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HomeMy WebLinkAboutMiscellaneous - 93 COVENTRY LANE 4/30/2018r Date 1.1 ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that Qj��l I I f1i r. 'A. 0. z I ................ has permission to perform.. e,.j i?,(�L 7":-7. Z. 0. R'\J ...... wiring in the building of ... "i J-�, ...................... at ..... Lr -1 ......... North Andover, Mass. Fee .4-!�'- 0.�24":;* .. rl:� t.. .... Lic. N .. .... Check #Z2- Oq ELECTRICAL INSPEd OR It 11276 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only j Permit No. ' Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z, City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform the electrical work described below. Location (Street & Number) `! � C-0\1 EO � LA►JV-- Owner or Tenant i Bo 1:i W�:> Q ( LE— L)�—,r Telephone No. Owner's Address -�-- D A, W� f— l U23 p `7 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Buildingy S ` nUtility Authorization No. QQ 1 A Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: i Q S7T7A l— ZO KVL) C -TELE 40� --T�Sr::�� Sw tTcC 4 . Completion ofthe following tahle may he waived by the Incnoetnr nfWiroc No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Battery 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons J.KWNo. .....•••... of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices 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 Wiring: No. 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: 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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ 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: k.Utl-LtPrlil -.7-'r ,Tkok)&a� Signature LIC. NO.: j Z (If applicable, ei tq,`exergpt"an the lic nsenumb line.,NQw 1A Bus. Tel. No.- Address: 6 �k �� Alt. Tel. No.: - *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth ofMassachrrsetts 13epartnrent ofIndristr•ial Accidents Office of Irrvestigations 1+ ' = ' 600 Washington Street y {' Bostosr, MA 02111 ivivio.mass.goiJldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�iblV Name (Businesslorganization/Individual): j �L 0, k I . �rlll (1 ui( LCA Address: City/State/Zip: b— _N u t0 Phone #: Ar e an employer? Clie the appropriate box: �l. i am a general contractor and I Type of project (required): 1. am a employer with ❑ g employees (full and/or part-time).* have hired the sub -contractors 6 ❑New construction 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 5.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § I (4), and we have no employees. [No workers' comp. insurance required.] 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Tiny applicant that checks box #1 trust 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 aln all ellfplOJ'ei- tlltlt is pl•ovlthlrg )t,oi-A-e1•sJ coillpelisatioll illslllalice fol• illy employees. Belo)v is the policy and job site information. A Insurance Company Name: Policy # orSelf-ins. Lic. #: Expiration Date: i D_-1'dU1j Jdb Site Address: City/State/Zip: 0 f Wt _ 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 crrtify under the pains and pentrlties of peljwj, that the information provided above is true and correct. Ph Official use only. Do slot write in this area, to be completed by city or to)plr official. City or Town: Permit/License It -�, 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 #: This certifies that ...................... has pennission for gas installation ent..7kc-r— .......................... in the buildings of. ... :S--^—. V--( . ............... Orr at ............. North Andover, Mass. IV Fee Lie. No. . 1.1 .. ...... /. �. GASINSPECTOR Check # a 1 -2,- 84 5 6 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 INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES &NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY N 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 Q AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are ue and accurate toAhe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cance with all,fyhinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \\ ((((((��'��' �YYYYY PLUM BER-GASFITTER NAME al� LICENSE # � SUNATURE MPJ MGF JP]} JGF D LPG] FCORPORATION Q# _ IP®# LLC # COMPANY NAME:.1 _ ' ( TI ADDRESS tiSSa ��u CITY y _ _ STATE ®ZIP $ TEL FAX CELL ]EMAIL �- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Y` CITY(fit! MA DATE PERMIT# JOBSITE ADDRESS r7_ _Jriv�_,_--T-�JOWNER'S NAME Sh�� GOWNER 2 ADDRESS TEL^__IFAX� TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL13 CLEARLY NEW: Q RENOVATION: FJ REPLACEMENT: PLANS SUBMITTED: YES Q NOE] APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER I =j-, I I 1 iPF BOOSTER CONVERSION BURNERCOOK STOVEDIRECT VENT HEATER. I .-f _ :...._ -- --. - - -..— C� wf I . � � . 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 INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES &NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY N 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 Q AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are ue and accurate toAhe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cance with all,fyhinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \\ ((((((��'��' �YYYYY PLUM BER-GASFITTER NAME al� LICENSE # � SUNATURE MPJ MGF JP]} JGF D LPG] FCORPORATION Q# _ IP®# LLC # COMPANY NAME:.1 _ ' ( TI ADDRESS tiSSa ��u CITY y _ _ STATE ®ZIP $ TEL FAX CELL ]EMAIL H °z 0 H V W W z°� O NF -I W } � W LU F IL ftZ LU W F- W Q w 5 � a W w w y w Cl) W �d o a a a J H a a Asa a � w x w LL. W H °z 0 H V W a N c7 r r ,i �J The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations UV. 600 Washington. Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address:I City/State/Zip:)brc,C,,f to I -A g,, phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 4_N? am have hired the sub -contractors a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other t *Any applicant that checks box 41 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. 1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. i am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy # or Self -ins. Lic. #: Expiration Date: 'ob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 -f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigations of the DIA for insurance coverage verification. do hereby pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 02 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 r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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 .elf -insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia r � D m .: n r • r � D m .: n • to F >C: q Z C-) '-' (D 0 0 z cn = U) = D m D CD to D o m.L i z W o g • c ►-� 3 -D D O r -i m < r C M 0 CD 0 a C)m m. mD m S Cl) N �1 t� j ' 1 f t l m This certifies that. paw -r ................ has pennission for gas installation. . -. el� in the buildingh of ....... at .... LT�J: ............. North An #ver Mass Fee(,/, Lic. GASINSPECTOR Check # 8 4, S..' 6 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE -01 J1 PERMIT# �S JOBSITE ADDRESS=? -- r-- , OWNER'S NAME GOWNER _ ADDRESS TE T FAX�f TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: [1 RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES __I NOO_I APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I BOOSTER_ CONVERSION BURNER - �1. -_.... - -I _.._ . I --- - - - --! --�. - COOK STOVE DIRECT VENT HEATER (L -I! i - _ __.. _ ( .,.� f I DRYER 1 �- _ ... ! M FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP TOP UNIT TEST J ! L_.Fl=p - -T�I I^,I-tl __=J L_ I __—J UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER (r-. ....... _................ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. i CHECK ONE ONLY: OWNER 0 AGENT [l SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tr ccurate to the b f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in plianc ith all Perlin ovisio f e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE GASFITTER NAME LICENSE # J ,j NATURE '��--- - MP MGF i JP 13 JGF LPGI CORPORATION D# PARTNERSHIPD#= LLC COMPANY NAME: ,kl -� _ ADDRESS ,�yLQtil� CITY STATE ZIP 3,d TEL FAX CELL EMAIL V, H °z H W W V„ y, o a z O NEl w } � ~ W OH a z w CO) w 5 a aLLI W to a o a a � U J a a a too: � w x w LL W H °z 0 H U W a a° The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: do,,f MA Q) g3D Phone 03 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. [ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work Myself [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reciuired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: Policy # or Self -ins. Lic. #: lob Site Address: Expiration Date: City/State/Zip: attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). �ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 &up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. lignature: Date Offlcial use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia w GENERATOR APPLICATION DATE: I -LI �IIZ LOCATION: L,J. OWNERS NAME: C Q,,sI,t_.11 GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: W PHONE NUMBER: !R:I%-foSS(.-�566 c-p%L.(- CF,---U� 91'�-U (o -(C6105 ELECTRICAL -v RESIDENTIAL F COMMERCIAL TEMPORARY LOCATION OF GENERATOR: G T S1 Da 0 �: C_ rfwT *ZONING DISTRICT: R,4 *CONSERVATION APPROVAL Town of North Andover w Page 1 of 1 http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx ;Select ;(show alp ±Owner Prop_ID i. NIGRELLI, THOMAS] 104.C.0141-0000.( 1 selected^ To Mailing Labels To Spre: Ownerl NIGRELLI, THOMAS) Owner2 JUDY B NIGRELLI Address 93 COVENTRY LANE PropertyM 104.C-0141-0000.0 . Lot Size 43560 S - Fiscal Year 2013 Land Use 101 Code Last Sale 12/26/1986 -. Date Book/Page 2391 Total $643800 Valuation Building CL - - Type Year Built 1987 - 12/3/2012 It Town of North Andover Page l of 1 � f�f � ` a �a�ase,raerccyraa��av�e�rei+eq mt�ap�O.roraegn,..5rir�+mnraw�ors�myrtrrea+rac�: can;Rnr�, `� ��i:�(ds}oxavrryavermrap�iasap`. fl+a tltta doe not ria ailPb�anra�itl9ldai sr sysnnar na s be cram ee ae avert sawWWc lemW.P&V&I& wow" amu. uerrackv.." ft ftca Mme: - �GilMrlaiBlG:gma Wa+elzmzmrsssueeaMl meMeitaxagYeY+9 nvm�€�r:hawBee�[emsesrowreriesrc ao]rYye4 aaid Caortaashn l rN tg et uts taemmtm �. w..a,.�.�.......... http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx aeiernon it Legend p.Location II M Select is J (show all). Owner Plop_ID NIGRELLI, THOMAS ] 304.0=0141-0000.( . I selected To Mailing Labels To Spree Ownerl NIGRELLI, THOMAS J Owner2 JUDY B NIGRELLI Address 93 COVENTRY LANE PropertyID 104.C-0141-0000.0 Lot Size 43560 S Fiscal Year 2013 Land Use 101 Code Last Sale 12/26/1986 Date Book/Page 2391 Total $643800 Valuation Building CL Type Year Built 1987 -.A 12/3/2012 4 Location 93 Zi2-� No. 11fo Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Al—AP13 18584 Building I ctor Zf I A Property Address: n / AIK 1.2 Assessors Map and Parcel -rays - Map Nurn� —" Number: IV Parcel Number 19 /flnff 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS 00 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Front Yard Side Yard Expiration Date Rear Yard Required Provide R red Provided Required Provided Expiration Date Signature ---.,.Telephone 1.7 Water S ly M.G.L.C.40 ' 54) Public t Private ❑ Zone 1.5. Flood Zone Information: / Outside Flood Zone @' 1.8 Municipal Sew a Disposal System: On Site Disposal System ❑ ar,%_ilvn z. - rnvrtulCl Y vWi'NAKbt1tr1AU111UMLLEV A(iUV1 11OLul iu U15Lriuu YeS NO _coof 2.1 Owner of Record �f I/d/,�A42-4 r �. &.AA20� z4me Name (Print) Address for Service: `2� Signature Telephone 2.2 Owner of Record: d6V_Y Njne Print Address for Service: ZAP Sifj2ature Telephone SELTION 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 Ma M X z O v M O z M O on ic r v M r r — z a r SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 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 ....... 0 SECTION 5 Description of Proposed Work (check ail auaiicable ) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. l Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �� ' Jt a-, 66 s�/,� I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY I . Building �O O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Q Building Permit fee (a) X (b) 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 I, , 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 SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION T Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TITVMERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DM ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHNINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE y m x m m y m v m � c �� o to z cto0cr G _ Mo oCA CL m n I Q to C.) 3 m Z CD co y O m ,w?m y Q C o �Ood' S �• oN � � y' o a � m � �„� 0 0 oz y GO m :O CD 0zy rrn a fix:• CD o "0m o a ci C!) m m H : �► Vd a� y n yamcr . r o ate. ya :G o � o c c o o0 yXCn o 0 a h �;�IL= c� " cocool r CL Cos CD 1=0 so= h1711, CA CD CD o� r m CCD _ �..CD cn � o �. g, �. 9d r x r. b r rA � 5 aJ ro n c . x V O O omi 0 0 X 1C F/6 sh rop FORM U - LOT RELEASE FORM 9/7/0� 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 *�* APPLICANTi'�'!S/f//G%C�1 L / PHONE LOCATION: Assessor's Map Number qZO4{4' PARCEL_ZI SUBDIVISION 6116V91 �LOT (S) STREETST. NUMBER 73 OFFICIAL USE ONLY OF TOM AGENTS: ATIM ADMINISTRATOR DATE APPROVED DATE REJECTED TOWN PLANNER COMMENTS J DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT Al. RECEIVED BY BUILDING INSPECTOR DATE Revised 9197Im n D Five 2 wry �- vt,oE�, a S /s/EREBY CE.rT/FY TO THE T/TLE IA/SlirOW 4VP �L O T o L 4AI TO Ti'/ET.vgT Ti✓EO-►'E[GticK v,S LACatTEO OA1 Ti6/E GoT . /S S/fGA✓N ANO TiWT /T OAFS GONFACif/ /N /Y/Tip/ TiS/E 7vfw JETACS79 e*,rX .4�6•LCO/.rt's FCOM ST'CEETS � LOT U•vES. "' ,H/ /l�'1.//J //,j/�/ CERT/FY TN.IT Ti4�/J GIA2rLl/NB /S �/oT / LOC.ITEO /� rwe fEAE.rAL/i��0 .1�.9?t.I 0 .IPE•4, �.PA%✓/V FO.P ' All (S lee= 7.3//.S o-CAit/ Fb,P .NO � ES - iVOT FD.P sovvoty L1C7'E.!'�1�.VA `.vp.�.ry /.f/FOR.!!- �E.P.�/.�l.4Gt' E.f/�.cdEE.P/•v6 .SE.Pf�/lES .�T/O-f/ T•I.NE.S/ f,�,y Ex1-r77-va oemewas. Tio2 / ANDO�'E.�, .f�AS.S.4E.fU/SETTS O/B/O 014c Tamm umt'" of Mus*usEtts letrartment of rubuc %fdu BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Onl Permit No. Occupancy ,& Fee Checked` 3190 (leave blank) Q` 3 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 _ (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date _ M� or Town of NORTH ANDOVER To the Inspe or f Wires: ` The udersigned applies for a permit to perform the electrical work described below. _ Location (Street & Number) Owner or Tenant Owner's Address 1:7AM�A- 01 Is this permit in conjunction with a building permit: Yes ❑ No I X (Check Appropriate Box) Purpose of Building oca /,741 Utility Authorization No. Existing Service Amps Ybits Overhead u Undgrnd ❑ No. of Meters New Service Amps _J Voits Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work If 1414., 44d 4)0 i -CJ No. of Lighting Outlets i No. of Hot Tubs i Total No. of Transformers KVA No. of Lighting Fixtures Swimming Pool Above grnd. � In- �— grnd.:_. Generators KVA No. of Emergency Lighting No. of Receotacie Outlets I No. of Oil Burners Battery Units I No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total I No. of Ranges No. of Air Cond. tons � Initiating Devices No, of Sounding Devices No. of Self Contained Heat Total Total No. of Disposals i No.of Pumcs Tons KV'J No. of Dishwashers I SpacerArea Heating KW DetectioniSounding Devices — Municipal Local! Connection ❑ Other No. of Dryers i Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW I Sions Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of h1 'ssachusetts general Laws I have a current Liability Insurance Policy including Comes ,ed Operations Coverage or its substantial equivalent. YES -/NO = I have submitted valid proof of same to the Office. YES NO = If you have checked YES. please indicate the type of coverage by checking the appropriate box. a INSURANCE = BOND OTHER (PleaseSec.f)0,u � bv't h xptr tion Date) Estimated Value of E'.ectricat Work S _ Work to Start Signed under the Penalties of perjury: FIRM NAME u% Licensee Inspection Date Requested: Rough Final UC.NO. A // P- LIC. NO. 315-1?SIF /1 /X LJGca� v o (n / Bus. Tei. No. Address r LG k� A� ��ac2 Alt. Tei. No. � �TS OWNER'6 INSURANCE WAIVER: 1 am aware that the Licensee noes not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws. and that my signature on this permit apptication waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent) x-6565 Date........ / ............ ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING cc .9 CHU This certifies that ....... ........... ......................... .......... // ............. has permission to perform ................. i ........................................................ ...... U9 wiring in the building of .................... ................ I ............................................ at ...... .................................................. . ....................... . North Andover, Mass. Fee....... .............. Lic. No....., ....... ............................................................... ELEcTwCAL INspEcrOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Date.. ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ -I�t .... VJ ........ ........ .............................. Ili I /' Ir has permission to perform ................................................. wiring in the building of .... ......... . .............................................. e X at ...... 9j ..... 4:::. ....... . Northt6mdover, Mass. ....... ... ...... .. Fee &,(' .... . ...... L� i c.... -No; ...... . 4. .. ............ 0 ....................... RICAL INSPECMR Check# /ZN,0 5 IC; 5 6 Commonwealth of Massachusetts Department of Fire Services - BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PELF( All work to be performed in accordance with the Massachus tits (PLEASE PRINT IN INK OX TYPE ALL INFORMATION) 1 City or Town of: A& A" bravlc By this application the undersigned gives notice of his or her intention to Location (Street & Number) q. -I L.AAI OwnerorTenant -rnM e A/1eR,--u/ Owner's Address Is this permit in conjunction with a building -permit? Purpose of Building Existing Service Amps / Volts Official Use Only Permit No. J V� � t og Occupancy and Fee Checked � 4 ev. 11%99 leave blank )RM EL Electrical Ce Date: To the CAL WORK 527 CMR 12.00 ispector of Wires: electrical work described below. Telephone No-V"f L'19 -fib Yes No ❑ (Check Appropriate Boz) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: IF _r.e„ n a ....r,ls ....,,. ho —i.,d by Iho Inrnerinr of Wires_ INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE- INSURANCE)( BOND ❑ OTHER ❑ (Specify:)/��('�%j(%% /i.�i�.I� 6J (Ex ration te) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepains andpenalties ofpetyury, that the information on this application is true and complete FIRM NAME: Gregory TaylorLIC. NO.: 322bRE Licensee: CRF('nRY Ta3�lar Signature LIC. NO.: 77768E l7fapplicable, enter"exsmpt-inthe license number line.) Bus. Tel. No.: 50 ��06 Address: 7'1'- Pike Street TewkGbury,Mn t11 R % 76 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. ,S Signature Telephone No. Receipt # v� - - - No. of Total No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA o. of Lighting Fixtures Above In-ry Swimming Pool d. ❑ d. J`a o. o Emergency rg mg BattM Units o. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and y� No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Namber Tons KW No. of Self -Contained No. of Waste Disposers Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Sias Ballasts - Data Wiring: No. of Devices or uivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivaient OTHER: srrnr of Wirn. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE- INSURANCE)( BOND ❑ OTHER ❑ (Specify:)/��('�%j(%% /i.�i�.I� 6J (Ex ration te) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepains andpenalties ofpetyury, that the information on this application is true and complete FIRM NAME: Gregory TaylorLIC. NO.: 322bRE Licensee: CRF('nRY Ta3�lar Signature LIC. NO.: 77768E l7fapplicable, enter"exsmpt-inthe license number line.) Bus. Tel. No.: 50 ��06 Address: 7'1'- Pike Street TewkGbury,Mn t11 R % 76 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. ,S Signature Telephone No. Receipt # T 4 Location No. Date TOWN OF NORTH ANDOVER 0 .F Certificate of Occupancy $ '000, Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee/-'�O/ $ TOTAL $ Check # 17103 /--Building Inspe 64r r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Seci+�o for O#il'x Use' OW _ ... . BUILDING PERMIT NUMBER: DATE ISSUED: O j SIGNATURE: Bu'Idin Co krioner/I for of BuildingsDate SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: u �� G � Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: iurvn„irn nr,^ 43.SG7. q .?9/ • 1—unIng 1Jlstnu rTupusw UJC 1-6 RIM.r)iNG SFTRACKS tftl Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided /o ' io' //,? /D' D L1.7Water S ly M.G.L.C.40. 34) 1.5. Flood Zone Information: 1.8 Sew a Disposal System: ic Private ❑ Zone outside Flood Zone 0 Municipal Q On Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record / 7"0rbV_1aur�F�-! _ 93 C oy " 7RT L.A/E - --------- --- Na�e) Address for Service Signature Telephone 1 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.! Licensed Construction Supervisor: IVF_ ,d• mo, -A' T b/5 it Licensed Construction uperviso,r. 7Tow RS�Sma.,A/L?�?05 A& Rwc „/jfe 3064 41A'Wdress Signature Telephone 3.2 Registered Home Improvement Contractor r V/,PbA1AgWNz4/ �ompanv Name Not Applicable ❑ License Number Expiration Date Not Applicable ❑ Lo768.3 Registration Number Vv v 7 -.2 8'oZJr� • DO Expiration Date denature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 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 bui in rmit. Signed affidavit Attached Yes ....:.. No ....... ❑ SECTION 5 Descriion of Proposed Work check all applicable) New Construction lif I Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑I Demolition ❑ I Other ❑ Specify (- Brief Description of Proposed Work: I cc!'TTnw r r CTTM A Tri Tl !`nNQT1aTTrTTnN !'nCTQ I Item - - Estimated Cost (Dollar) to be ��© OI�{FSEIiiYF Completed by permit applicant 1. Building (a) Building Permit Fee 40— Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) OV 4 Mechanical HVAC 5 Fire Protection Ao— 6 Total (1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WIMIN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize % to /act on My beh in all ma s r five to aifthoiizedby this building permit application//23/ `1 Signature of Owner Date SECTION 7b OWNER/XUTHORIZED AGENT DECLARATION I, �UI OIV /n �A/'T1L� �N�(",��,AGt�t/f as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Owner/. ,meq -04 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvfBERS I ST 2 ND3 RD SPAN DINIENSIONS OF SILLS DINIENSIONS OF POSTS DMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFUNMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 k. eIZg1lted 6 FORM - U - LOT RELEASE FORM INSTRUCTIONS:. This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. .. . . . ... . . . ... . . ....... ■ ■ ■ ■ ■ ■ ■ ■ m m m ... m .. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ • ■ ■ ■ ■ ■ ■ ■ now 9 ■ , ■ APPLICANT l` M L/,/N7'4T S�k'C • PHONE ASSESSORS MAP NUMBER / LOT NUMBER l SUBDIVISION LOT NUMBER STREET.._ �.�11�C/V`l . �Q/V ........STREETNUMBER .13 .... Omni OFFICIAL USE ONLY REC MAIENDATIONS OF TOWN AGENTS ................................................. . ............... ■ m m . m m . m ■ �< DATE APPROVED 9 C SERVATION ADMINIS OR DATE REJECTED R k"tW'C.*, 671VED DATE DATE REJECTED '/ 7/D FOOD INSPECTOR - HEALTH DATE REJECTED SEPTIC INSPECTOR - HEALTH CONUVIENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE ;hez) I / J A G N s �E,PEBY oE�cTi,� AW �i`G I tO/,ate, Jf --s4r rS' r ��i.CT.YG'.�' tE.CT/FY F�O.y ST.�'EGri Cf6!/UTp,�/,j• �Ol.ITEO /N AT T.vi� s i sNE.3:. G6 �-4•P,E' .ST.rEETE.P.W6 . �'PvilEs t �f N s �E,PEBY oE�cTi,� AW �i`G I tO/,ate, Jf --s4r rS' r ��i.CT.YG'.�' tE.CT/FY F�O.y ST.�'EGri Cf6!/UTp,�/,j• �Ol.ITEO /N AT T.vi� s i sNE.3:. G6 �-4•P,E' .ST.rEETE.P.W6 . �'PvilEs t 914- �' o . l&.IiBoard of Building afpulations One Ashburton Pface, m 1301 Ptoston ala 02105-1618 License: CONSTRUCTION SUPERVISOR LICENSE Blrthdate: '12124/1948 Number: CS 013965 Expires: 12/24/2005 Restricted To: 00 STEVE A KALAITZIDIS 7 POVVERS LANDING #203 MEKRINI_A.CK, NH 03054 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number �CS_ _ 013965 ! Bitth&te TV -24/1948 EXTr. no: 12346 Restricted 130 STEVE A KALAITZIDIS Tr, no: 12346 Keep top for receipt and.change of address notification, �� U�� f L!C# i , ci.Ass cilL B ow 121241/548 alp, b'S; A // 7 POWERS LANDING;#203 tide � STEVE A KAt MOM MERRIMACK, NH 03054' Administrator 7 POWERS LAIMIG OR 203 . h9ERRIMAOK Nt# ( i .._,',i1.\, ;,,, �%fZ-P VC19�2/It2.O'�ZCI.�<:fZ�fifZ O- c..%•!/((Xik1�,1�C�f?�L•G��E���/.� ` Board of Building Regulations and Standards One Ashburton Place - Room 1301 �3oston. Massachusetts 02108 Home Improvement Contractor Registration ENVIRONMENTAL POOLS INC. Andrew Everleigh 184R Riverneck Road Chelmsford, MA 01824 i, ; h -' Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 107083 Expiration: 7/29/2004 Type: Private Corporation ENVIRONMENTAL POOLS INC: Andrew Everleioh 184R Rivemeck Road ChOms ford. MA 01824 Adminimralnr Registration: 107083 s Type: Private Corporation Expiration: 7/29/2004 •: Update Address and return card. Mark reason for change. ? Address FI Renewal i Employment " i Lost Card rl License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1361 Boston, Ma. 02108 x. Not valid withortt sie name: location: city phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity- the following workers' compensation polices: �a,,..ii�:ii.,. one years' imprisonment as well as civil penalties in the form ora STOP WORK ORDER and it fine of S100.00 a day against me. I understand that a copy of (Itis statement may be forwarded to the Orrice of Investigations of the DIA for coverage verification. I do hereby certi nr he ns an penalti uj�erjury that the information provided above is true and correct. �J 6x Signature Print name officialuse only do not write in this area to be completed by city or town ,7.:: city or town: C) check if immediate response is required E contact person: pertgittllcegse iY nBuilding Department �. C] Licensing Board -" " • •=�❑Selectmen's Office ❑Health Department phone N; rlOther (,-.std 9/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a Joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 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 witp the insurance coverage required. Additionally, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. IN IF City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of InvesligatiOns 600 Washington Street Boston, NI.i. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 L DATE (MMIDD . ) n 10/14/03 PRODUCER THIS CeKTIFICATF- IS 13 FINMRIUTION ONLY AND: CONFERS NO RIGHTS UPON THE CERTIFICATE Curtin-Twinbrook Insurance a 1 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 400A Franklin Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Braintree, MA 02184 COMPANIES AFFORDING COVERAGE COMPANY A C N A Insurance Company INSURED COMPANY B Environmental Pools Inc. COMPANY 184R Riverneck Road Chelmsford, MA 01824 C COMPANY D CO 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. ` COTYpE LTR OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MMIDD/M UiYTS GENERAL LIABILITY GENERAL AGGREGATE S 2,000,000 A X COMMERCIAL GENERAL LIABILITY C 2 067739729 3/24/03 3/24/04 PRODUCTS -COMP/OPAGG S 1,000,000 CLAIMS MADE a OCCUR '.'trp•. PERSONAL 6 ADV INJURY S 1,000,000 OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE S 1,000,000 FIRE DAMAGE (Any one fre) S 300,000 X Per Pro'iect AC,(Q MED EXP (Arty one person) $ 5,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i 1,000,000 A ANY Aura 7841028 3/24/03 3/24/04 BODILY INJURY $ ALL OWNED AUTOS X SCHEDULED AUTOS (Perpe,sm) BODILY INJURY $ X HIRED AUTOS X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN AUTO ONLY: b ANY AUTO EACH ACCIDENT S AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE i UMBRELLA FORM SI51 OTHER THAN UMBRELLA FORM VYORKERS COMPENSATION AND gee ' n Apr, TORY LIMffS ER -,; , , • ? - �� EMPLOYERS' LIABILITY EL EACH ACCIDENT $ 500,000 A THE PROPRIETOR/ INCL WC 2 70863922 5/14/03 5/14/04 EL DISEASE-POLICY LIMIT $ 500,000 PARTNERS/EXECUTNE OFFICERS ARE: EXCL EL DISEASE -EA EMPLOYEE $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Environmental Pools Inc EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 184R Riverneck Road 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Chelmsford, MA 01824 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENT-.OR ; ENTATIVES. 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N m t� cn... .� m N ` d N CD Fw CD p �o cn Z � O A C:� cn a CA .moi ' s CMD C-2 oCA 0 a a z 0 6) �� g o f° o a- � P �� 0 a- 'ti C'" tz �� x a w 0. to r �o ba (), Y O rZ M a 0 c II 0 A i �• 0-3) O c a3 c ]p n n b ee Q ; Y V 0 n A i �• 0-3) O c a3 c ]p r� n b ee Q ; Y C � r o O N3�N�m m S � or ora COcn y�MO 2-i= r z vi ,0 T x r- m ?,) To rn C, ► � Sll�s�� VQ a c n °2 L4 I C � `O o O a � m� i I NEW ENGLAND ENGINEERING SERVICES INC February 24, 2004 Julie Parrino, Town Planner North Andover Planning Board 27 Charles Street North Andover, MA 01845 Re: 93 Coventry Lane Xato %o/ /"'// Dear Julie: This office has inspected the proposed pool location and surrounding area at the above referenced property. No wetland exists within 400 feet of the proposed pool location. If you have any questions or require additional information please advise. Re ards, Richard C. Tangard, PE. tH^M\ ►�' �HARfl , c ' TANGARD r �.0�0� FU/sTER�p '�j�sS/pNAI 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099