m m m m m mm H C � CD azy CD O "0 CL r c. CD d CO) �-W cm) CD cm CL r CD S C CD O CD C O co) CL v Ci O I cm � CD a v C4) O CD a 71 O CCD O CD C w"0 P- m N O �• C C• N Eco o AmaC'9 Z " �'n H 0 0 d �. m N :: d 0' 0 l9 C C N p o =r CD Cl) Q > >�o n 1a �. c .+ G CN• C 1� co V ���yy 0• � 0.10 1a o cn CD C CD N O n� C CD rL —N N' n pf CO)CD C :A C t0 Cn ? f N ti. m CD CO Q C a zN D G Cn m r r^ W y r : CD 0.'0 O : c -J CD.: 2 n .0•► C O :`D . ►� ; 0. C . CO2 Cl) m T m CO2 —I x Im �q cn Z cp c O I Oz n Oc O cc r a . .aa a .� VL d o Circptz v r- to O Cn O O M 2 z071 y b b M0-3. 0 z ,0 H 0 O C -VI or . This certifies that Date,./�`*/`****�`*/`�/"`�*�*"*`*"* .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING � � /, &,- -.,j � �- .................................................. has permission to perform ......... ..................................................... wiring in the building of ......... ............................... .............. alo .. . ......................................... at &rvl" ................................ . North Andover, Mass. ................................................. ..... Y Fee ...... Li, .... ...................... E—C— T*"R* *I'C*' A**L'* *1* N— *S* *P* E**C'* T**O'* Check4t ?Ao-2- Commonwealth of Massachusetts O �oal Use j Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (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 (PLEASEPRINTWINKORTYPEALLINFORMATION) Date: 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 Owner's Address sr e_ 1 Is this permit in conjunction with a building permit? �, Purpose of Building i� Telephone No. Yes F' �No ❑ (Check Appropriate Box) Utility Authorization No. - Existing Service / Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Amps Volts No. of Meters Number of Feeders and Ampacity J ev Location and Nature of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis Disposers p Heat Pump Totals: Number Tons � ��� KW ....................... No. of Self -Contained Detection/AlertingDevices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances gay Securityo. Devic s or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �,� (When required by municipal policy.) Work to Start: %O /�'" �S� 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 covetBONDE] m force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: �7%l ,g,�jQ Ube_ Signature LIC. NO.: P - (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: D D / *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 s required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agen . Owner/Agent [PITIMITMEf $ Signature Tele one o. , 1 4 51 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: xt - Inspectors Signature: �� '' , Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com N • The Commonwealth of Massachusetts :. Department of IndustrialAccidents I Congress Street, Suite 100 "" _ tl Boston, MA 02114-2017 �< www mass.gov/dia ASM Sy� Workers, Compensation insurance Affidavit: Builders/Contiraciors/Electricians/Pluin ers. TO BE FILED WITH THE PERMITTING AUTHORIUY. Name (Business/Orgmizaiion/Sndividual): Address: City/State/Zip: Are you an employer? Check the appropriate box: Phone 4: i.[] I am a employer with employees (full and/or part-time).* 2, am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required] 3. Q I am a homeowner doing allwork myself (No workers' comp. insurance required.] t 4-E]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. ❑I 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.# 6. ❑We are a corporatign and its, officers have exercised their right of exemption per MGL c. 152 § im and vwe have no employees. [No workers' comp. insurance required.] Type ofproject ()required); 7. ❑ New`oonstriiction 8. [] Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12TQ.Pl4umbiing repairs or additions 11E] Ro6f repairs 14. [] Other *. must also fill out the section below showing their workers' compensation policy information. such Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating Any applicant that checks box #1 TContractors that check this box must attached'an additional sheet showing the name c the sub -contractors and state whether or not those entities have ontractors have employees, they must provide their workers' employees. If the sub ccomp. 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 Name: Policy # or Self -ins. Lic. #:. Expiration Date:, Y Z City/State/Zip: lob Site Address: /T_ (showing thnumber and expiration. date). Attach a copy of the workers' compensation policy declaration page ( ge polic Y Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a 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 DIA for insurance coverage verification. X do hereby certify under the pains andpenalties of perjury tliat the information provided abave is true and correct Official use only. Do not write in tliis area, to he completed by city or town official City or Town: Permit/License U. Issuing Authority (circle one):i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: J 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' d'effied 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 receivbfor 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 Iicensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), 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 Industrial_ Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write •"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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 ri 6 LOCATION: roi OWNERS NAME: M r -f M % GENERATOR kw oZo< kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: � � - -)-3 5 - 5c-/ ELECTRICAL RESIDENTIAL P46 61dr-"7 GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: I eF7— S r d e o F leo v.se- T�VF40,1�tOFch"MM0ey *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED} &W�4-N/tr -► n r\ , *CONSERVATION APPROV, 035 lok /// '5 - Date........... ... ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Inis certifies that .... (7 .... .................................................. ;r ............... has permission for gas stallation ............. ........ in the buildings of ......... lo, at ......... 7,2 ........ ......... e�� ................... . North Andover, Mass. q'33 F e e,.-;—� .. . .... Lic. No . .......................... ..................................................................... Check # c),Dqr GASINSPECTOR S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: ALAN & CAROL LEBOVIDGE MA. DATE: 11/4/2015 PERMIT # JOBSITE ADDRESS: 93 BONNY LANE OWNER'S NAME: ALAN & CAROL LEBOVIDGE ^I OWNER ADDRESS: TEL: 978-689-3758 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Lei PRINT CLEARLY NEW: ©' RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES E NO B� APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ If yA have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted (or entered) regarding this permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued, will be in compliance with Pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME:?6�-"Z ��szetICENSE # 33 SIGNATURE COMPANY NAME: OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP: 01844 FAX: 978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFO@OSTERMANGAS.COM \\ MASTER 0 JOURNEYMAN ❑ LP INSTALLERORPORATION ❑# PARTNERSHIP ❑# LLC 2q5-326-3311 S The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 400 Washington Street Boston, MA 02111 6" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Osterman Propane, LLC Address: One Memorial Sauare City/State/Zip: Whi t insvi l l e MA 01588 Phone # 508-234-1573 Are you an employer? Check the appropriate box: 1. ® I am a employer with 2 7 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.® Other LP Gas Install & Repa tiny appacanr mar cnecxs Dox st must also till out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Belo iv is the policy and job site information. Insurance Company Name: Insurance Company Of the State of PA Policy # or Self -ins. Lic. #: ANCO 15883775 Expiration Date: 06/30/2016 Job Site Address: All LOCafionS In. North .Andover City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby�ify under the prgs and penalties ofperjury that the information provided above is true and correct. Phone #: 508-234-1573 Official use only. Do not ivrite in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other 7/01 Contact Person: Phone #: ACqR "® CERTIFICATE OF LIABILITY INSURANCE page 1 of 1F DNYYY /29/2015' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis of Texas, Inc. c/o 26 Century Blvd. P.O. Box 305191 PHONE FAX . 877-945-7378 888-467-2378 E-MAIL certificates@willis.com Nashville, TN 37230-5191 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA:Lexington Insurance Company 19437-000 �� 2ENTED ) K1l?Eaoccur$ 100,000 INSURED NGL Energy Partners, LP INSURER B: The Insurance Company of the State of Pen 19429-100 INSURERC: 6120 S. Yale Avenue Suite 805 Tulsa, OFC 74136 INSURER D: INSURER E: B B INSURER F: COVERAGES CERTIFICATE NUMBER: 23299818 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 OF INSURANCE DL SUB POLICY NUMBER POLICY EFF POLICY EXPITR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR 034205248 6/30/2015 6/30/2016 EACH OCCURRENCE $ 2,000,000 �� 2ENTED ) K1l?Eaoccur$ 100,000 MED EXP (Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY [:]PRO LOC JECT OTHER: GENERALAGGREGATE $ 4,000,000 PRODUCTS-COMP/OPAGG $ 4,000,000 $ B B AUTOMOBILE LIABILITY X ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS CA4584397 AOS CA4584396 MA 6/30/2015 6/30/2015 6/30/2016 6/30/2016 COMBINED SINGLE LIMIT (Ea accident) $ 5,000,000 BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ PROPERTY DAMAGE (Per accident) $ A X UMBRELLALIAB EXCESS LIAB I X OCCUR CLAIMS -MADE 015881338 6/30/2015 6/30/2016 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 51000,000 DED I X RETENTION $ 10 , 0 0 $ g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEY OFFICERIMEMBER EXCLUDED? (( Mandatory inNH) ff yes, describe under DESCRIPTION OF OPERATIONS below N/A WC015883775&079331530 6/30/2015 6/30/2016 X PER 0TH - E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,0001000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additonal Remarks Schedule, may be attached if more space is required) 193 ill ILL7LMS1\I 3 i PJ 111 NJ a L4 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 Town of North Andover 120 Main Street N. Andover, MA 1845 Coll:4718034 To1:1970970 Cert:28'299818 171988-2014AC0RD CORPnRATinN_ All rinhlc rPQPrvPr1 ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 4 NAL Retail Supply NGL Retail Supply,_LLC NGL Supply Terminal Company, LLC__ NGL --- Supply Wholesale, LLC -- -- — ---- - - - - - ----- -- --- ---- — -- - - - ----- - - --- NGL Water Solutions, LLC NGL -MA, LLC --- ----- ---- - ------------------ -- NGL-NE Osterman Propane, LLC Osterman Propane, LLC dba Anthem Propane Exchange Osterman Propane, LLC dba Downeast Energy Osterman Propane, LLC dba Lessig Oil and Propane Osterman Propane, LLC dba Thompson's Oil and Propane Thompson Oil — Named Insured Includes: AntiCline Disposal, LLC Centennial Enerav, LLC Hickgas, LLC dba DeLuca Hickgas, LLC dba Enviro _ Hickgas, LLC -Lincoln Hicksgas, LLC Hicksgas, LLC - Blackstone Hickgas, LLC - Bloomington Hicks as, LLC - Braidwood Hicksgas, LLC - Decatur Hicksgas, LLC - DeKalb Hicksgas, LLC - Kankake Hicksgas, LLC - Kankakee Hicksgas, LLC - Lowell Hicksgas, LLC - Monticello _ Hicksgas, LLC - N. Pekin - ._Hicksgas, LLC -Oakwood ----------------- --- -----------------------; Hicks as,_LLC-- - —Renesselaer------------------------------------------- -� -g ---------- - - -- ---- --------- ---- - ---- --a Hicksgas, LLC - Roberts Hicksgas, LLC -_Toluca Hicksgas, LLC - Urbana Hicksgas, LLC - Vandalia — Hicksgas, LLC_ dba DeLuca Hicksgas,LLC dba Enviro Hicksgas,— LLC dba Global Propane _Hicksgas, LLC dba Indiana Hicks- Hicksgas, LLC dba Liberty Propane - Hicksgas, LLC dba Pacer Propane _Hicksgas, LLC dba Pittman Propane— Hicksgas, LLC dba Rocket Propane --- — Hicksgas, LLC dba Rocket Supply,_Inc_ Hicksgas, LLC dba Service Gas Hicksgas, LLC dba Urbana ----------- ------ - -_-- - ---- ----- ---- ' Hicksgas, LLC -Utah LP - - - -- - L -- - - - -- High Sierra Crude Oil & Marke-ting, LLC High Sierra Energy, LP — ^.NGL Crude Logistics_____ ' NGL Crude Transportation, LLC _ NGL Energy Operating, LLC_ -- NGL Energy Partners, LP NGL Liquids, LLC - — -- NGL Propane, LLC NGL Propane, LLC dba Brantley Gas NGL Propane, LLC dba Propane Central NGI Propane LLC dba Propane Energies Group (PEG) NGL Propane, LLC dba North Georgia Propane NGL Propane, LLC dba Pro -flame - - NGL Propane, LLC dba RB's Gas -- NGL Propane, LLC dba Woodstock Gas 013 . � 1,A IVC Location 301VIL)�� No. e C� Date ZZ/ A� f . 401tTh TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ P13, Fminriation Permit Fee Other Permit Fee Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 3 o�20317 Building Inspector 9 07/09/99 12:41 143-00 MD. Public Works is y_ z m n z o Ln' O y z z Q Z o w � P z o " z d � s +W n - 0 o s o co L Y 0 0 n o 0 z - o 0 z z z zn Z rs m o b o o n n n z rn G Q z z � O O f- oc� pu '� ION z d m Qt Al o Q � Y :7 [=7 is 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***************** *** APPLICANR PHONE LOCATION: Assessor's Map Number 0 tj PARCEL ✓ 3 SUBDIVISIONLOT (S) G STREET / 3 ST. NUMBER ** * ***** * ***** * OFFICIAL USE ONLY******************* VAI 6+,-- 1 i1c MENDATIONS OF TOWN AGENTS: �emoUt k� A tvvy V •}2,,- -.% CONSERVATION ADMINISTRATOR COMMENTS A/ I w, ? a 8' DATE APPROVED _.VL) DATE REJECTED Act SAI' S ✓,v n o m ryi V Aff. IW.. TOW PLANNER DATE APPROVED replQWJX0�-f—DATE REJECTED • u S Dern Irpeo, FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm 0 TE MOIL (GAGE INSPECTION PLAN SULLIVAN SURVEY 45 LEWIS ST. READING MA, 01867 TEL. (617) 944-8750 FAX. (617) 942-2437 13 L�oN N� �1}NC — .t'AX ( COCNJCJJ L/1 CX — THIS TAPE SURVEY, CERTIFICATION & MORTGAGE INSPECT [PPLAY ARE MADE FOR THE USE OF FOR MORTGAGE PURPOSES ONLY TIFY BASED ON MY CONFORM CS] ITC] OTHE TION ZONI NG BELIEF, [DIMENSIONAL L THE DUILDING IS] ynRr/V AN04VC:/L MASSACHUSETTS REQUIREMENTS] OF THE CITY OF REA THEW, ON THE FEDERAL EMERGENCY NCIYTHE SPECIAL MANAGEMENT FLOOD rHMAPROFATHE AS SII❑ �1%CITY OFI�P(f r�-- N'4ZUe6� MASSACHUSETTS COMMUNITY PANEL NUMBER Z-so090005--C-�_ ! UNE /y93 FLO011 INSURANCE RATE MAP EFFECTIVE DATE F-,c,T. IY DATE REGISTRY REFEP.EtICESCALE vo , FG. B, )49� N. 0 ACORD CERTIFICATE OF LIABILITY INSURANCkPID BC WIGH-1 DATE(MM1GD,'YY) 06/21/99 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSR LTR ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Gorman -Litchfield Ins. Agcy. 1105 Lakeview Avenue HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. POLICY EXPIRATION DATE MIv1,'DD/YY) Dracut MA 01826 Phone: 978-957-1234 F'ax:978-957-2458 INSURERS AFFORDING COVERAGE INSURED INSURER A. Zurich Group - Portland INSURER B'. EACH OCCURRENCE $ 1000000 INSURER C: Dwight Landry Construction 522 Hildreth Street Dracut MA 01826 INSURER D: INSURER E: 05/10/00 COVERAGES 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. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY FFECTIVE PATE MM1GD/YY POLICY EXPIRATION DATE MIv1,'DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY TBD 05/10/99 05/10/00 FIRE DAMAGE (Any one fire) $ 300000 CLAIMS MADE Fx_] OCCUR MED EXP (Any one person) $ 10000 PERSONAL &ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'LAGGREGATE LIMITA.PPLIESPER, PRODUCTS - COMP/OPAGG $ 2000000 PRO-CT X POLICY JE LOC AUTOMOBILE LIABILITY ANY AUTO COP.9BINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJUP.`1 $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA. ACC $ ANY AUTO AUTO ONLY. AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE .$ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION AND EMPLGYERS' LIABILITY C A U� TvO6JRT LIMITS EP, E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERA..TIONS/LOCA.TInNISA/EHICLESIEXCU_I_IONS ADDED BY ENDnRSEMENT/SPECIAL PROVISIONS Caprentry - residential CERTIFICATE HOLDER Ij ADDITIONAL INSURED. INSURER LETTER: CANCELLATION mmovE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE C.A.NCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of North Andover 10 DAYS VVRITTEN NOTICE TO THE CERTIFICATE HOLDER N.WED TO THE Attn : Building Dept. LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. ACORD 25-S (7/97) ACORD CORPORATION 19m IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S ADDITIMAL HAZARDS ...... ... ....... .... OP iEi BC Dwight Landry Construction DWIGH-1 Attach to Certificate of Insurance PAGE 3• LOCATION # :-: 1 BUILDING # 1 :: CLASSIFICATION ._. CLASS .... . PREMIUM TERR RATE PRE IUM CGDE BASIS PRENVOPS PRODUCTS PREMIOPS PRODUCTS Caprentry - residential 15213 P 15600 ADDITIONAL COVERAGES COVERAGE CODE LIMIT DEDUCTIBLE DEDUCTIBLE TYPE LOCATION #:::: : BUILDING # .... ..... CLASS PREMIUM R'TE PREMIUM . CLASSIFICATION CODE BASIS TERR PREMIOPS PRODUCTS PREWOPS PRODUCTS ADDITIONAL COVERAGES COVERAGE CODE LIMIT DEDUCTIBLE DEDUCTIBLE TYPE LOCATION # > BUILDING # ...... CLASS .. PREMIUM .>P -TE PREI IIUM CLASSIFICATION CODE BASIS SRR PRENVOPS PRODUCTS PRENVOPS I PRODUCTS ADDITIONAL COVERAGES COVERAGE CODE I LIMIT I DEDUCTIBLE DEDUCTIBLE TYPE LOCATION #:::: ::::BUILDING :# ..... ...... CLASS , . > PREMIUM RATE .. .. PREM IUM CLASSIFICATION CODE BASIS TERR FRENVOPS PRODUCTS PRENVOPS PRODUCTS ADDITIONAL COVERAGES COVERAGE CODE LIMIT DEDUCTIBLE DEDUCTIBLE TYPE LOL;Ai ION #:-: BUILDING.# .. CLASSIFICATION CLASS PREMIUM TERR RTE PREMIUM CODE BASIS PRENVOPS PRODUCTS PREWOPS PRODUCTS ADDITIONAL COVERAGES COVERAGE CODE LIMIT DEDUCTIBLE DEDUCTIBLE Tr RE ATTACH::TO COMMERGAL:GENERAL LIA$IUTY APPLICATION . BEAM LAYOUT CUSTOMER -- DWIGHT LANDRY DATE 45/19/99 REF DDL333 15' 10 1/4" 1' 11 1/2" 2' 2 1/4" JACKSON LUMBER 215 MARKET STREET LAWRENCE, MA 978.686.4141 Post spacing is measured center -to -center. Depth of post -ire -concrete footers --- 48 inches. 14' 8 1/2" 4' 2 1/4" 1' 1 t/j" I T CU N rJ� ui RJ BEAM BEAM POST POST LABEL LENGTH COUNT SPACING A 4^ 8" ` 2 2' 9 1/2" B 21' 5 1/2" e 10' 6" C 29' 9" 4 9' 9 1/4" D 27' 1" 3 13' 3 3/4" Post spacing is measured center -to -center. Depth of post -ire -concrete footers --- 48 inches. 14' 8 1/2" 4' 2 1/4" 1' 1 t/j" I T PLAN VIEW CUSTOMER -- DWIGHT LANDRY DATE 05/19/99 REF DDL333 JACKSON LUMBER 215 MARKET STREET LAWRENCE, MA 978.686.4141 54' 22' 4' 28' LOAD AND SUPPORT: Your deck will support a 43 PSF live load. Posts have Af" below -ground post support. bVAT._ DECK AND POST HEIGHT: You selected a height of 120" from the top of decking to level ground. The top of the deck support posts will therefore be 107.25" above ground level. Your salesperson can provide information for uneven or sloped ground. JOISTS: Set joists on top of beams, 16" center to center. NOTE: The design may require knee braces and bridging between joists. Your materials list includes the necessary items. The suggested design is not a finished building plan. You are responsible for all measurements being correct, for verifying that the design (and any substitutions or modifications that you make) meets all local building codes and requirements. To verify that the suggested design, and any substitutions or modifications, is consistent with conditions at the construction site, review the design with your architect. Also consult your architect for proper construction and use of materials in the structure. Be sure to follow the deck construction detail available from your store salesperson. •00 o cu 4 �t JACKSON LUMBER 215 MARKET STREET LAWRENCE, MA 978.686.4141 54' 22' 4' 28' LOAD AND SUPPORT: Your deck will support a 43 PSF live load. Posts have Af" below -ground post support. bVAT._ DECK AND POST HEIGHT: You selected a height of 120" from the top of decking to level ground. The top of the deck support posts will therefore be 107.25" above ground level. Your salesperson can provide information for uneven or sloped ground. JOISTS: Set joists on top of beams, 16" center to center. NOTE: The design may require knee braces and bridging between joists. Your materials list includes the necessary items. The suggested design is not a finished building plan. You are responsible for all measurements being correct, for verifying that the design (and any substitutions or modifications that you make) meets all local building codes and requirements. To verify that the suggested design, and any substitutions or modifications, is consistent with conditions at the construction site, review the design with your architect. Also consult your architect for proper construction and use of materials in the structure. Be sure to follow the deck construction detail available from your store salesperson. •00 0-4 DCO -icnv G o m Bmf a rt M o CD � 0 C, N tDrh r D U 00 m ; oo) z lioxz Ti, m m C cn K >--1a) Do m mm m -4 G rt CO 0 v 0 (n r- rj C - go :E 0') 0) 30 00 m D co A 0 Z a�mMr- D -i ay x m m m -4 IV O W D C O .--i cn —1 m -1 -4 00 (0 K -- < (D t t C CD t C CD v M� M= n v yr r D WZ Wv w� STRESS ANALYSIS CUSTOMER: DWIGHT LANDRY DATE: 05/19/99 REF: DDL333 SALESMAN # ------------------------------------------------------- MEMBER STRESS FACTOR COMPOSITE TYPE SIZE FACTOR LOAD LOAD ------------------------------------------------------- JOISTS 2X12 DEFLECTION 109 PSF 16IN BENDING 101 PSF SHEAR 116 PSF COMPRESSION 127 PSF 101 PSF BEAMS 2-2X12 DEFLECTION 126 PSF BENDING 63 PSF SHEAR 53 PSF ' COMPRESSION 203 PSF 53 PSF BOLTS 1/21N SHEAR 2062 PSF 2062 PSF POSTS 6X6 STABILITY 504 PSF 504 PSF ----------------------------------- TOTAL LOAD 53 PSF DEAD LOAD 10 PSF LIVE LEAD 43 PSF ------------------------------------------------------- STRINGER 2X12 DEFLECTION 53 PSF BENDING 123 PSF SHEAR 257 PSF COMPRESSION 1147 PSF ----------------------------------- TOTAL LOAD 53 PSF DEAD LOAD 10 PSF ------------------------------------------------------- LIVE LOAD 43 PSF BILL OF MATERIALS AND LABOR PRICING CUSTOMER: DWIGHT LANDRY DATE: 05/19/99 REF: DDL333 SALESMAN # UNAVAILABLE COMPONENTS --------------------- 6X6S IN PT PINE NOT AVAILABLE FOR GROUND POSTS (12 13 FOOT LENGTHS) 2X65 IN CEDAR NOT AVAILABLE FOR STAIR HANDRAIL/CAP (2 18 FOOT LENGTHS) 2X12S IN PT PINE NOT AVAILABLE FOR STAIR STRINGER (10 18 FOOT LENGTHS) --------------------------------------------------------------------------- SUMMARY LUMBER MATERIALS $ 7798:71 OTHER MATERIALS $ 1965.76 TOTAL $ 9764.47 (984.00 SQ FT; $9.92 PER SQ FT) LABOR PRICING $ 9465.30 (984.00 SQ FT, $9.62 PER SQ FT) TOTAL $19229.77 (984.00 SQ FT, $19.54 PER SQ FT) .WOOD TYPES USED IN DECK DECK PLANKS STAIR TREAD STRINGERS JOISTS FASCIA LEDGERS BEAMS GROUND POSTS RAIL POSTS RAIL CAPS RAIL SPINDLES OTHER RAIL MEMBERS TREX TREX PRESSURE -TREATED PINE PRESSURE -TREATED PINE PRESSURE -TREATED PINE PRESSURE -TREATED PINE PRESSURE -TREATED PINE PRESSURE -TREATED PINE WESTERN RED CEDAR WESTERN RED CEDAR WESTERN RED CEDAR WESTERN RED CEDAR TO COMPLETE YOUR DECK THE FOLLOWING TOOLS ARE REQUIRED: CIRCULAR SAW HAMMER CRESCENT WRENCH CHALK LINE RAFTER SQUARE 2' LEVEL LABOR PRICING SHEET CUSTOMER: DWIGHT LANDRY DATE: 05/19/99 REF: DDL333 SALESMAN # --------------------------------------- ---- PRICE UNIT TOTAL DESCRIPTION ----------------------------------- DECK AREA, ONE LEVEL 7.50/PER SF 984 7380.00 MANIPULATION OF DESIGN 50.00/EACH 2 100.00 LONGWAY DECKING (ADD) 0.00/PER SF 984 0.00 NUMBER OF SUPPORTING POSTS (ADD) 30.00/EACH 12 360.00 STEPS UP TO 5,INCL, 3X3 CONC, MIN. 125100/A SET 1 13 125,00 325.00 STEPS OVER 5 (ADD) 25.00/EACH LINEAL FT OF RAILING 2.85/PER LF 88 250.80 2X4 TOP/BOTTOM, 2X4 PICKETS (ADD) 0.00/PER LF 88 0.00 POST/BALL/ACORN CAPS (ADD) 0.00/EACH 37 0.00 BENCH - LINEAL FOOT 12.50/PER LF 31 387.50 APRON OVER 4FT 4.75/PER LF 92 437.00 BUILDING PERMIT APPL. SERVICE --------------- 100.00 1 100.00 ---------------------- TOTAL LABOR PRICE: $ 9465.30 Cl) m m m CD C/) 0 CA 10 CD CD O a r d � Q =. ato � O o p CL cr d i CD O y -v CD O O CO) .p C O CO) Cl) CD 0 �F CD CD ro. CD COI) O 0 CD 0 CD O OCl' E O O77- rD C y O O m d 2 N w G cm d0 »��C"I m y G ^ O 7d ycino G �' m y = .+ _ d n .•► G T b ^„ m O m N = p m y o �®�' = ods o D c.'9 _ . r- O W ICC 0 'm. ea C CL o CD m O 0 n-0 N O d N N a d 7 Q C C, N N CC. :x, m A N QCD :4,kw CD CD •O_-► N : m to a CD — om &9V o A � C, Z ` s �_�E; t t CD o=: O77- rD ztno 7 w G cm C) y G ^ O 7d w G �' b O � y G 7' C CL rt QJ � b p a r O j z 0 QV Ct r 0 c (Print or Type); r i Check one: Certificate Installing Company NamejOi1G�t2 (- �V�7q - (� Co Address 4 �o bcm iz., Drive— ye- Partner. -�- 60FO, o I.S 7 9 ❑ Firm/Co. Business Telephone J-�$ — 6 4 q—tj o-1 7 Name of Licensed Plumber: ! FIl �Jc�2e(� _ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 2 Other type ,of indemnity 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. Signature of ownerlagent of property Owner Agents. ❑ ( bcacby cclli(y Wal all of lllc dclails and in(o/nglion 1 ha.c w0unillcd (ac enlcicd) in alwne applicaliew ale Ilwt a� Y/ale W lIN Otat e/ ay �. k"wkdgc aad (bat all plumbing wo(k and inllallal4nna 1ic1(nfnlcd undcf rc111111 1%.1/cd (at this appiical/Wl wlu `e tMlllll(iwp I" w POO"" ow a'Isis" el lbs Ma"acllwcllt SlUlc Plumbiag Codc and Cluplcl 142 of llic Ccnual La.c . I • f4 By Title City/Town: A DDRr1VFn 7OFFICF USE ONLY1 Signature f'Licensed Plumber 9,,, vpe of Plumbing License License Number aMaster ❑ Journeymen � i Pr' 3906 Date/!? TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SACHUS This certifies that .................. has permission to perform -,e ..... . ...... plumbing in the buildings .7 . ..... ................ at. . .............. North Andover, Mass. FeeOo -r-� .. Lic. No. ... .............................. PLUMBING INSPECTOR 12/28/98 14:31 40- 00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer