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Miscellaneous - 93 JOHNSON STREET 4/30/2018
I o � o w m o Q z U' 00 Z O Orn O rn r" 0 Claim # 2669329 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings Town Hall North Andover, MA 01845 Re: Insured: Stever_ Marsh Property address: 93 Johnson St. Board of Health o Board of Selectmen Town Hall North Andover, MA North Andover, MA 01845 Policy #: 2669329 Loss of: 2014/02/13 File or Claim No. AD 9924 Claim has been made involving loss, damage or destruction of the above .captioned property, which may either exceed $1,000.00 or cause Mass. _Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_ Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 44_a i t�.,'.�.'i(na 02-9-14 S.gnatnre an date: Claim # 2669329 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner cam` Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: Steven Marsh Property address: 93 Johnson St. North Andover, MA 01845 Policy #: 2669329 Loss of: 2014/02/13 File or Claim No. AD 9924 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. _Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_ Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 02-9-14 SNgnature anal date I 10 i't 7 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4e, // *,,'-Alq 7 -c - This certifies that ....... .................................... ............................... has permission to perform ....... ....... h. -AfZon:� .... ��t ... 41,11. wiring in the building of ........... .................................................. .... .... ... ... ... at ............. :� ........... 7��:�� -S .......... North Andover, Fee.?-. Lic. No/��ff� .......... INSPECTOR Check # CnIJ1nW1U&9GWL aj maddar/uLda� oCloParfnwltl< a�..tira �araitni BOARD OF FIRE PREVENTION REGULATIONS Ofciol Use Only Permit No. - 1111117 Occupancy and Fee Checked [Rev.1 /071 0cave blank-) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance widi die Massachusetts Electrical Code {MEC), 537 CMR 12.0D (PLEASE .PRINT 1NINlt OR TYPB A L INFOJ WATIOA9 Bate: </3l /// City or Town of: 1-tNpoylE /2 To the, Inspector of n -es: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 9'3 ,01-11\t,S0AJ S j Owner or Tenant MACSH Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes [- No ❑ (Check Appropriate Box) Purpose of Building cSFD Utility Authorization No. Existing Service 2-00 Amps 120 / 2NOVolts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Worir. KIT-04ETIJ REMO4) 'LL imm�Jnllnn nf►im ! IL....i.... ...RL. .. . t-..._ ..J t_..r_- r. -- No. of Recessed Luminaires ! 2, __... ._.._.. -...._ ,-........ No. of Ceil.-Susp. (Paddle) Fans j ....,.....yr .....un•cu u • u.=.1u� eceur cy 1'r1reS. oaf Total Transformers iCVA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grad. No. at mergency Lighting Battery Units No. of Receptacle Outlets / Z No. of Oil Burners - ALARMS No. of Zones No. of Switches 10 No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cand. Total Tons No. ofAlertin g Devices No. of Waste Disposers ! HentPump Totnis: I Number I Tons it o. of elf- ontained Detection/Alerting Devices No. of Dishwashers Space/Area Heating itW Local ❑ Municipal ❑Other Connection No. of Dryers No. of Water ICY Heaters ]No- Heating Appliances Icy No. of No. of Signs Ballasts Security Systems: No. of Devices or Equivalent Dafn Wiring: No. of Devices or, Equivalent No. Hydromassage Bathtubs of Motors Total HP Telecommunications Wirin : No. of Devices or Equivalent OTHER: nuacn aaamolwi aelau Y destred, or as required b}+rlia Inspector of H Tres Estimated Value of Electrical Work.- SZ-� • oa t (When required by municipal policy.) Work to Start:inspections to be requested in accordance with MEC Rule 10, and upon completion. = == ........... INSURANCE=COYG Gi';: Unless-waived-by-the=o,.vner; no=permit fdr tlie=performance rlfelectrical wacIc=inay=issue vriless the licensee provides proof of linbility insurance including "completed operation" coverage or its substantial equivalent_ The undersigned certifies that such coverage is in force, and has exhibited proof ofsame to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTIER ❑ (Specify:) I certify, rrnder the pains and penalties ofperjuly, that the information on this application is trite and co»rplete. FIRM NA]1'fC: /1 LIC. NO.• LIC. NO.:/3ZP, q Tel. No.:�1.967-61�4 Alt. Tel. No.: *rer tVLU.L. C. 147, S. 57-61, security work requires Department ofPublic Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: 1 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 Signature Telephone No. PERMIT FEE. S 2 7y Licensee: AJ Pt6A14j-C> Signature (lfapplicable, enter "exempt " in the license number line.) Address: Bus. a7y-3� d O O vl b9 O O O O O O O O O Q O O vj M N Ery 69 69 p O 0 0 O O Ln vl 69 Cl 0 V1 N 64 0 0 ki .--1 69 0 0 Q O 0 0 C�! 69 Cl 0 .--1 Q O -� fA O O V 1 N 69 0 O V1 NGS 69 0 O .- 0 O 64 O O 69 O Q vj N 69 O O Q O O O Vl O c!1 N '-• 69 61) 69 O O h.- Cl FA O O 69 O O O kr)N 69 O O V1 69 O O O — 69 Q O O O — Ge 0 0 0 0 O. M 69 CA O O O O 1.0 6 4 69 O O 64 :1 W �' a`i v kl FC G O V O ,..r N •v ,.P..+.1 0 •U C •L o cc E v a �° m U � � o ••O w ° '7 �• b�D c W �. p A 'l. O •� a� G o C m V O R. co o o G ZZ. L1. Q. o� U d U U tn Cl. . ..p y a� a) ,.p , •`� a� � N : it a, C a o a,r c E ..�,, ... I•q. ........... .. .",..... �... �_....... .. .N .................. V V U o cc ul ¢3 a� � o �.�a U m C o 0 o a 0 ca O Fp � L. o G • 1 1+y Lw �• V o F+ d L". U 2,U 'y in N Vl A oL. 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'c ICS: vl U Col ro R7 .D CD w V cn c>~ awE-1 v o v SF-�v�5r>a y a�A� w 5 vi C a.0 UrA0 m Q ¢ ? 1 1:21N m qP I qN M � v-� •-• N M � �p OO O h N fA O O O. O . 0 0 0 0 Cl O v1 of N —hl S1 6R 6R (A O O O O O O O O O V CII —64CII 69 69 fA O O v1 O O tn 69 O Cl Cl O Q O 0 0 0 0 0 fV N NN 1l 64 69 6% O O O O V7 O N vl 64 fA 0 CD 0 0 0 0 0 0 0 0 0 0 O O O O O O O 0 0 0 0 0 O O O to 0 0 Vl Ul O O O 'IT et69N N" N.•-•MNN6%64 69 69 69 b9 64 609 6% 69 69 69 69 Cl 0 .--1 0 0 .- O O O 0 0 0 .. h tai fAN('I b4 69 O O -- E,9 :1 W �' a`i v kl FC G O V O ,..r N •v ,.P..+.1 0 •U C •L o cc E v a �° m U � � o ••O '7 �• b�D c W �. p 'l. O •� a� G C m V O R. co ca V o G ZZ. L1. Q. o� U d U U tn Cl. . ..p y a� a) ,.p , •`� a� � N : it a, C a o a, c E ..�,, ... I•q. ........... .. .",..... �... �_....... .. .N .................. V V U o cc ¢3 Q23 �.�a U m C o 0 o a 0 ca Fp �o�Q�� ~ L. ca 0, Urz G cC Qp C 1.: a�+ 0. q d L". U 2,U in N Vl A oL. O Q y .� aj £ ebdA Q' c o Y a ccr~�� �' 3' 'o •�v •r. ca cp cC o v �• F- ca ca 4r .>� " Q .. V O ob g O y :o y o p ��d+ V y C p G ca c•: y w 4. .0 N 'G G pop y N G CI CD R bo ����UU=�� k. �bC�o .>'•: U�� �a �tj ;C ,C a �•> c° ca cd is o M y c n a� a¢a�: a •o ¢ a .� '� R R cc Ac�xw' ID U ��ww �Q¢¢c cn c) y oarHrn_q U V tC .O U G O •'� of .O U 67 .O A .0 U "O al 4�.. b!1 .^� '� i • O .^�� .^ a• d U N > N z d) d / O x C7 cn 44 .4 � N M d•v�1 � � ooa� ^• El 6 '000� M M 0 iq,W E IF► L -ELECTRICIANS As A.R;E:G.JGURNEY MAN ELE CTRlClkN ISSUES THE ABOVE LICENSE TO. DAMON J PI GNATO ca TURNER RP U) M-A-R-BLEHE&D -MA 01945-2442 13289. B 07/31/13 v 88099ci 1 ,0 . _: � , . r') 8964 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ev This certifies that ...... 0. la ............ has permission to perform ..... 0A, . . . . . . . . . . . . . . . . L -11r, . plumbing in the buildings of . . 5-t s4i North Andoyer, Mass. at. ........ Fee.qk7W. . Lic. No3a 7 7 ... ...... A. -4 PLUMBING INSr E Check# 191 --)( ... MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town-_r k VQ r— MA. Date: Q _&__1LPermit# —,2Q1 Building Location: 7�-nr�In-� { „f Owners Name: c� j�►1, Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residentiale' � New: [] Alteration: ` ❑ Renovation: ,�,/Ltd' Replacement: ❑ Plans Submitted: Yes ❑ No ❑ \ FIXTURES Installing Company Name: YO Check One Only Certificate # Address:�`irgyy�)� f ly./ S� ❑ Corporation _ City/Town:%rl State:ftgl Cel( ❑ ��(���� �I �� �` Partnership Business Tel: -_/D f 7 Fax: � 9��l' 9 ❑ Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below. A liability insurance policy. Q/ Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ,�,� U PI ber Qty/Town aster APPROVED (OFFICE USE ONLYI I ❑Journeyman tgnature of Licensed P e License Number: 9 $q l DEDICATED LU W z 0 S SYSTEMS h� ✓ Y N D Hy CL Z Z F- Y a U FN- W O C Q m W C aR' of } W ..� y 0 a ccz N H W W O LL aLn o ¢ Z aC R Y Z vyi u a �_„ x w u r ?� x 0 c 0 3 E. w V Z a O LL w `� w e `3 a z 2 w w u L- 2 o� _ ¢ o W 3 3 a m m o Ln o LLLLJ xLA 0 g g O N y N 3 3 3 o u a -SUB BSMT. 3 BASEMENT 1sT FLOOR 2ND FLOOR 3" FLOOR 4T" FLOOR ST" FLOOR 6' FLOOR 7' FLOOR 8T" FLOOR Installing Company Name: YO Check One Only Certificate # Address:�`irgyy�)� f ly./ S� ❑ Corporation _ City/Town:%rl State:ftgl Cel( ❑ ��(���� �I �� �` Partnership Business Tel: -_/D f 7 Fax: � 9��l' 9 ❑ Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below. A liability insurance policy. Q/ Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ,�,� U PI ber Qty/Town aster APPROVED (OFFICE USE ONLYI I ❑Journeyman tgnature of Licensed P e License Number: 9 $q l The Commonwealth of Massachusetts wF Department oflndustrial Accidents fj'U'L. (l Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information . Please Print LeaiiblY Name (Business/Organization/Individual): oa Address:- 3 Go iN. i ne-All i m60k 6►ead r -Y) AP,. City/State/Zip: 019 K Phone #: ock 2$1 `5-? 6— Are you an employer? Check the appropriate box: Type of pxoject (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. (full and/or part-time).* have hired the sub -contractors w construction rRe, hamployees 2. ia a sole proprietor or partner- listed on the attached sheet. I odeling ship and have no employees These sub -contractors have 8, molition working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. VBuilding addition required.] officers have exercised their 10.❑ EIKrical repairs or additions 3. ❑ I atn a homeowner doing all work right of exemption per MGL 11. umbing repairs or additions myself. o workers' comp. Y LN p c. 152, 1(4 , and we have no § ) 12.❑ Roofrepairs " insurance required.] i employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowneis who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lie. Job Site Address: Expiration Date: 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 Iead 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 maybe forwarded to the Office of Investigations of the DIA for insurance'coverage verification. I do hereby certify under the pains and penalties ofpeijury that the information provided above is true and cofrect.' Phone #: y Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone M. 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 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 may be submitted to the Department of Industrial Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit or license is being requested, not the Department of Industrial Accidents. Should you have any. questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed Iegibly. 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 pennit/lieense number which will be used as a reference number. In addition, an applicant that must submit multiple,-pen-nit/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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CQmmonWealth of Massachusetts De,parftnent 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 OM IpsRiverPropertyGroup Y FAX NO. : 9783566380 May. 12 2011 03:13PM P1 05/12/2011 14:44 7815937260 CORD„ CERTIFICATE OF LIA THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AI CERTIFIUA I IE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EX BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, tho pt the terms and conditions of the policy, certain policies may require an el certificate holder in lieu of such endomement(s). % Duffy �Ynsurance Agency, Inc. 317 Broadway Wyoma Square Lynn, MA 01904-2602 INSURED David W Byors DBA: Byors & Sons Mechanical 3 commercial Street Marblehead, MA 0194S COVERAGES CERTIFICATE NUMBER: 46 DUFFY INS AGENCY PAGE 01 31 LITY I N S U RAN C EDATE (MMIDOIYYYY) 05/12/2011 iD CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS rENn OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED licypos) must ha andormed. If SUBROGATION IS WAIVED, subject to dorsement A statement on this certificate does not confer rights to the CONTACT NAME: P"781.593.1200 FAIC AX No E>R)781.593.7260 (A!C No : E•MAII ADDRESS; rrcv R cus•[oMER ID a: INSURERS) AFFORDING COVERAGE NAIC tl 1NauaeRA: Safety Insurance Company 39454 INSURER B: Safety Indemnity Company 33618 INSURER O: Liberty Mutual Insurance Group 0032 INSURER D! INSURERS! INSURER F: _ KhVISIUN rvymtSCK: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIRFMFNT, CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. L7fk 7YVF OF INSURANCE ,NSR SuNn LISTED BELOW HAVE BEEN ISSUED TO T HL TFRM OR CONDITION OF ANY CONTRACT OR INSURANCE AFFORDED BY THE POLICIES DESCRIBED LIMITS SHOWN MAY HAVE BEEN REDUCED BY POLICY NUMBER MMLDD/VYYYj INSURI•D NAMtu AeIUVC PUM I rtt rvLtk,t rerclvv OTHER DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJLU I I u ALL THE TERMS, PAID CLAIMS. MMIDD*M LIMITS GENERAL LIABILITY BF00010997 1010512010 10/05/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY TO DAMAOE PREM 15 ES Ea o¢ ED ee $ 100,0()0 CLAIMS -MADE riq OCCUR MUD EXP (Arty onv var x n) S 1 n , 000 PERSONAL & ADV INJURY $ 1,000,000 A GENERAL AGGREGATE $ 2,000t000 PRODUCTS - COMP/OP AGG $ 2 , 000 , 000 GEN'L AGGREGATE LIMIT APPLIES PER; X POLICY JE LOC $ AUTOMOBILE LIAGILITY 5024167 0411012011 0411012012 COMDINED SINGLE LIMIT $ (Ea eccldenl) ANY AUTO BODILY INJURY (Par person) S 100,000 B X ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per accident) S 300,000 PROPERTYOAMAGE $ (Pe(accident) 100,000 '^ Nf)N-nWNPA AIITOS $ UMBRELLA LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE S EXCE33 LIAR _ AGGREGATE 3 ~' DEDUCTIBLE $ W. S RETENTION $ WCZ31S3715O6O1 _ 01!31/2011 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY y / N 0113112012 X '^ R E.L. EACH ACCIDENT $ 100, 000 C ANY PROPRIETOR/PARTNER/EXECUTIVE I�I OFFICFR/MEMBER EXCLUDED? N I A C.L. I)ICCADr - CA EMnLOYEE B 100, 020 (Mandatary In NN) Ir yee, describe under DESCRIPTION OF OPERATIONS below -- — - EA., DISEASE - POLICY LIMIT $ S001000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) v�.n urrvh r r— r wVVGn UANGtLL.ATIUN FAX: 978.688.9S42 SHOULD ANY OF THE THE EXPIRATION D, ACCORDANCE WITH 1 Town of N. Andover °1 Attn; Plumbing Inspector N. Andover , MA ACORD 25 (2009109) The ACORD name and logo are I '(9) 19392009 AC( marks of ACORD ED POLICIES BE CANCELLED BEFORE NOTICE WILL BE DELIVERED IN reserved. r t` 1 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Yarcel Number •F� 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required I Provide Required Provided Required Provided 1.7 Wateramply M.G.L.C.40. 54) Public P Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone Sew 1.8 a Disposal System: Municipal On Site Disposal System ❑ aMs- 11V14 6- YKVYEK 1 1 V W 1'VEKa11W/AU 111VK1GEL AUEIN l 2.1 Owner of Record OL me (P ' t) Address for Service: (> o ?/01 gignattife _ Telephone 2.2 Owner of Record: Name Print SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: l� Licensed Construction Supervisor: 11 Telephone 3.2 Registered Home Improvement Contractor f p 1 c � Company Name I _ ci - `J,A VV, CC Address for Service: -_S� 3S -5 Not Applicable ❑ s-1vOL License Number LUQ Expiration ate Not Applicable ❑ �at0-11-r Registration Number b 1oy Expiration Date Wo M M z 0 0 z M 90 0 mnr M r r ^z V/ SECTION 4 -WORKERS COMPENSATION (M.G.L C 152 § 25c(6) i 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 buildin¢ hermit. Signed affidavit Attached Yes .... No ..... ...❑ SECTION 5 Description of Pr6p6sed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SRCTTON 6 - FSTTMATF.n CnNCTR11CT1nN CnCTC I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building j 7 , Sb �C/ (a) Building Permit Fee Multiplier .............. . 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X (b) / 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 v D Check Number ar,411Uiv is UWfNEH AU 1nUK1,bAllUIN lU UE CUMYLI±;IED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Here ai ortze to act on My i If, in all natters lative to work autho ed this building permit application.; �- ` U- Si na e of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1 1, , ;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 ( Signature of Owner/Agent Date NO. OF STORIES SIZE -2-OL-2."Jo BASEMENT OR SLAB SIZE OF FLOOR TIIVIBERS 1 y,p 2 3 RD SPAN L 13, DM ENSIONS OF SILLS DMENSIONS OF POSTS 4 DINIE NSIONS OF GIRDERS HEIGHT OF FOUNDATION k (b` -THICKNESS SIZE OF FOOTING ` X l MATERIAL OF CHIMNEY N.Y' IS BUILDING ON SOLID OR FILLED LAND Ip -,.r Ln IS BUILDING CONNECTED TO NATURAL GAS LINE t�/�% FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION****"***************** APPLICANT h," -- LOCATION: Assessor's Map Number 09-0 SUBDIVISION STREET PARCEL 2,,6 LOT (S) ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** RECOI ENDATIONS CONI§rffRVATION ADIMN COMMENTS TOWN PLANNER NIQ Til FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS ENTS: R DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print V Location: l� �� cia.✓ S� ig City �LL''� Phone # (fin 53 � I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Address A LI tn., t= V 'I ?,r) Company name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as_well_as_civil.Renaltiesin thelmn-d-a STOP WORK ORDER..and a.fine_of.l$lDD-OD)atiay.againstme. I understand that a copy!A this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby provided above is true and correct. -*Y-s33� Official use only do not write in this area to be completed by city or town officiar City or Town Permit/Licensing Building Dept ❑Check if immediate response is required (] Licensing Board p Selectman's Office Contact person: Phone #. E] Health Department Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: Y (Lg�c tion of Facility) Signature of a it pplicant l I� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1 "=40' DATE 512812002 Scott L. Giles R. P. L. S. Frank. S. Giles R. P. L. S. 50 Deer Meadow Road North Andover, Mass. I CERTIFY THAT THE OFFSETS SHOWN COMPLY VVITH THE ZONING d Y LAWS OF NORTH ANDOVER WHEN BUILT OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. 13972 N 0 z r x w q m u u°. m V) V. o w r z z co w° ao' v :c U G w w a to ao' —cz w u w 04 US w x p U ow. z ao' ii z w w w rQ zto C/) o o C/) ui am wa m ti CD .y CD L- CL a CD .0 C O Co V In - CA 0 0 .y C O V 0 CD Eft O � O L L Q. O a om < c cc OO Z � C. CA C 0 LLJ W W w c y- c s p c C Cl) O C O C.) C.) C. C �: A O 1:52 Ea 0 m 0 si y '!� o=C: .5 O O mtm E CL= CA m e ��m = 3 .. cm > • °' S c Z _N m > y � CLC.) m m m ¢ 50 C, C1 y Z O is c a p c a � H m c N = w O m«3o yD W O L w m y -0t .p....w cc .y . O ~ CL=z r=.. C Z = m .y O V p O m C wa' CO)` m p ti �� � = 4- CL � wa m ti CD .y CD L- CL a CD .0 C O Co V In - CA 0 0 .y C O V 0 CD Eft O � O L L Q. O a om < c cc OO Z � C. CA C 0 LLJ W W w 31 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ T /( (3 ..... FE.4��.7� .............................. has permission to perform ............ .......................... wiring in�the building of .................. ....................................... at ........... 1.5 ....... ..... SZ . ............. . North Andover, Mass. Tee ..... Lic.No..!.M(� .............. 'Ai- - - - �-Sr6. Check# (0 n iucrRICA� INSPECTOV 67 6Y -� uommonweatm of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS �p— Official Use Only Permit No. _ -676-7 Occupancy and Fee Checked ev. 9/OS] save 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 PRINTWINK OR TYPEALL INFORMA77I Date: G, )/ 9 /I t'- City or Town of: X6 . AA-! d ✓ Elk 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) . f s A) Owner or Tenant Q5 � ,� �� Q h Telephone No. Owner's Address . , t1//in4 Is this permit in conjunction with a building permit? Yes ❑ No (� (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd [] No. of Meters New Service Amps / Volts Overhead ❑ Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters V ' Com lesion o the ollowin table may be waived by the I r of Wires. No, of Recessed Luminaires No, of Cell,-Susp. (Paddle) Fans o. of Transformers KVA No. of Luminaire Outlets No, of Hot Tubs Generators K'VA No. of Luminaires Swimming Pool Ye❑ o. o mergency g grad. l d. Butte units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones ' No. of Switches No. of Gas Burners 0.0 etechon an Initiatin Devices No. of Ranges No: of Air Cond. Tons No. of Alerting Devices S No. of Waste Disposers cel um er. ons 1KW o. o ontaut ed Totals: IDetetdiou/Al Devices No. of Dishwashers Space/Ares Heating KW Local Q Connection ❑ Other No. of Dryers Heating AppliancesSecurity ICVN Nof 'evicesorEauivalent No. o ea KW o. S Ballasts Data Wiling, Heaters No. of Dvices or Equivalent No. Hydromassage Bathtubs No, of Motors Total gp eco capons Sent No..of Devices or uiv e . 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 l the licensee provides proof of liability insurance including "comp operation!' tion" coverage or its substanitial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE ElBOND ❑ OTHER ❑ (Specify ;) I certify, under the pains and penalties of per ury, that the information on this application is true and complete. FIRM NAME: ah NS ' 1'P C,ir, G LIC. NO.: / 8 I (a Licensee: ,/D W G�e -e ¢ n1 S Signa LIC. NO,• (o (If applicable, enter " pt " 'n the license nugb�er line Bus: Tel. No. '3 ` Address: r `J a /Z1�1- 01 *Security System ontractor License required for this work, ' licable, enter the license numbbeer hTo . 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 0-v%m r/Agent h ) ❑ D owner's agent. Signature Telephone No. PERMIT FEE: $ Y 1 J�' Date.5 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................... . 4?,r.7 ................................ COL ................................ has permission to perform .......... wiring in the building of ...................... M ................................ at ............................................. S ............... :-:,:In .......... 4qorth Andover, Mass. Fee ..... Lic. No. L3 ... ?� q .............. 7� .. . ...... . c� s E ICAL INS�PE�CTOR� Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. U 9' Occupancy and Fee Checked :ev. 1/07] (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 ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noticeof his or her intention to perform the electrical work described below. Location (Street & Number) 7-�5 �DA 4 =�"�yn s' Owner or Tenant sl/SA h d' _'> Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 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: Com letion of the11 bl b No. of Recessed Luminaires 0 owing No. of Ceil: Susp. (Paddle) Fans to a may a waived by the inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs generators KVA No. of Luminaires Swimming Pool Above ❑ In- o. o Emergency Lighting nd. rnd. BatteKy 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 No. of Air Cond. TotTons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons ....... KW No. 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 Water No. No. of No. of No. of Devices or Equivalent KW Signs Ballasts Data Wiring: . 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 a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE B OND ❑ OTHER ❑ (Specify:) I certify, under the gins ¢ndpenalties o perjury, that the information en this application is true and complete. FIRM NAME: C / C LIC. NO.: 3 Licensee:�t'Gfi f ture LIC. NO.: Sibna (If applicable enter "exemp in the license tuber li ) Bus. Tel. No.: �' 4� Address: tai C'- s%` %�m� � ✓�. 4Z _Z'Alt. Tel. No.: 2:?F-yiy- 3Ty Per M.G.L c. 147, s. 57-61, security work requires 15epartment 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ /)�� / 0/t, 41 The Commonwealth of Massachusetts k� ! Department of Industrial Accidents Office of Investigations 600 YEashington Street Boston, MA 02111 r l www.»xassgov1dia . Workers' Compensation Insurance Affidavit: Bailders/Contractors/Electricians/Plumbers Name (Business/Organization/individual):_ A6 ,- i� a r,�V l-ne Address:--z;Z% City/State/Zip:, Phone #:. Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4, ❑ 1 am a general contractor and 1 employees (full and/or part-time).* 2. ❑ I am a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet ship and have no employees These subcontractors have working for mein 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. 1.52, § 1(4),' and we have no insurance required.] t employees. [No workers' comp, insurance reguired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs l3.❑ Other 'Any applicant that checks bo)t# 1 must also fill out the section below showing their workers' compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their worke s' camp. policy information. I ant an employer that is.providing workers' compensation insurance for m1' employees. Below is the policy and job site information. k Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: 6� g %� City/State/Zip: L4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).r Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th n "afns an�AenaUks ofperjury that t"ormation 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: Date�. / . . TOWN OF NORTH ANDOVER 0 —L�_-Jxfthl 0 # . . 0 PERMIT FOR PLUWING Isis This certifies that ................. has permission to perform ... .......................... plumbing in the buildings of ..................... at . . .4�� :7 .. r ........ > ... North Andover, Mass. F3.0.— 41 ... 1 ee .. . .... Lic. No/,?? ...... ..... ........ PL Check # - 7012 41 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Rl'ashington Street Boston, MA 02111 e-1 www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Nar 1e (Business/Organization/Individual); /� �j/ Q t✓ C %7`Cj �%e Z, Address: �— City/State/Zip: Phone #:. Are you an employer? Check the appropriate box: I-0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am .a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet t ship and have no employees These su&rontractors have working for mein any capacity, workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4), and we have no insurance required.] t employees. [No workers' _- comp. insurance required -1 Type of project (required): 6. ❑ New construction 1. ❑ Remodeling 8. ❑ Demoliti.on 9. ❑ Building addition 10.❑ Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks bort# I must also fill out the section below showing their workers' compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box mustatteched an additional sheetshowing 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. k Insurance Company Policy # or Self -ins. Lic. #: V Expiration Date: Job Site Address: L? 3 J0�4-9 p� g City/State/Zip: /0 #44� Attach a copy of the workers' compensation policy declaratiou page (showing the policy number and expiration date).P Failure to secure coverage as required. under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under thlMatns an�genaltws of perjury that tl�ormation provided above is true and eorreci 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. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) rr 1, NZ3f A.-iboup , Mass. Date `� w-244 Permit# :261 2. Building Location---!L,3yl a j)AJy6'h � Owner's Name Vel eg'tLe Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No ❑ FEATURES Installing Company Address --A Ak Business Telephony Name of Lleensad .111J . Check one - C rporation Certificate INSURANCE COV AGE: I have a Curren lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please i dicate the type of coverage by checking the appropriate box. A liability insurance policy Other type yp of indemnity ❑ 'Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: $lonature of Owner or Owner`s Agent Owner ❑ Agent ❑ I hereby certify that all of the details and the best of my knowledge and that all pit be in compliance with all pertinent prov' By TRIO !`ih.lrn..... I I have submitted (or entered) in above application are true and accurate to k and installationspe d under the permit Issued for this Vplication will Massachusetts State bing Code and Chapter 142 of the General Laws. N Type of License: Master(j.30' Journeyman ❑ 'BASEMENT NOON ONMONNNIM .. - MONO mom NONE �3RD FLOOR MENEM ... ■nnnnnnnnnnnnnnnnnnnnnnnnnIM MENEM �..- ■nnnnnnnnnnnnnnnnnnnnnnn�n� Installing Company Address --A Ak Business Telephony Name of Lleensad .111J . Check one - C rporation Certificate INSURANCE COV AGE: I have a Curren lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please i dicate the type of coverage by checking the appropriate box. A liability insurance policy Other type yp of indemnity ❑ 'Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: $lonature of Owner or Owner`s Agent Owner ❑ Agent ❑ I hereby certify that all of the details and the best of my knowledge and that all pit be in compliance with all pertinent prov' By TRIO !`ih.lrn..... I I have submitted (or entered) in above application are true and accurate to k and installationspe d under the permit Issued for this Vplication will Massachusetts State bing Code and Chapter 142 of the General Laws. N Type of License: Master(j.30' Journeyman ❑ Date/ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . r. Z ................... has permission to perform ... /� �, �� � �- i ................... plumbing in the buildings of ... F / .................. at ................ North A�dover, I Mass. Fee..>.� Lic. No.. ........... PLUMBING INSPECTOR Check # 5491 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location 3 JG Ah s dli Owners Name d ��'' /� ✓�� Permit # ITL( , C / Amount— —r Type of Occupancy New Renovation Replacement Plans Submitted Yes ❑ No FIXTURES (Print or type) Check one: Certificate Installing Company Name /� �C�� h C S Corp. 1CAddress D Partner. r/ u/ usinessTe ep one 1 Firm/Co. Name of Licensed Plumber: G�j,q �d ('/ lm e- 1/ Insurance Coverage: Indicate the twe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnityD Bond p Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner I hereby certify that all of the details and information I have best of my knowledge and that all plumbing work and i stall compliance with all pertinent provisions of the Massasetl City/Town APPROVED (OFFICE USE ONLY QAgent :ted (or entered) in above application are true and accurate to the peed der Permit Issued for this application will be in in o4and Chapter 142-of.the General Laws. Type o� lumbn cense License um er Master D Journeyman Location 7:10 I,� v-, No. kok Date 4 tzq T-,) 8209 Div. Public Works TOWN OF NORTH ANDOVER 'x Certificate of Occupancy $ Building/Frame Permit Fee $ S35 Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ 19 Water Connection Fee $ CU TOTAL $ -9 3 ?-j 6V Building Inspector Div. Public Works PER111T NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP h40. LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK 'PAGE ZONE SUB DIV. LOT NO.I LOCATION PURPOSE OF BUILDING _ OWNER'S NAME � 1 � S 1 NO. OF STORIES SIZE , OWNER'S ADDRESS ADDRESS �1 T`1 �S c �1 BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST .Z�ri. 2ND 3RD BUILDER'S NAME /J�,,,, 4 SPAN DISTANCE TO NEAREST BUILDING^�odAf pc• -� DIMENSIONS OF SILLS DISTANCE FROM STREET U f POSTS DISTANCE FROM LOT LINES - SIDES 65 I REAR Ti I GIRDERS ( 1 iii !r AREA OF LOT j e l FRONTAGE i` HEIGHT OF FOUNDATION THICKNESS THICIKNESS F' IS BUILDING NEW SIZE OF FOOTING �1 X 1 IS BUILDING ADDITION o c �-•t MATERIAL OF CHIMNEY IS BUILDING ALTERATION l `] IS BUILDING ON SOLID OR FILLED LAND G 1 WILL BUILDING CONFORM TO REQUIREMENTS OF CODE e.s IS BUILDING CONNECTED TO TOWN WATERGls BOARD OF APPEALS ACTION. IF ANY + `Q 1V IS BUILDING CONNECTED TO TOWN SEWER e 5 IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILEDANDAPPROVED BY BUILDING INSPECTOR DATE FILED/ t '1 I l :)--(, ( 1 5 — S§GNATUITE OF OWNER OR AUTHORIZED VGENT v ( J FEE 33e. bd V PERMIT GRANTED 9 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST 15 rl 57 a Y EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM -�-� SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPRI OWNER TEL. # k38 i 18 CONTR. TEL. # 11,6 9- �S�3S CONTR. LIC. # CSS "1 H.I.C. s 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION _ 8 INTERIOR FINISH CONCRETE PINE a 1 2 13 CONCRETE BL K. BRICK OR STONE HARDW D _ PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ '/. '/t t/. FIN. ATTIC AREA NO BMT HEAD ROOM FIRE PLACES MODERN KITCHEN _ _ 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 2 3 �_ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING _ CONCRETE EARTH HARD\rJ'D COM/dCN ASPH. TILE VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. 8 FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR POOR _ ADEQUATE NONE 11 1 5 ROOF GABLE HIP 10 PLUMBING BATH (3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. 8 COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ t.r I 13rd ELECTRIC NO HEATING BUILDING RECORD THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. � A-T--Ir-al- c Ll�( rA s. a _o c Q CD 2 C � 770 O C V V d� CLC eo ev m c :z O p i �/� N C ) r= Cc CO :r C th: s Q Z N rj Oo m ca r V O! A K C oM- a+, E o 3 z CO Go �_a o N 0� E • C� Amo o, fl -m � m Cn o c W W� ,R C= CD m w 0 a=� c �� F- CL - m �4Dc o = o mS 3 N � O COD egos CD W O 1- N 3vui CA w x .00 o w° a cn w° c o°' U w ca u. W ce0 w w . v o w°' w°' cn C2 m U) cn _o c Q CD 2 C � 770 O C V V d� CLC eo ev m c :z O p i �/� N C ) r= Cc CO :r C th: s Q Z N rj Oo m ca r V O! A K C oM- a+, E o 3 z CO Go �_a o N 0� E • C� Amo o, fl -m � m Cn o c W W� ,R C= CD m w 0 a=� c �� F- CL - m �4Dc o = o mS 3 N � O COD egos CD W O 0 E co O Z co d ^' O ND 0 � CD am COD o� - a3Q — � y mm O co C3 w �v m Q o �+ Q L m o Q CL CM< C3 C'a Cc CL C3 ts -� C Z G3 C3 CL V y O c C C13 H z 0 w cn z 0 V 1- N 3vui CA 0 E co O Z co d ^' O ND 0 � CD am COD o� - a3Q — � y mm O co C3 w �v m Q o �+ Q L m o Q CL CM< C3 C'a Cc CL C3 ts -� C Z G3 C3 CL V y O c C C13 H z 0 w cn z 0 V +-. Swc�.w3e,.•s .., ... s-. i.. .. .... :. ." ..s:�,,.�a.•�,:»µ ...a....±,:.,...:: ,. .,.o ._a-�: �...- :.x:a�t,'F+,�.�oa�:t+.3'xq?,� 5.. a......,yv.;....+':'-.,+.�ai�cta�:«m:u+-,_ 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 local or state law, regulations or requirements. ****************Applicant fills out.this section***************** APPLICANT:Phone > LOCATION: Assessor's Map Number Parcel Subdivision c Lot(s) Street L S C- ry St. Number ****************** *****Official Use only************************ RECO1�II�iENIA IO F WN ENTS : Date Approved 'Conservation Administrator Date Rejected Comments Town Planner Comments Food Inspector -Health r✓Septic Inspector- ealth Comments Public Works - sewer/water connections Date Approved Date Rejected Date Approved Date Rejected Date Approved 4 Date Rejected - driveway permit Fire Department - jJ`"` /�L��✓�� y�zc/�'J� Received by Building Inspector Date 25.05 _� --7L/OHNSOK . STREET MORTGAGE INSPECTION PLOT PLAN . NORTHERN ASSOCIATES, INC. 630, TURNPIKE STREET N. ANDOVE/a HA, 01845 TEL. 508-975-7117 g0Rr6A8a v STEVEN C. 6 SUSAN E. MARSH LOCATMV 93 JW"ON STREET M, STA Te N. wNDOV15? . JNA DATA' 06/02/93 DEED REF. PLAN RE7r. SCALE:' JOB 1040 J 210 11491.370 1— 40' 9303267 Z5.05 . _.J C RT.rFrED Tar ABBEY FINANCIAL CORP NOTE: This mortgage Inspection was prepared spe4k44 for mortgage purposes and Is not to be relied W as a survey. N6rthem Associates, Inc. accepts no rospon Wily for damages resulting from said reliance by anyw* 41her than the sald mortgagee and Its assigns In connection with Its proposed mortgage financing to said wow - This rtgrVV--,n"cUon was propared in accordance with the ( :nkal Standards for Mortgago Loan Inipoctlons Adopted by the Massachusetts Association of sand &xw' yrs and Civil Engineers, Inc. 179. JOHNSON STREET I FURTHER STATE THAT IN MY PROFESSIONAL OPINION the principle structureJ.s and accessory outbuildings, CONFORM with the setback requirements of the local zoning ordinances, and that there are no encroachments of major improvement either w across ropertY I' os except as shown.aOOp.O9Of ALSO: 7. u �! 1. Property is not in a Flood Hazard Area, r proporty is in a Flood Hazard Aroa. Information Is insufficient to determine Flood Hazard. Fh.)d Hazard dotermined Irom latest Federal Flood Ins 1-mnco Rato Mao Pannll i +3 + C,} + + 1 a t _ J s� t + t + 1 + } 1 } I4 1 1 I I—; } + �. i i + + + + + I �I I + + f + + k + + t -1 t I t eP-" I i I I • + { 1+ + I t + + + I I I I I + t ± + t + 1 4.'3' t t t + + + + + + + + ± + + + + + i + 4- 1 + + + + + +- t- - + + t + + r + + + + t + + + i I I , • I j I I �� I i � I I + i 4 t�+ + 111 I t t t + + i + + + + 1 + } ' 4. + W SIC J] I I I +I f y} �+ t t �` t + T f- i- i } y + f I + j. + E I + I � � +�i i i + I I I � I I , I t + + + + 1 I + + + + + } F I � I I APR 26 195 10:11 FROM GP MANCHESTER NH 'f'c C ration 04/26/1995 11:14 ,Borgia - 17aci z orpo 300 Gay St. Manchester NH 03603 % 3P FASTBeam (C) 199Q-5 GEORGIA -PACIFIC CORPORATION Y 4.10S Project : DOYLE Location BRIAN Mark : 1 Description RIDGEE usage : Roof (Beam) Rep.Strs. - No Max Defl: 1,L = L/ 240 TL = L/ 180 + 26- 0- 0 + nts ® 3.500,565psi ® 3.50",565psi PAGE.001 spacing 0.0" slope: 0.00/12 O.A. length = 26- 2- 0 (span is horizontal dimension to centerlines) project Design roads: Roof- Live- 40.00 psf, Dead- 17.00 W Live+Dead 14&d(T) Live igad(L) DDI, LOCat7an* a Shane IdLd tfid_ art 49 K. -QANa starts Ems _ Arad, _Info.. span Carried 57.0 paf 40.0 psf 15t 0 0 26.00 20.01 S e_ 1 ttmi.form 20.7 vlf 0 1 ❑ 26.00 &if Kt •Dimensions itcer), amsured from left and xhen spaE is o, othexviae, E_ left end of the specified span Support Max R°n (Ibs) Min R'n (lbs) DL R' n (lbs) Min Brg ( inch) Brg Str (psi) 1 2 7679 7679 2479 2479 2479 2+79 2.66 2.66 550 550 Design Value Span# x Group Allow Ratio V (lbs) 6707 1 1- 8 41 18113 0.37 M (ft -lbs) 49914 1 13- 0 41 72721 0.69 D-LL(inch) 0.85 1 13- 0 41 1.30 0.55 L/368 D -W inch) 1.25 1 13- 0 41 1.73 0.72 L/249 USE: Gp MpLANRNI 2.0 18 (1.75x18.00) 3 plies Master Plank LVL tm McCausey Lumber Co. RCyI'3& 3. Desigsm& in acCsrdance with Natiamal Design bpecifications for Wood construction anti appliaiaLe Appzovals or Reserlizercii R:lrparta. 2. Fxovide leteral support at the be4wing IOCaticn neaseat cach end of the uK"ber. Ccnkiautnra lateral avpport reg�4red for cvV—Bioo eche. 3. Loads have been input by the user ?ltd have not been verificd by Ggoze�ia-Pacific Engineered Lumber Techisfeal $sYvices. 4. Design valid far dry use only. S. Bearing length based On design s&terial; support materiai capacity shall be verified tiny others)- $- Roof Ut"e: Install with minitmmt 1/4LI2 slope for adequate drainage. 7. When rogwired by the building code, a rasistered design professional ar haf2dxq Official should verify the input loads and prodaet applseatien. e. Thia engineered IwMer product has been siz*4 for zideatial use. A Concentrated load tkeck, per the knti1ding C rsOde, mast be perfo=Wd fon acamiasei.al. uses. 9. Verify that load is applied at top or eq+aally Exam Loth sides. la. Nail plies e*getbar with 16d nails 0 12 o/c alon3 top pad bottom edges rind thm center. Nail from alternate faces, 2 from arises. 11, Cwpany, product or brand names referenced ars trademeks or xcgiatexiod trademarks of their respective owners. a i Post -W Fax Ncft7671 Sana #d FMM To �T� ♦ d ff0;DAh.3pt CP�aeR ** TOTAL PAGE. 001•• T* ,• qv" CONSTRUCTION ENGINEERING SERVICES JOB vez 12 Pleasant Street SHEET NO. l OF / NEWBURYPORT, MASSACHUSETTS 01950 (508) 465.2216 CALCULATED BY DATE `� ZS S CHECKED BY DATE Sr.A1 F p, � � �� , �s 1"lc�s� �S � r � MASSACHUSETTS UNIFORM APPLICATON FOR PERMPT TO DO GAS FITTING C (Type or print) Date e? -2 3 NORTH ANDOVER, MASSACHUSETTS Building Locations 03 3 h s G 71 S1 Permit # nn /�- Amount - /?Y�. V/- k/ ''I Owner's Name 5. MAS New ID/ Renovation ❑ Replacement ❑ Plans Submitted ❑ Address f !� ❑ Partner. �S� 3 Business Telephone ®Firm/Co. Name of Licensed Plumber or Gas Fitter L,4.4.�� INSURANCE COVERAGE Check one. I have a current liability Insurance policy or it's substantial equivalent. Yes ❑/ No ❑ Ifyou have checked yo_ please indicate the type coverage by checking the appropriate box Liability insurance policy ❑ Other type of indemnity ❑ Bond D Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Sienafure of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby cerhty that all of the details and miormation t nave submitted (or entered) in above appllcanon are true and accurate to the best of my knowledge and that all plumbing work and installati°s performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachq4is Stie Ga�,od *AChapter 142 ofthe General Laws_ ICity/Town OVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber d-e,13zxGJ ❑ Gas Fitter License Number ElMaster n/(ourneyman a0 W W 0 W CIO E» a O O O C7 U d E p GZ W Gx w w � � � w a� � a4 w �aw r„ x Go 8 0 SUB-BASEM ENT BASEMENT IST. FLOOR 2ND. FLOOR ti 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) /'� ^^ l �� ` Checkone. Certificate Installing Company Name xf G `C l Corp. Address f !� ❑ Partner. �S� 3 Business Telephone ®Firm/Co. Name of Licensed Plumber or Gas Fitter L,4.4.�� INSURANCE COVERAGE Check one. I have a current liability Insurance policy or it's substantial equivalent. Yes ❑/ No ❑ Ifyou have checked yo_ please indicate the type coverage by checking the appropriate box Liability insurance policy ❑ Other type of indemnity ❑ Bond D Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Sienafure of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby cerhty that all of the details and miormation t nave submitted (or entered) in above appllcanon are true and accurate to the best of my knowledge and that all plumbing work and installati°s performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachq4is Stie Ga�,od *AChapter 142 ofthe General Laws_ ICity/Town OVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber d-e,13zxGJ ❑ Gas Fitter License Number ElMaster n/(ourneyman Date ��. -. .'5:�7 .? . . . . . . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... .................... has permission for gas installation . . P. L') ..................... in the buildings of . ............................. at ........ 0 No4 Andover, Mass. Fee.,��.)..--- . Lic. No ........... ....... AS * INSPECTOW Check # K ( III 'A. 3 0 4250 Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ...... ............................................... t U '-) has permission to perform .... ........................................................................ wiring in the building of ... ......... .............................. at ... 9. ...... .............................. I North Andover, Mass. .... .. ....... I 3, P1401A Fee. ....... Lic. No. . .............. ........ ...... ..................... i��CrRICAL INSPECrOR Check # .x THE COMMORfflEALTHOFMASS4CHUSEM Office Use only DEPARTA11AT0FPUXJCWMy B0,4RD0FFIRCPREVF,NI70N HONS527CMR12.� [occupancy ermit No. & Fees Checked APPLICA77ONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) ,� �/ Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wires: Location (Street & Number) Owner or Tenant <404 Owner's Address Is this permit in conjunction with a building permit: Purpose of Building 5 j 'mi l Q. Existing Service Amps Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work v No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets 30 No. of Switch Outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers Vo. of Water Heaters KW io. Hydro Massage Tubs No. of Hot Tubs Yes ® No (Check Appropriate Box) Swimming Pool Above No. of Oil Burners A ^ y Utility Authorization No. Overhead Underground No. of Meters Overhead Underground No. of Meters :B*No. of Transformers elowGenerators No. of Emergency Lighting Battery Units No. of Gas Burners No. of Air Cond. Total FIRE ALARMS Tons No. of Heat Total Total No. of Detection and Pum s Tons KW Initiating Devices Space Area Heating KW No. of Sounding Devices No. of Self Contained Heating Devices KW Detection/Sounding Devices Local Municipal No. ofNo. of Connections Si ns Bailasis No. of Motors Total HP Total KVA KVA No. of Zones M Other tranceCovaagft RusumttOthe ><equiteni2MOf dalse:LSG=al laws waaunrltLiabl*kis ua mp,Db cy>t Coverageorits e,,,,by msubnf*dvalid p m?Ofmw10the Offim YES Zoww M NO �g�CJ � ffywhaNedirkediilt et hetypeofmvaagebY URANCE BOND OMER (PJea9eS,*) LLT�JJ F%piratimDek kto Start Esti =W ValreofE W� $ N1urxi2r7 iePtrlaltiesOfperjtny h ectionl Rarer Fina1 4NAME ^, IxerseNo. 39oa tEr �+ n INo cs--f Ll City S7�%/t� I ` p SEA e � 4 n Bus�Tel �2 S INSURANCE WAIVER, Iam aware that the Licere does notMPI have the instttart� wvaa,°e orits substantial Alt Tel. No. Z � atmysigmhueonthispemlitapp ® t}vsregtmz lmt equivalulasm4wedbyMamdn CcnealLaws se check one) Owner Agent Telephone No. PERMIT FEE $ Signature o caner or gen Name lama The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02119 Workers' Compensation Insurance Affidavit 4i performing all work myself. I am a sole proprietor and have no one working in any capacity Please Print ft I am an employer providing workers' compensation for my employees working on this job. Company name: Q ; C- Y, Q j CACC) Address 1 GctJ %ILD "A.,. City: q U S Phone #- Insurance. Co. W cv, r, -L A\10 *1 D-1;-, 441 Company name: Address City: Phone # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment-inthelmn�f-a-STDP.WORK..ORDER.aad..a fine.cf.($1.0OM)artay.againstme1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the infarmatian provided above is true and correct. 00'% — - Signatu Print name P ; C cmicrai use only do not write in this area to be completed by city or town official' 1113 0 le # rQ - 7C-0 7r City or Town PermitiLicensi ng❑ El Check if immediate response is required Building Dept ❑ Licensing Board Contact person: E] Selectman's Office Phone #. ❑ Health Department ❑ Other xx� .,..o W O.jes z r 'I •F' h hM01. ; y Ro I s. ,4 UJ o CL • � o ' O ` c h OG V ci CL ZG � =.vo • :oma N M .EaO 0 CA y E c ZkC2 m c E E D CM G •: m ,•yo _ m � M c c H m •� O = tm mm o CD G y � c�v�o c� •� Z o 0 c _ m N o m G •G CD m . 3 N i— h 0 m ca z Go CL=Z m o`er m•y O C ®mac 5 V� CL _ m` y•= O U O 0 s Z CD CL O y D O O cm O 'a D _ H O O �E m m CD cl CD m CD Cc O d a- cmQ ca C O = C �� v J= .a. O CD CD V CO) R C C cts i. O. CO2 0 Cn U) w W W VJ � v E � .w U to z ib w Ay u. m u. b O a�G r� cn cn ,4 UJ o CL • � o ' O ` c h OG V ci CL ZG � =.vo • :oma N M .EaO 0 CA y E c ZkC2 m c E E D CM G •: m ,•yo _ m � M c c H m •� O = tm mm o CD G y � c�v�o c� •� Z o 0 c _ m N o m G •G CD m . 3 N i— h 0 m ca z Go CL=Z m o`er m•y O C ®mac 5 V� CL _ m` y•= O U O 0 s Z CD CL O y D O O cm O 'a D _ H O O �E m m CD cl CD m CD Cc O d a- cmQ ca C O = C �� v J= .a. O CD CD V CO) R C C cts i. O. CO2 0 Cn U) w W W VJ �, �iiit UIdliItNUN1Utal �Ila�>�f�>Irl�uflettf5 Office Use Only Ing I bepol ifil fif of Milt: Solely Permit No.`� 00ARb OP PIRI: 011MOON kboULATIONS 527 CMR 12:00 Occupancy & Eee Checked APPLICATION I=OP 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 INEORMAtION) Date �l/'? �l�S City or town of O//© V e To the Inspector Wi►Ls: At! of undersigned applies for a permit to perform the electrical work described below. 0 Lbcalion (street to Number) 23 o Li h o S f Q F Owner of tenant S 7/C v e f Sus az A/r F t-I/I Owner's Address Is this permit in conjunction with 4 building permit: Yes ® No ❑ . r (Check Appropriate Box) Purpose of Building lv � Utility Authorization No. _ 61.014g §t±rvitt Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of keeders and Ampacity, No. of Meters No. of Meters Location and Nature of Proposed Electrical Work;Ct,v.��ly /c�eo., /ddi71iQ 74-A17(— No. of Lighting Outlets 0 No. of Hot tubs TOTAL No. of Transformers KVA No. of Lighting Fixtures Above In - SwimminS. Pool rnd. rnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas (turners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices of Sounding Devices. No. of Self Contained No. of Ranges Total No. of Air Conditioners Tons No. of Disposals Heat Total TotalNo. No. of Pumps Tons KW No. of Dishwashers SpacetAtea Heating .KW Detection/Sounding Devices. Municipal Local" ❑Other No. of Dryers Heatingbevices 3 kW Connection No. of Water Heaters kW No. of No. of Signs Ballasts Low Voltage Wiring Wo. Hydro Massae Tubs I No. of Motors total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws have a current Liability Insurance Policy Including Completed Operations Coverage or Its substantial equivalent. YES Ej NO O 1 have submitted valid proof of 34me to this office. YES ELNO ❑ If you have checked YES, Please Indicate the type of toverage by checking the appropriate box. INSURANCE BONb LJ OtNER❑ (please Specify) Estimated Value of Electrical Work >; / �� C ° 0 (Expiration Date) Work tri start _6��9—s Inspection Date Requested: signed under the penalties of perjury: FIRM N, .licensee Address Rough r,v/'/l C 6 § Final _ LIC. NO. 1-3 �/ % _ LIC. NO. 6-23 GO G Tel. No. All. Tel. No. .OWNER'S INSURANCE WAIVER: I am aware that the Licensee dobi hof hive the insurance coverage or Its substantial equivalent as required by Massachuetls .General Laws, and that my signature bn this Ormit application waives this te4uirement, Owner Agent (Please check one) telephone No. PERMIT FEE i (Signature of Owner or Agent) I Location lq�v�soy\ �f, No. Date TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ 500 � 01 CHU —7— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ It, 500, OP Check # 15541 Building Inspector '40 4, .. '6 0 0 49 SACNU Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that L..! 7�. A -k A ............. has permission to perform ....... 0� el " �r ' k wiring in the building of ............. .... . .......................... ...... .................................. . North Andover, Mass. Fee..................... Lic. No..(41.3:� I ............................................................... ELECTRICAL INSPECTOR 06/19/95 11:07 55. 00 PAID PINK: Treasurer GOLD: File WHITE: Applicant CANA ; RY: Building Dept.