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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... . ..............
has li mission for gas installation Y�U.4 ... e-ez .......... .
f4�j . ... ........ ... ......... .... ............
inthe buildingso .........................................................................
at ....... ...... f�rX ................... . 2 ......... ; ....... North Andover, Mass.
FeeARO . 7 ...... Lic. No. 15bqt� ..... N -�� ...................................................
..........
GASINSPECTOR
Check
0 9 S" 0 3
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'DATE[A' PERW
CITY A
JOBSITE ADDRESS ST- OWN E R'S N AM E
OWNER ADDRESS =TE _7:7::�JFAX
TYPE OR
.PPJNT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CXXARLY NEW: F-1 RENOVATION:E] REPLACEMENT: [3— PLANS SUBMITTED: YES El NOM—
]-iiii-I 1 4 1 5 1 6 1 7 8 1 9 1 10 1 11 1 12 1 13 1 14
APPLIANCES 1. FLOORS- 1
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
TOR
GRILLE
INFRARED HEATER
LABORATORYCOCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/ SPACE HEATER
ROOFTOP UNIT
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE I
I have a current Ilabilify nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YESWO 13
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND F -j
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and acc �0! I a �bx f nowledge
0
of
rmit issued for this application Wil be' I'
and that all plumbing work and Installations performed under the pe Pe r n the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I -Da,,j,cz, (,) r,,_..cj-rc-C7> ]LICENSEM 136149111;�'- t1- - -SAATURE'
IMP D"'MGF El JP [I JGF E] LPGIE1 CORPORATION PARTNERSHIP ED#[:= LLC; [39=
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COMPANY NAME:FJ�,-:,---e--
_:]ADDRESS
CITY Et =tyl ZIP
STAT A ___]TEL
FAX � CELL EMAIL rn 14 1 1
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FEENBRO-01 SMORAN
.............
CERTIFICATE OF LIABILITY INSURANCE
DATE (MhttDDNYYY) --
113012015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cortificato holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsoment(s).
PRODUCER
Ro ers & Gray Insurance Agency, Inc.
43TRt, 134
South Dennis, MA 02660
CONTACT
NAME:
PHONE FA—X
NOMN—Lo - Exti: No): (877) 816-2166
-ADDRESS'_
INSURER(S) AFFORDING COVERAGE NAIC 0
A2CG0750160i
INSURER A: Old Republic General Insurance Corp. 24139
0210112016
INSURED
INSURER B:
Feeney Brothers Services LLC
103 Clayton St
PO Box 220801
INSURERC:
INSURER D
E:
Dorchester, MA 02122
-INSURER
INSURER F:
$
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE 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 VvHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION$ AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
Ty E OF INSURANCE
ADDLISUBR
INSO
%'No
-POLICYNUMBER
LICY EFF
IM&VDDJYYYY)
POLICY EXP
(MMJDDrfYYYJ
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE M Or -CUR
A2CG0750160i
0210112016
0210112016
EACH OCCURRENCE— S 1,000,00(
PREFJISES Ea occurrence) $ 300100(
MED EXP (Anyone person) $ 10,nn(
PERSONAL &ADV INJURY 1,000,00(
GEN LAGGREGATE LIMIT APPLIES PER�
PRO-
POUCY FRIJECT M L6d
ROTHER:
GENE . AGGREGATE 2,000,00(
PRODUCTS - COMP/OP AGG S 2,000,00
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALLO"NED SCHEDULED
AUTOS AUTO$
NON -OWNED
HIREDAUTOS AUTO$
H .
ED,)5INGLE LIMIT
219.'Ndan $
SM LYI NJURY (Per person) $
BM LY INJURY (Per accident) $
PRO AMAGE $
$
UMBRELLA LIAB
EXCESSI.IAB
HCLAIMS-1AADE
OCCUR
EACH OCCURRENCE $
AGGREGATE $
OED I I RETEW(ON$
$
A
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETO"ARTNERIEXECUTfVE
OFFICERWE).MER EXCLU
(Mandatory In NH) FRI
Ues,d scri'boundef
ID SGRIOPTION OF OPERATIONS below
NIA
A2CW07601601
021011/20115
020112016
X �PERT
STA UTE I JER
E.L. EACH ACCIDENT 1,000,000
E.L. DISEASE - EA EMPLOYE 1,000,000
E -L DISEASE -POLICY LIMI 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES JACORD 101, Additional Remarics Schedule, maybe attached Itmofe space Is required)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover, MA 01845
AUTHORIZED REPRESENTATIVE
0 1988-2014 ACORD CORPORATION. All rightsi reserved.
ACORD 25 (2014101) The ACORD name arnd logo are registered marks of ACORD I I 'i
Date. ?-7. or—.C—j ........
40RTN
x ... TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
SACHUS
This certifies that../ ......................
has permission for gas installation . . ...................
in the buildings of ... I I I I
.................. .............
at ... ............... North Andover, Mass.
Fee...�!�.'.. Lic. ........
GASINSPECTOR
Check #
5'16-9
A
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LOON
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IN SURANCE -CO-VERAGI_:-,
I have a CWM -kw
Aflabft manm
pdiw-*r Its substantWVequhWeq*.wt*:h -meets, tM -fequiremaft
yes No 13
if YOU ham:chacked-3tg;npiaaw*vcncaW-:It.4
ftc-=�gezbych�V*
2PPMPdate�box,
A li"ItY kmwar*cevoqcyX.
O#wu-- bA)j ccWannity. [I.
P"IMOS INSU . RAt4CE Bond- 0
A?M_ro_thr,�g--VW kuwaam
Chapter-. 142af-the-Mam-GeraW��Laivc-wwv* -on 'Covenge requiredj)y.
-Mly.,signative- -this pem* 2PPU=Mon wabees Afft requirement
Cbe<* onet
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Owner(3 Agest,13
A hereby -detais w
cW* tW AR Of ft,
kAOWIO-dge ww %d kdormation.1- have Mft*W (Or Sfft"4 in abm
Partivierg P(OVWMS d OMW*Q Woki�i kMWWW"PWkmMd appkafion ara bue. and accurate.to,the bdd,of
of the Manichusefts StMe. Gas under the pwo - for US. MY
Code WW ChaW*� 142 of the wiN be in pfiw4i
BY.
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or or
city/Town MiAer License Number
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I have a CWM -kw
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pdiw-*r Its substantWVequhWeq*.wt*:h -meets, tM -fequiremaft
yes No 13
if YOU ham:chacked-3tg;npiaaw*vcncaW-:It.4
ftc-=�gezbych�V*
2PPMPdate�box,
A li"ItY kmwar*cevoqcyX.
O#wu-- bA)j ccWannity. [I.
P"IMOS INSU . RAt4CE Bond- 0
A?M_ro_thr,�g--VW kuwaam
Chapter-. 142af-the-Mam-GeraW��Laivc-wwv* -on 'Covenge requiredj)y.
-Mly.,signative- -this pem* 2PPU=Mon wabees Afft requirement
Cbe<* onet
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A hereby -detais w
cW* tW AR Of ft,
kAOWIO-dge ww %d kdormation.1- have Mft*W (Or Sfft"4 in abm
Partivierg P(OVWMS d OMW*Q Woki�i kMWWW"PWkmMd appkafion ara bue. and accurate.to,the bdd,of
of the Manichusefts StMe. Gas under the pwo - for US. MY
Code WW ChaW*� 142 of the wiN be in pfiw4i
BY.
T Gala.
or or
city/Town MiAer License Number
Man
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Date...... .......................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
A �-.US'
Thiscertifies that .............................................................................................
has permission to perfo rin ......... A?�
.....................
wiring in the building of .................. ..................................
at ............. 1.:� ... gk&
............................................... North Andover, Mass.
3
Fee.N4?-O--� ... Lic. No . ............. ...................
�E
ELECMICAL
Check #
7644
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07]
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (M 27 CMR 12.00
PLEASEPM7flVflV
K OR Yy
PE,4LL I
N
FORM
,4T
ION
Date: 41 200'7
City or Town of.- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) f .3 Re es C 0
Owner or Tenant L"AALA
Owner's Address Telephone No.
Is this permit in conjunction with a building permit? Yes EPP No (Check Appropriate Box)
Purpose of Building ZA;61tri., -< I Utility Authorization No.
Existing Service /00 Amps 12o 2Vo Volts Overhead F Undgrd 0 Na.� of Meters
New Service Amps Volts Overhead EJ Undgrd El No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
A, S�44J
— ', e
4%,
Uompletion of the followin ble inay be waived by the Ins ector of Wires.
No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans 1140.01 Total
Transformers WVk
No. of Luminaire Outlets No. of Hot Tubs Generators KVA
No. of Luminaires Abov 0. oi Emergency Ughting
Swmuning Pool In-
- ::!�nd. El rnd. B"atte Units
No. of Receptacle Outlets No. of Off Burners FIRE ALARMS No. of Zones
No. of Switches 1.3 No. of Gas Burners o. of Detec *on nd
IwWtiatina D . ces
No. of Ranges No. of Air Cond. Total
I ons No. of Alerting Devices
I , 1!11 ri 1 11 i 11!1: 1:!! i�:
No. of Waste Disposers Heat Pump I Number Tons 114E
Totals: I-*-** ...... ........... — .................. ................... ..
Detection/Alertinn' . Devices
No. of Dishwashers Space/Area Heating KW Local 0 C
onne9E�—ElOQther
ction
No. of Dryers Heating Appliances KW Security s ms:* %
No. of Water No-.-6f—No. of No- of Devices or Equivalent
Heaters KW S, BaHasts Data Wiring: I
No. of Devices or nivalent
No. Hydromassage Bathtubs No. of Motors Total HP Teleco-mmunica 'ons Wiring:
OTHER: No. of Devi- - or E
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: d a — (When required by municipal policy.) I
Work to Start: /4 / - Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C01�61 R�ILCIF t 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 W BONDE] OTHER F-1 (Specify:)
I cerl�o, under thepains andpenalties ofperjury, that the information on this application is true and completa
FIRM NAME:
Licensee: --) C. X LIC. NO.: /JI
- et 44,,1- Signature LIC. NO.: 13 (.9 5—
(Ifapplicable, enter "exempt " in the license number line.)
Address: 0?/ 4c4ss' * Oq A -`f- Bus. Tel. No.:
Alt. Tel. No.: 60 3 FJ 3 Vyy14-
*Per M.G.L c. 147, s. 57 -61, -security work requires Department of Public Safety "S" License: Lie. 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) R owner [] owner's aRent.
Owner/Agent
Signature Telephone No.
0
0 -7
67
1�
I
of
U,
The Commonwealth of Massackuselft
Department of Industrial Accidents
QJf1ce of Investigations.
600 Washington Street
Boston, AL4 02111
I www.rnass.gov1d1a
Workers' ComPensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers
A�Plicant Information
Please Print Legibly
Naixie
& Ir
Address: .21 ca-wd;1-oo AV,(
City/State/Zip:
Phone#:
Are you an employer? Check the appropriate box:
I - 11 I'Eim a employer with 4. 1 am a general contractor and 1
Type of project (required):
m
e ployees (full and/or part-time).*
2. WI am a sole proprietor or partner-
have hired the sub -contractors
or7
listed on the attacheidsheet
6. C] New construction
7. E] Remodeling
ship and have no employees
These su&contractors have
8. Demolition
working for me.in' any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. We are a corporation and its
9. Building addition
required.]
3.[3 1 am a homeowner doing all work
officers have exercised their
right of exemption per MOL
10. R Electrical repairs or additions
I LM Plumbing repairs or additions
myself. [No-workeirs� comp.
c. 152, § 1(4),'and we have no
12.[] Roof repairs
insurance required.] t
employees. [No workers'
13.[] Other
comp. insurance required-]
—, -PF .. . ... W1qUKN oux IF I MUST also n1l out the section below showing their workert' 6orrrperisatio� policy information,
t 140meowners who submit this affidavit indicating they am doing all work and then hire otuside contractors must submit a new afri . davit indicating such.
lContractors that check this box mustattached an additional shectshowing. the name ofthe subcontractors and
their workers' comp. policy information.
.... ...................
I am an employer that is Prquidingworkers I compensadon ins Below if the policy andjoh site
information. UranceJor M efflFlOYedL
Insurance Company Name:
Policy # or Self -ins. Lie.. Expiration Date:
Job Site Address: CitY/Statr./Zip:
Attach a copy of the worke mt'compensiition 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 fon-n 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 uyder the pains andpenalties ofperjury that the information provided above is true and correct.
Phone 7 f ?(- Y?
Officiatuseanly. Do not write in thEy area, to he completed by c* or own officiaL
City or Town:
PermittLicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityfrown Cierk 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 enWloyer is defined as "an individual�, partnership, assodiation, 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 timstee -of an individual, partnership, association or other legal entity, employing employees. 'However the
own6r.-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 mainteriance,,construction or repair wdrk on such dwelling house
or on the grounds 6r buifding' 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.te construct buildings in the commonwealth for any
applicant *ho has not produced' acceptable evidence of compliance . with the insurance I coverage required."
Additionally, MOL chapter 152, §25C(7) states 'Neither the commonwealth nor any of its political subdivisions shall
enter into any conm& for the performance of public work until acceptable evidence of complie mce 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-contracto�s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Lim ited 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 affidavitmay 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 mquested, 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'appropnlite he.
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 permittlicense 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 affidav�k is on file for fiAire 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 of permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooptration and shGUld 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 Investi.-Stions
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 6xt 406 or I - M.-MASSAFE
Revised 5-26-05 Fax 4 617-727-7744
www.mass.gov/dia
Date ..... /�/
TOWN OF NORTH ANDOVER
G
PERMIT FOR AS 1,14/STALLATION
This certifies that ... /? . P. ! .... J" A 7-/
..................
has permission for gas installation ... P -. t -f KI.
in the buildings of ��e -.9. ...........................
at ..... P/)'!� .............. I North Andover, Mass.
Fee. Lic. No.. P. .. ......
GASINSPECTOR
Check # .5
6229
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date "1 7
Perm,7# ? 7-1
Building Location Owners Name
Type of Occupancy Amount
New Renovation Replacement Plans Submitted Yes No
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(Print or type) Check one: Certificate
Installing Company Name 2, 1- t- -
L Pl.� Corp.
Address 3 ?"0141f Eel J))q/1VL,//'dr Partner.
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Business Telephone(. ke:�, � - 0 Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box:
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Liability insurance policy �r Other type of indemnity Bond
17 F1
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 I Owner 1:1 Agent rl
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and i . ns perforine er Pe * ssued for this application will be in
compliance with all pertinent provisions of the M�a an�� ts State PI 0 apter 142 of the General Laws.
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By: L>gna
,We ojXicense0ZPTum5er/
Type 6f Plumbing License
Title
lCity/Town Master
APPROVED (OFFICE USE ONLY j rMse IN UMDer ourneyman
Date. //- ?��4 ?
01tTh
TOWN OF N'ORT'H ANDOVER
0
PERMIT FOR PLUM,BING
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This certifies that 1: ......
F�. 11, ......
has permission to pe rform ......
P !!� A-. u f! ................
plumbing in the buildings of ...
..................
at. . . ........... North Andover, Mass.
Fee. 3. Lic. No./? .
..... .....
PLUMBING INSPECTOR
Check #
7572
1
14
MASSACHUSETrS UNNUIRMAPPUCATON FORPERNUTO DO GAS FMING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
2
Building Locations ilre-scoyf Permit #
Amount $
Owner's Name
New Renovation Replacement Plans Submitted
(print or Check one: Certificate Installing Company
Name-- 1-3 Corp.
Address 3,;- co Partner.
Business Telephone (007) -2- -7$� -2-4,6 Firm/Co.
Name of Licensed Plumber�or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Inu it's substantial equivalent. Yes 13 No
If you have checked yes, pie type coverage by checking the appropriate box. 13
Liability insurance policy Other type of indemnity 13 Bond 0
Owner's Insurance Waiver: I ' am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and in5" performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massy0i—useUs-Sfate Gas��dXWpter 142 of the General Laws -
By:
Title
City/Town,
APPROVED (OFFICE USE ONLY)
,!!�igrfature of LicerYfed Plumber Or Gas Fitter
Plumber / a;�
�Gas Fitter License Number
Master
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1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
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APPROVED (OFFICE USE ONLY)
,!!�igrfature of LicerYfed Plumber Or Gas Fitter
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�Gas Fitter License Number
Master
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plumbing in the buildings of . E�,i .5.6 .'). .� .....................
at ... C�� I eAl rr. I. .7—r ................. I North Andover, Mass.
Fee..)Q Lic. No..f.3. � ... ....... I ..... .........
/PL-*UMBING INS ECTOR
Check # (.3
6577
T
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
41
SACHUS
zoThis certifies that X .... T) .............
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plumbing in the buildings of . E�,i .5.6 .'). .� .....................
at ... C�� I eAl rr. I. .7—r ................. I North Andover, Mass.
Fee..)Q Lic. No..f.3. � ... ....... I ..... .........
/PL-*UMBING INS ECTOR
Check # (.3
6577
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Yes No 0
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A liability Insurance poilcy Other type of Indemnity Bond El
OWNER'S INSURANCE WAIVER: I am aWaM that the licensee do s not have . the Insurance coverage required by
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Owner 0 Agent 0
L��;Wlnmtufc 0i 6w7er or CO)"wInAl-s1z Agent
-------------
I hereby cerW that Wl of the details and infonnation I have Submitted (or entered) in above application are true and accurate to the best of my
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pertinent provisions of the Mas�-achusetts State plu j4 0 C40,v 1 42of comP'
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PERMIT FOR GAS INSTALLATION
This certifies that -7- C' ..........
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in the buildings of ... ........ ................
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Fee. j� . —. Lic. No.. AR
IS 'INSPECTOR
Check # _? j 3
5210
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MASSACHUSETTS UNIFORM APPLICATIONFOR PERMIT TO DO GASFI-rTING 2-o
(Print rr Tvce)
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Mass. Datez/
Permit
Bu:iding Location 7�3/�,eF Owner's Nam
Type of Occupan
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Address Corporation
Fl. Partnership
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Name of Ucensed Plumber or Gas Fitter
w6e,-;l
Certificate
INSURANCE COVERAGE:
I have a curr%�ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No 7
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 11 Bond 0
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 r.equirement.
Check one:
Owner -0 Agent 7
Signature of Owner or Owner s Agent
I hereby certify that all of the details and information I have submitted (or entered).itn. above application are true and accurate to the best of my
knowiedge and that all plumbing work and installat.Jons performed under th perm issued for this application will be in compliance with all
,41
perUnent provisions of the Massachusetts State Gas Code and Chapter 142 of th ene I Laws
BY T of Ucense:
Plumber nature of Ucens6d[Plumb�arr Gas Fitter
Title Gasfitter
M I
aster Ucense Number Ila
aty/Town 'Journeyman
APPROVED (OFFICE USE ONLYI
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Installing Company NameCL;/'1-f/,,- Aa_cr- ;,57/t/ 17-1--,y 10t17-6-- Check one:
Address Corporation
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Business Telephone_ J 792 0 Firm/Co.
Name of Ucensed Plumber or Gas Fitter
w6e,-;l
Certificate
INSURANCE COVERAGE:
I have a curr%�ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No 7
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 11 Bond 0
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 r.equirement.
Check one:
Owner -0 Agent 7
Signature of Owner or Owner s Agent
I hereby certify that all of the details and information I have submitted (or entered).itn. above application are true and accurate to the best of my
knowiedge and that all plumbing work and installat.Jons performed under th perm issued for this application will be in compliance with all
,41
perUnent provisions of the Massachusetts State Gas Code and Chapter 142 of th ene I Laws
BY T of Ucense:
Plumber nature of Ucens6d[Plumb�arr Gas Fitter
Title Gasfitter
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aster Ucense Number Ila
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Certificate of Occupancy $
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TOTAL
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Check #
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17107 . -'It� /q, (C1� -
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO -CONSTRUCT REPAI!� RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERNUT NUMBER: DKIE ISSUED: 3
SIGNATURE -
Building Commissioner/IETector of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address:
9?3 Are-seoe 1-/,
1.2 Assessors Map and Parcel Number:
S (:;), -3
Map Number Parcel Number
1.3 Zoning Information:
Zoning Di;Uict Proposed Use
1.4 P�operty Dimensions:
Lot Area (sf) Fronta&e (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Ricar Yard
Re(pired Provide RegIfired Provi&d
Reclitired
Provided
1.7W&ter Supply M.G.L.C.40. 54) 1.5. , Flood Zone Information:
Public 9 private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal z On Site Disposal System D
SECTION 2 - PROPERTY OWN-ERSHIEP/AUTHORIZED AGENT
2.1 Owner of Record
Z es ley C,, Is o 1-7 73
Name (Print)" Address for Service:
Signature Telephone
2.2 Owner of Record:
-72 0'?-,1Se-6h"
N -a e Pnnt Address for Service:
Si ature 0 telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
d-ue
Address
Signature Telephone
Not Applicable 0
License Number
Expiration Date
yRegistered Home Improvement Contractor
Not Applicable 0
CQmpany Name
71
Registration Number
Address
141
W1. 4/1--�
Expiration Date
Signature TeleLbone
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71
I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 § 25c(6) 1
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 ....... W , No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s)
Accessory Bldg. 0
Demolition 11
Other 0 Specify
Brief Description of Proposed Work:
e t,,.J 1,9�f il,, 7,
s74,'-, '71e kJ C, P"'e t,
P_ 'Q_ K4 0 0 -0-- 4- P-- r- a Ai 9, 0 u
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SECTION 6 - ESTIN[ATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit apE!��
_a
ky- ON
OF 7q; 'd SE --3
R FIC L A.
TIN -t x" 23Z4'
lk
I . Building
I
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbim,
Building Permit fee (a) x (b)
3LqCq_
-4 Mechanical (HVAC)
5 Fire Protection
-6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OW A ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
T
les-lg�,v as ONAmer/Authorized Agent of subject property
U V,
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
I ?�- 3-o
Signature of Owner Date
SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION
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
Print Name
Signature of Owner/Aient Date
-NO. OF STORIES SIZE
BASEMENT OR SLAB
-SIZE OF FLOOR TINMERS, iST 2 ND 3RD
SPAN
-DRvIENSIONS OF SILLS
-DIMENSIONS OF POSTS
-DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X
-MATERIAL OF CHIMNEY
-IS BUILDING ON SOLID OR FILLED LAND
-IS BUILDING CONNECTED TO NATURAL GAS LINE
North Andover Building Department
Tel: 978-688-9545
DEBRJS DISPOSAL FORM
In accordance with the provision of IVIGL 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 IVIGL
c 11, S 150A.
The debris will be disposed of in:
/6-S rll<"2,-,
(Location of Facility)
Signature of Permit Applicant
3�"
Date
NOTE: Demolibon permit from the Town of North Andover 'must be obtained for
this project through the Office of the Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name: /�n/ /11/
Location: �'3 Ars e
City /1/, Phone f,7F'
am a homeowner performing all work myself.
A
I am a sole proprietor and have no one working in any capacity
I am an employer providing. workers' compensation for my employees working on this job.
Company name:
Address
Cily: Phone #-
Insurance Co. Polia #
Comoanv name:
Address
Cily: Phone #7
Insurance Co. Polief #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of crirninal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civilpenalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provk*d above is true and correct.
Signature;��,-��,--e- Date
Print name Phone# fl�Y-
Official use only do not write in this area to be completed by city or town official' Ei Building Dept
ElCheck if immediate response is required Building -Dept El Licensing Board
n Selectman's Office
Contact person. Phone A Ej Health Department
0 Other
FORM WORKMAN'S COMPENSATION
Board Of Building Regulations and Standards
HOME IMPROVEMENT 6'NT
0 RACTOR."
Registration: 105029
Expiration: 7/16/2004
Type: individual
MICHAEL F GOODIA-1
License.or iregis
-trgtiOlk�valid for individuLuge only.,,.
before the' jx0iration. date. If found return to:
Board of Buildin� Regulations and Standards
One Ashburton Place Am 1301
Boston, Ma. 02108
Michael Goodwin Jr.
.263 Andover St
Danvers, mA 0 1923
dinistrator
Not valid without SiLnatu�e
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: -CS, 081670
Birthda^.L-: 06/1-5/1965
Expires: 0.6/15/2006 Tr. no: 81670
Restricted: - 00
MICHAEL F GOODWIN
24 RANTOUL ST
Administrator
BEVERLY, MA 01915
Name / Address
Lesley Carlson
93 Prescott st.
N. Andover, Ma.
M.F. Goodwin Co.
71 Middle,Rd.
Brentwood, N.H 03833
Description
M.F. Goodwin Co. is providing this estimate to remodel the kitchen.
General;
We will rip out the entire kitchen and back porch.
The 4 windows on the porch will be replaced with vinyl replacement double
hung windows.
The window over the kitchen sink will be replaced with a vinyl window to fit just
above countertop height..
The window presently at the back door will be removed and patched on the
exterior.
A new 9 -lite steel exterior door will be installed leading onto the deck with a
Larson storm door.
The wall between the porch and kitchen will be removed and supported with a
beam.
All the exterior walls and ceiling will be insulated with fiberglass insulation.
The basement under the porch will be insulated.
All walls and ceilings will be blueboarded and veneer plastered.
The new cabinets and trim will be installed.
Vent the new hood through the exterior of the house.
Phone #
978-423-8463
Page 1
Total
Signature
Estimate
Total
Date
01/29/2004
26,457.00
Name / Address
Lesley Carlson
93 Prescott st.
N. Andover, Ma.
M.F. Goodwin Co. Estimate
71 Middle. Rd. Date
Brentwood, NA 03833 01/29/2004
Description
The window trim will be 2-1/2" pine casing and the baseboard will be 3-1/2" pine
base.
Electrical;
All the electric in the kitchen will be brought up to code.
the electricians will install 10 outlets, 7 recess lights on dimmers, an 18" & 24"
undercabinet light fixtures, wire the garbage disposal, dishwasher, stove hood,
oven and cooktop.
Plumbing-,
Disconnect all the fixtures.
Install the new sink., faucet, gas cooktop, gas oven, waterline for frig, garbage
disposal. *
Relocate the radiator to the other side of the valve.
All rubbish will be removed from premises.
The work will take 3-4 weeks to complete
Homeowner to supply cabinets, plumbing fixtures, appliances.
Countertops and flooring are not included.
Phone #
978-423-8463
Page 2
Total
Signature
Total
Name / Address
Lesley Carlson
93 Prescott st.
N. Andover, Ma.
M.F. Goodwin Co. Estimate
71 Middle Rd. Date
Brentwood,, N.H 03833 01/29/2004
Description
Painting is not included.
All work fully guaranteed for one year.
References available upon request.
Ma.Lic#018670 Ma.fHC#105029
Total cost: $ 26457.00
Payment Terms-,
• deposit of $2000.00 upon signing.
• payment of $9000.00 upon starting
• payment of $9000.00 upon completion of plastering.
Balance of $6457.00 upon sign off of building inspectors
Total
Signature
Phone #
978-42*3 )-8463
Page 3
Total
M.F. Goodwin Co. Estimate
71 Middle Rd. Date
Brentwood, N.H 03833 01/29/2004
Name / Address
Lesley Carlson
93 Prescott st.
N, Andover, Ma.
Description Total
Phone #
978-423-8463
Page 4
Total $26,457.00
Signature
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ -7 -� A.. �., � I ....... ...... C!� .....................
has permission to perform ...... ...... . .........................................
wiring in the building of ...... .... 65:IZA& ...............................
at ............
............... North Andove
r, ass
Fee,� ............ Lic. No..617"�*� ... 7.�. ....... .............
Check # S) ?�- Z�� LECTRICAL INSPECTOR
4876
Official Use Only
Permit No. #,e Z,
?wg emmm5w?w 61�7 W.455xeW455??S
*DO -,4_,c 4 P404 S4r.,# / Occupancy & Fee Che
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12-00
APPLICATION FOR PERMII�TO P�ERFORM ELECTRICAL WOR I K
All work to be performed in accordance wit6he Massachusetts Electrical Code 527 CMR 12:00
, I fl�L / 1
(Please Print in ink or type all Information) Date
To the Inspector of Wiles:
Town of North Andover
The undersigned applies for a permit to perform ttp�electrical work described below
Location (Street & Number.
Owner or Tenant
Owner's
Is this permit in conjunction with a building
Purpose of Building -51 V)
Yes a
Existing Service Amps Volts
il
New Service Amps voits
Number of Feeders and
Location and Nature of Proposed Electrical
9�_
No &,,oO'(Check Appropriate Box)
Utility Authorization No.
Overhead 0 Undgmd 9 No. of Meters
Overhead 9 Undgmd 0 No. of Meters
_7
J L<Lllp
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremenSts of Massachusetts General Lavvs
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - If h checkedYPS please indicate the t7 c?v
2 irage by checldng the appropriate box.
INSURANCE - BOND - OTHER - (Please Specify) _7�MZ 460,Ks-
(Expitatiog Date)
Estimated Value of. Electrical Work$ z1z
Work to Start Inspection Date Resquested -Rough Final
Signed under the Penalties of perjur"'n- - C :>
FIRM NAME T)obx fke'llif 61) LIC. NO.
Licensee Tub4 g�z7etC Signature LIC. NO.
(44 k Af32�i-_3j
'I Air B;: Tel No.
Address S� L"h I(- Tel. No.
OWNER'S INSURANCE WAIVER: I am aware t&t the Licenses doWnot have the insurance coverage or its substantial equivalent as required by Massachusel
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
el 4 -
,Telephone No PERMIT FEE &
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 9
In a
No. of Lighting Fixtures
Swimming Pool gmd 9
gmd a
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Bum rs
FIREALARMS No.ofZone
No. of Deteebon and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No. Pumps
Tons
KW
No. of Sounding Devices
NoJ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
0 Municipal 0 Other
No, of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Law Voltage
No. of Water Heaters KW
Si ns
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
I
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremenSts of Massachusetts General Lavvs
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - If h checkedYPS please indicate the t7 c?v
2 irage by checldng the appropriate box.
INSURANCE - BOND - OTHER - (Please Specify) _7�MZ 460,Ks-
(Expitatiog Date)
Estimated Value of. Electrical Work$ z1z
Work to Start Inspection Date Resquested -Rough Final
Signed under the Penalties of perjur"'n- - C :>
FIRM NAME T)obx fke'llif 61) LIC. NO.
Licensee Tub4 g�z7etC Signature LIC. NO.
(44 k Af32�i-_3j
'I Air B;: Tel No.
Address S� L"h I(- Tel. No.
OWNER'S INSURANCE WAIVER: I am aware t&t the Licenses doWnot have the insurance coverage or its substantial equivalent as required by Massachusel
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
el 4 -
,Telephone No PERMIT FEE &
(Signature of Owner or Agent)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. . 02111
W01*eMF Compensation. Insurance A ffidavit
Fame Please Print
Name:
Location:
cily Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity'
F-1 I am an employer providing workers! compensation for rrry employees working on, this`iob.
Company name:
Address
city: 'hom-*,
insurance Co. policy#
Corno!]y name: �� I I I I
A
Ld_clge�.
PlIone
FaikWe to secure coverage as mqtfinDd under Seebon, 25A or MGL 152 canlead t6thet bpa crknihal pena
and/or one yeare wrpmonment-as w eff_asjcb44)enaftWs_w
undwstand Urct a copy of this statement may be' forwarded to the Office of Irnestigations ct the DIA for coverage,
I do hweby cerNyr mdar Me pam and parwffies ofjoegmy bW 670 mfwwbon prov"ed above is bw& and conrect
Signature -Date
Prird name -Pbone-#
Official use only do not write in this area to be completed by city or town W=W
PER3fff NO.
,'PPLICATION FOR kitfift TO BUILD - NORTH ANDOVER, MASS.
PAGE I
P +40.
ZONE _I
LOT NO.
SUB DIV. LOT NO.
2 RECORD OF OWNERSHIP IDATE v!
BOOK ;PAGE
LOCATION !7-=?
PURPOSE
OWNER'S N,+,ME,.,,If,,7/
NO. OF STORIES SIZE
OWNER'S ADDRES6
9L?
13ASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME e, 6009u,-)),,,7
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION 1#0
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION A/O
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
tre Co c) I
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
11
ATT HED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
�,LT �.r.
ANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
4over
iIGNATURE-0F OWN -&R OR.,AUTHORIZED AGENT
F E E
PERMIT GRANTED
9
3 PROPERTY INFORMATION
LAND COST d,
EST. Bic -0G. COST f qSo D 1 (907
=mg. a��. q�%m u I.&K MI. r -t.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
OUILDING INBPKCTOR
OWNER TEL. #
CONTR. TEL.
CONTR. LIC. #
H.I.C.# _112S-�04212
BUILDING RECORD
OCCUPANCY 12.
SINGLE FAMILY SiORIES I
MULTI. FAMILY
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
3 1 2 13
PINE
CONCRETE
CONCRETE BL'K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
_�RY _11ALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. B'M'T AREA
114 1/1 1/1
FIN. ATTIC AREA
tLO 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
a
1
3
DROP SIDING
WOOD SHINGILFS_
C�ONCRETE
�ARTH
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
�ARDIIJ D
COMIACN
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STIRS. &
FLOQ�R
BRICK ON FRAME
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIO I_] POOR
ONE�ADEQUA% NONE
5 ROOF
10 PLUMBING
GABLE
I
HIP
BATH (3 FIX.)
GAMBREL]
11
-dip
MANSARD
TOILET RM. 12 FIX.)
FLAT
SHED
WATER CLOSET
—LAVATORY
ASPHALT SHINGLES
L7'
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER EMS. & COILS.
STEAM
STEEL BMS. & COLS.
HOT W*T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T G
-UNIT HEATERS
7 NO. OF ROOMS
I As
L
2nd
B*M'T d
I.t I 3rd
EL CTRIC
I NO HEATING
jr-
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF -BUILDINGS.- WITHPORCHE6. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
I
17 -
'OR
HOME'IMPROVEMENT CONTRAC1
Rejistration 105029
Tj�e..7. INDIVIDUAL
Expir.ation 07/16/98
MICHAEL F. GOODWIN JR.
263 Andover St
MA 01923
ADMINISTRATOR
J/L 6�11,N)IO'lWe'a /a
of PUBLIC SAFETI
coHSIRUCTIOR SUPERYISOR LICEM
Expires: airthdate'
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Location �7 -:--> di,
No. 6 19 e Date
TOWN OF NORTH, ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
$
TOTAL
,_V15eck # J �5
646 -) P��
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATIO TO CONSTRUCT REPAI!_� RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
xh
BUILDING PERNUT NUMBER: DATE ISSUED:
SIGNATURE: C
Building Commissioner/InSp—eetor of Buildings Date
SECTION I- SITE INFORMATION
1. t Property Address:
re -g c, o
L2 Assessors Map and Parcel Number:
Map Number Parcel Number
No - wv,�j
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
I Lot Area (sf) Frontage (ft)
1.6 BURDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Reqtlired Provided
l.7Water Supply M.G.L.C.40 54) 1.5. Flood Zone Informati
Public 0 Private 0 zone Outside Flood Zone 0
1.9 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT
2.1 Owner of Record
�j
Nam Address for Service
Signature V Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si&Ature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 �icensed Construction Supervisor:
P Y'ry t C - 11, 7—
Licensed Construction Supervisor:
I d- r4v,-kv V vz"t _7
I
Address
cl 7 d6 -3 3
Sigr,�46re Telephone
Not Applicable 0
C
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
-�j "- C �--5 Kk 7Y
Not Applicable 0
( �— 9
Company Name
Registration Number
11 (Vf (6 3
A ess
d)Q q7& �,6LAL'333?
Epiratio, Date
Sigin at re Telephone
Ma
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I v.F.rTION 4 - WORKERS COMPENSATION (AG.L C 152 6 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result-
the denial of the issuance of the building permit.
-in
affidavit Attached Yes ....... V No ....... 0-
-Signed
Descriptiono Proposed Work (chevck applicable)
-SECTION5
New Construction 0
Existing Building 0
Repair(s) [I
1
Alterations(s) 0
1 1
Addition 0
Accessory Bldg. 0
Demolition 0
Other Specify I n� /A/
Brief Description of Proposed Work:
V-4 VK -0 V'R_ 0 t
6 - ESTIMATED CONSTRUCTION
COSTS
-SECTION
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
]M SE�
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
Plumbing
Building Permit fee (a) x (b)
-3
Mechanical (HVAC)
-4
5 Fire Protection
Total (1+2+3+4+5)
.7 &-V
Check Number
-6
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, / LLEY dvq&�' Z_ S b /-J , as Owner/Authorized Agent of subject property
Hereby authorize #tfi—c# / /\/ S �tj"J L) 6ttA (AJ �-) to act on
M behaj�,in all ni��U! Ala, ve to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
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
Print Name
Si ature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SVE OF FLOOR TTMBERS I ST 2 ND 3M
SPAN
DIWNSIONS OF SILLS
DINIENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HLfGHT OF FOUNDATION THICKNESS
SVE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLD) OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
HUTCHINS REMODELING JUS UNUMCFE
4is- P.O. Box 871
N. ANDOVER, MA 01845 1045
686-3337
TO L g- s i -e, C m4 1!90
Y4 s c- o 4 -
IV 0 0 "r—ev lok4 14
TERMS:
('PHONE
--MATERIAL
DATa/jI12
/ 10 :�) - N
ORDER TAKEN BY
CUSTOMER'S ORDER NUMBER
E] DAY WORK
1�-<O'NTRACT
E:1 EXTRA
JOB NAME/NUMBER
JOB LOCATION
JOBPHONE
STARTING DATE
)7 P " _
QTY.
--MATERIAL
PRICE
iMOUNf
DESCRIPTION OFWORK
60, e
OTHER CHARGES
TOTAL OTHER
LABOR
HRS.
AMOU T
>
TOTALLABOR
DATE COMPLETED
TOTAL MATERIALS
TOTAL MATERIALS
Work ordered v.
Signatur
I treby a�knowledge the satisfactory completion of the above described work.
TOTAL OTHER
TAX
TOTAL
7S -D-6
01
101
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 I is -that -the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S.150 A..
The debris will be disposed of in:
14*VL I
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
I Name Please Print
Name: 14 u kfA nf2�:
V
Location: -.2> pr_e S C_0 -I-- S T-,
CitV rvio 44 -VV t--. PM P19- Phone #
I am a homeowner performing all work myself
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
COMDanv name:
Address
city- Phone
Insurance. Co. Policy #
Company name:
Address
cay- Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of crirninal penalties of.a fine up to $1,500.00
andfor one years'imprisonment-as-weU-as-c!Wowaltiesjn-jhe-fntm-dA-STOP.W-ORK-ORDER-md..a.fine4l$ID.0-00)-ajdWagainstnw- I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DLA for coverage verification.
do hereby certify un3�r the pai . ns and penalties ofpetjuty that the information provided above a true and coffect
Signature Date.
Print name Po -v 1 4 1A"'T jr Pbone.# q 7 7' 6 A - 3 33 -)
Official use only do not write in this area to be completed by city or town official'
City or Town PermWUcensin_q
nCh . eck if immediate response is required 0 Building Dept
.0 Licensing Board
E] Selectman's Office
Contact person: Phone #.- n Health Department
n Other
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Date... "� ... ..........
,40RTH
TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that ...... -/ ........ ............
114.
has. permission for g�s in tall. tion ... ...............
in �,he buildings of . ..... ................................
at North Andover, Mass.
Fee . ..... Lic. No,.,
......... C�os ...........
Check# 13 6 0
F,
NLAS�ACHUSMTS UNIFORMAPPUCATON FOR
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations Prca-64- �
L,G — — I ,�) Owner's
New Renovation Replacement
TO DO GAS FfYMG
Date
Permit #
Amount $
L
Plans Submitted
(Print or type) Check one: CertificateInstalling Company
Name Corp.
Address rn Partner.
Business Telep=one 1 79-/ — c? J-3 4D 0-15irm/Co.
Name of Licensed Plumber or Gas Fitter t "�T P—C 3,1 -Z 6
INSURANCE COVERAGE Check one -
I have a current liability Insurance policy or it's substantial equivalent. Yes ff-��No 0
If you have checked yes, please indi e the type coverage by checking the appropriate box.
Liability insurance policy ffi�� Other type of indemnity r-1 Bond 0:
@wner'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 waive ' s this requirement.
Check one:
Aignature of Owner or Owner's Agent Owner Agent
I hereby certify that all of the details and information I nave suormitea kor entere(l) In aDOVU dPPII(.;dUVII dlU LIUC d11U dL;L;UId1C LU Lne
best of my knowledge and that all plumbing work and installations perfon-nedunderpernutil su for this aAwlication will be in
CW70�' P.-O�Fal—Laws.
compliance with all pertinent provisions of the Massachusetts State Gas S2dVn(WqFt
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
-------- j
�4�ature of Licensed Plum�e-r Or Gas Fitter
Plumber 44 � r 6 C')
Gas Fitter License fNumt)er
Master
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SUB-BASEM ENT
B A S E M E N T
IST. F L 0 0 R
2ND. F L 0 0 R
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. F L 0 0 R
7 T H . FLOOR
8TH. F L 0 0 R
(Print or type) Check one: CertificateInstalling Company
Name Corp.
Address rn Partner.
Business Telep=one 1 79-/ — c? J-3 4D 0-15irm/Co.
Name of Licensed Plumber or Gas Fitter t "�T P—C 3,1 -Z 6
INSURANCE COVERAGE Check one -
I have a current liability Insurance policy or it's substantial equivalent. Yes ff-��No 0
If you have checked yes, please indi e the type coverage by checking the appropriate box.
Liability insurance policy ffi�� Other type of indemnity r-1 Bond 0:
@wner'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 waive ' s this requirement.
Check one:
Aignature of Owner or Owner's Agent Owner Agent
I hereby certify that all of the details and information I nave suormitea kor entere(l) In aDOVU dPPII(.;dUVII dlU LIUC d11U dL;L;UId1C LU Lne
best of my knowledge and that all plumbing work and installations perfon-nedunderpernutil su for this aAwlication will be in
CW70�' P.-O�Fal—Laws.
compliance with all pertinent provisions of the Massachusetts State Gas S2dVn(WqFt
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
-------- j
�4�ature of Licensed Plum�e-r Or Gas Fitter
Plumber 44 � r 6 C')
Gas Fitter License fNumt)er
Master
Date. S :
, " .. ...4, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
S C
This certifies that ...... ... .. ...........
has permission to perform ......
...........
plumbing.in-the buildings of ...................................
--'Z�
at ... .......... ........ ..............
North Andover, Mass.
"I?—
Fee Lic. No:c7?q
.. ..............
--PL
-�UMBIZ6
NSF
�NSPECTOR
Check ff X2
" C/
5 IS" 3 8
MASSACHUSETTS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
I
Owners Name �
of I
FOR PERMIT TO DO PLUMBIN(
Date
� 4��4
Permi7t#_�,
Fq 0-7 Amount
New Renovation Replacement Plans Submitted Yes No
0
FIXTURES
(Print or type) Check one: Certificate
Installing Company Name_ tj 17 3 Fr --,7 -t- pf/u M 1:1 Corp.
Address 0 Partner.
Fu'siness Telephone 72 1 .1 7 7 Z-10 0—FirnVCo.
Name of Licensed Plumber: Q, I'l C?
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent 11
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perf er Per?924sued for this application will be in
pmed qd
compliance with all pertinent provisions of the Massach��PhK-Cone and VVta&44-2-of the General Laws.
By: Signature oT Licensea FiumDei—
Type of Plumbing License
Title L 0
City/Town ulDer Master Journeyman
APPROVED (OFFICE USE ONLY
DaW�.-Z.7-..��"v .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
.'s US
This certifies that . ..... �1-� .........................................
has permission to perform ...................................
wiring in the building of . ...............................
(123
at ........................................ ............. . North Andover, Mass.
Fee7r� ... . .... Lic. No`�/Z�0� ... ....................
'iLEcTRICAL INSPECTOR
Check# 7-
50,81
_!t\_
mmmm The Commonwealth of Massachu
'WEDepartment of Public Safety
BOARD OF FIRE PREVENTION REGULATIONS
APPLICATION FOR PERMIT.1it P
All work will be performed in accorda the h
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
City or Town of 'Ahd_t:� And tt'
MR 12:00
FOR OFFICE USE ONLY
Permit No. ?J/
Occupancy & Fee Checked 7S --
(leave blank)
FORM ELECTRICAL WORK
isetts General Code. 527 CMR 12:00
Date
To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below:
Location (Street and Number) -2-25-- -- --- Map:
Owner or Tenant 6'C;51 i e— r-12 r /5 6_6 Zone:
Owner'sAddress 40'ang- r_x-4
Is this permit in conjunction with a building peri -nit?
Purpose of Building 0
Existing Service — Amps Volts
New Service — Amps _/_.— Volts
Number of Feeders and Ampacity
�__v
Yes X No[]
Utility Authorization No.
Overhead 11
Overhead 11
Underground 0
Underground El
g 6n 1
Location and Nature of Proposed Electrical Work b= f Lf�'"4 eq - 4- 1 if)(44 tie, I
he� 1,7 K 4�1 n, ) 4- 1, kc, �_) %* " 9 1-4-1- " ^ 14 rj"(" I- , . . - � 11 - . - Q'_
Lot:
(Check Appropriate Box)
No. of Meters
No. of Meters
F �7
X0. _0� "L-ig"liting, 0"u'tf1e'ts`
16�, 1 — 1 11 — I
No. of Hot Tubs
- I
No. of Transformers Total KVA
No. of Lijilting Fixtures �7
Swimming Pool Above grnd. El In-grnd. 11
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emerg. Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection'and
Initiating Devices
No. of Sounding Devices
No. of Self -Contained
Detection/Sounding Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Disposals
No. of Total Total
Heat Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No. of Signs No. of Ballasts
Local El Muncipal Connection 13 Other
No. of Hydro Massage Tubs
No. of Motors Total HP
Low Voltage Wiring
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy
including Completed Operations Coverage or its substantial equivalent. YES El NO El I have submitted valid proof of same to this
office. YES 0 NO El If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE$.BOND 0 OTHER El (Please Specify)
Estimated Value of Electrical Work $
Work to Start
Signed under the penalties of perjury:
FIRM NAME 01 nC, E�l 9XICOC
Licensee
Address
Signature
(Expiration Date)
Inspection Date Requested: Rough Final
LIC, NO. A 1 Q�369
LICNO. C38G)91
Bus.Tel.No.
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee DOES NOT HAVE the insurance coverage or its substantial
equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Owner 0 Agent 0 (Please check one)
Telephone No.
PERMIT FEE $
INSPECTION RECORD
Date I Notes — Remarks I inspector