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HomeMy WebLinkAboutMiscellaneous - 96 STAGE COACH ROAD 4/30/2018February 11, 2015 THERlO981FOd0(fU-SEDo-OARAGROUN FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1585892 Insured: LISA WHITE Address: 96 STAGE COACH ROAD, NORTH ANDOVER, MA Policy No.: H0934979A Loss Date: 02/07/2015 Loss Type: Building or Other Structure Damage A 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, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, '-- (:::� - Lorraine A. Peirce Sr. Property Claims Examiner 1-800-688-1825 x1139 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. p Fax: (781) 329-1818 ,1v Date ...... yl ... ".f .... �Jo .e •ry TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ...... :..c... ............................ has permission to perform Q-�—=-. . �-F wiring ng the building oft:-r....-........................................................ at...... ?��........... ..I ..... ...................... Feei(�.......... Lic. No. . .m..� ...... Check # �h Permit Nc. c0 C aJLmslJ a _.%.re Jsrc �Ca3 t r i. Occupancy attd Fee Ct eckF�d BOARD Or F- IRE PREVCN ION REGULATIONSev. 1/07J Icavcblank) APPUCAT�ON FOR PERMIT TO PERFORM ELECTRICAL W.0RK; • All work to be perfo:mcd in accordance with the Massachuscrs Elecuicxl Ccde (,\,EEQ, 527 CMTS 12.00 (PLEAS.; PRINT JX .W.K OR TYPE A_ L INFO MTION) Date:v- City or Town 0f: ho tine Inspector of Wires: By(this applicztion the unde signed gives not ca`i e` of his or i;e'r ::i'.entior to perforn t Ie ele--mcal work described below. I otioa (Street & Number)_ �d�/ f�4!2 � / Grvuer or Tenant ����/��.(��` _ Telephone No. 1o�=� Owner's Address Is this permit in conjunction with.a building permit? purpose of Building Existing Service Amps / Volts New Service _ Amps / Volts Yes ❑ No (Check Appropriate Box) Utility Aut:,or:=.tion NO. Overbead ❑ Undgrd ❑ Overbead ❑ Undgrd ❑ No- of Meters No. of.Meters Number of Feeders and Ampacity ^ Location and Nature of Proposed Electrical Work:. ' 0-Xat("�r 0-)17��CC tcwtt ?_.: __ - -'L_ r n r rCbfo "n hP waived by the Inspector of Wires. ' J1-11— (When c.,uinYiu avn yr . --- No. of Total Ne. of Recessed Luminaires No- of Ce-iL-Susp- (paddle) .Fans Transfoi-Iriers Wo- of Luminaire Ouilet3 No_ of Hot Tubs Generators '�.K ,, -• Above 1n_ ❑ ❑ 1 o_ o me gency tg ng ,No- of Luminaires Swimming Pool rn� �rnd_ Batte �Jnits _ No_ of.Receptscle Outlets No. of Oil Burners FIRk ALARM No_ of Zones . _ o. of Detection and No. o4' Switch= ni. of Gas Burners Initiabu Dfyices Total NOei A-ir Cdnd- •, cons No_ of Ale rting Der'ces No- of Ranges Heat Pump Nnrat>er Tons No_ of Self -Contained Dete-ction/Alerting: Devices' o. of Waste Disposers Totals- Loe31 ❑ Municipal ❑ Other P{o. of Dishwashers SpscelAres Heating KW urity stems:* Heating AppLiayces S� �uivalent No. of Dryers f Data iring: No. of Water. of No. o'h KW B11Lasts No- of Devices or E uivaIent �xesters Sins T"eleeom_,aunientions Wiring: No. Rydromassabe Bxtbtubs No. of Motet rs Total HP of Devices t ojWires '=-- Attoch additional detail ifd�srre i or as requ rad by •�,e nspec or e Estimated Value of Electrical Work (When required by municipal Policy-) I : � - Inspccti ns to be rcquestul in acc:.ordancc with IYEC Rulc 10, and upon comglction. Work to q INSURANCE COVERAGE: Unless waived by the ovner_ ao permit for the performance of electrical work may issue unless the Ijccnsc c prov ides proof of liability insurance including "?(SP""fY:) lcted operation" covera& or its s4bstantial cquivalcuL The undersigned certifies that such coverage is in force, and has itcd proof of smi ame to the pert issuing office CHECK ONE: INSURANCE ❑ BOND ❑ OTHER - I ca••tify, under the pains and pearalde_c ofperjury, that the infortnadon or"f'i1s plica oR is trsre end compxtL 7 " ��Ri1I NAME: �� 7 SEC' U r' 4tk) SignaturLIC NO-: �4 �� ? 21-�a kr Ole, enter"e -e.7r t" in the license nwnber fine.) $ils: Tel. No.._. - 'Crf PP ' ,. �f D 0 4t 9 _ Alt. Tel_ r;o_ ��' . Address: / .3 !_/ 2 , _� rcq `S" Lif;nnsc: Lic. No. 'F:. -r 1tiLG_I... c_ 14?, s. 57-6 1, security work irr_s Department ofPubli :Safety' f�WNER'S INSURE Nl -E W.LVm ER- I aawa_fe that the Licensee: does not h�rve he Iiability nsurance•r�ve:aY,e norm311% ❑ o�vncr s a cut c_.,.... v,. ,�n,.rf,clr'v i hereb�r waive this r-�uiremcnt I �r l the (check one El owner _ �/ - /- 0"'q Date...!...`.. ............ NORTH TOWN /OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... .. ... .. has permission for gas installation ........ in the buildings of .................. ... .................... at ...?G .......... ............ ....hVorth Andover, Mass. Fee-3�. Lic. . ........ G/vGv/v SPECTOR Check # 6661 kook AndovQr ,brass. D.Ue gf- 2 09 Permit# S 9 Building Location --% S T l .D6 C k 0 . Owner's NameAA O nS Owner Tel# Type of Occupancy Qs `i ce New ❑ Renovation ❑ Replacement k Plan .%bmitted: Yes ❑ No ❑ FIXTURES Installing Company Name fs'r, r , t' ,49 Check one_ Certificate Address Co ration Al ❑ Partnership Business Telephone # / % ^ o % ❑ FirmlCo. Name of licensed Plumber or Gas Fitter 41,& S7 INSURANCE COVERAGE I have a cunt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have ed yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Cheek one: Owner ❑ Agent o Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted (or entered) in above 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 rtinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By. Type of License: fi" "� • -Plumber Signature of Uc&Cqed Plumber or Gas Fitter Title • •Gas fitter • -Master License Number [ Cityrrowr Joumeyman APPROVED (OFFICE USE ONLY) A' `? p Date /-1? . ;�; -e-0 . — . .. . .. .. . .. 14TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING AIID This certifies that . ...... 61 has permission to perform ........................... plumbing in the buildings *North'Andover,' Mass*. Fee .k.�.. Lic. No .......... ... PLUMBING INSPECTOR 67U9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS '77 -Date % Gf� ' p Building Location ()-��' � �,�wners Name Z S�jy4/tJ e/y Permit # (/ v Amount (oq, Type of Occupancy New 1:1 Renovation a Replacement 1:3 Plans Submitted Yes C] No 0 cm it 1' • 16W DLVJ 001EMMMWWMMMMMMMWMMWMMMMM MMM (Print or type) _ Installing Company Name_�7` Check one: Certificate �orP• ��Qr Q ❑ Partner. Firm/Co. Name of Licensed Plumber: G.0/riG / f Insurance Coverage: Indicate the type of insurance coverzrge by checking the appropriate box: Liability insurance policy E Other type of indemnity ❑ Bond ❑ 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 11 Agent El 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 forme under Permit Iss e r this application will be in compliance with all pertinent provisions of the Massach lu e C 142 e General Laws. �. By: igna ure 31 Ocenseaum er Title c�" T pe of Plumbing License City/Town Master kenseum er �� APPROVED (OFFICE USE ONLY ���...JJ J Journeyman / r✓ V9 Location 9i No. Date Check # ,/ ld 18792 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Building Inspecfof U ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP FtEN0VATt4 OR DEMOLISH A ONE OR TWO FAMILY DWELLING >, BUILDING PERMIT NUMBER.• � DATE ISSUED: SIGNA "-)Q1dWg O ner/IRWr of Btl.111 n Date SECTION 1;61n INFORMATION 1.1 Proprdy Address: S+aq�e ccach ed 1.2 Assessors Map and Parcel Number: C" 5 Map Number Parcel Numlfer N—� n _ Q Oar 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 Water Supply M.G.LC.40. 34) 1.3. Flood Zone Information: Public ❑ Pete ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIiIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record //� ,, f 1 SQ tb�!'4 Si I^11©n 5 gl0C.IGF , ��,cC_ ►' \ am Print) Address for Service: Si ' ture Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Lrcensed Construction Supervisor. Andress Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 M z O SECTION 4 - WORKERS COMPENSATION (KG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check an applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant 1. Building QQ U-� �IFICIALUSEtOl�1 1, . w. (a) Building Permit Fee Multi Tier E7N° 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing O Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number lela SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, %as Owner/Authorized Agent of subject property Hereby authorize 4-1 S)g 1�1/ M hi ops/ 14- and u /'n ay) to act on My behalf, in all matters relative to work authrized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,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/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR Tl vMERS isl2 ND 3 RD SPAN DMIENSIONS OF SILLS DRAENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION Please Rdat DATE: JOB LOCATION: / G . 6�e COO � '` � `�� D 0 � S� Number S/,-o StreeAddress Map/Lot HOMEOWNER l Ci jW Z S-2� 39 Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNA APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT ` 400 Osgood Street North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION Please Rdat DATE: JOB LOCATION: / G . 6�e COO � '` � `�� D 0 � S� Number S/,-o StreeAddress Map/Lot HOMEOWNER l Ci jW Z S-2� 39 Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNA APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption f 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 at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by NIGL .111,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I 0A. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit (Location of Facility) Signature of Permit Applicant .00~ i� ••. Date :f Q t a _ H C* W H W V COD Ea CD c :.. a o cCD . co a O m o= mcm c v v W A .o a2 U w C_ �2 w .m o�4 =CqC w UW c P4 w w CA cn cn t a _ H C* W H W V COD E ic Ag :5 N N c cm co cm c C12 O co C N 0 t 0 Z O J F. fl ZI .�14 co O w L O Z co C. O h D C O cm I O y O O 'E m m CD O L via C O C C Z O V y C C C C. CO2 0 ui 0) W W ce W cn Ea CD c :.. o cCD . co O m o= mcm c N A � O N H 1 ' 3 m C_ C .m =CqC N N ' � N m aL ` '~ c c yQ 0 0E H V Z �r CO C O CL m N O c 'COLS O m w Cc m$ m .y 'd A A c .N �E ca cv co O Co C2 O C_ O. m' ONe A N •O a*zm E ic Ag :5 N N c cm co cm c C12 O co C N 0 t 0 Z O J F. fl ZI .�14 co O w L O Z co C. O h D C O cm I O y O O 'E m m CD O L via C O C C Z O V y C C C C. CO2 0 ui 0) W W ce W cn Date . ,40RTN _1 y TOWN OF NOR;THe'A'NDOVER PL PERMIT 0 ' PLUMBING SS US This certifies thatF-11-4--1 / 41 has permission to perform plumbinc, in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . at. ... North Andover, Mass. FeeL i c. ............... INSPECTOR Check 7219. MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING (Print or�pe) _—U, p(a2o� ,, Mass. Date Permit # Building Location 4,o Owner's Name New 0 Renovation 0 B.P. # Type of Occupancy_j'L-Q___�� Replacemen>< =5FWFR * FIXTURES Pians Submitted: Yes O No O ecrr"f- a Installing Company Name A— tr , .r.. Business Telephone_ ( 1�V'?Q ) y"jl-j -!�t.A-Z -.A Name of Licensed Plumber or Gas Fitter Check one: Certificate [�Orporation -Z_(., Vic, (�L 0 Partnership 0 Firm/Co. INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 142. " Yes 0 No.❑ If you have checked Ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond 0 OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent O I hereby certify that all of the details and information I have submitted for ente n abo application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the per it ' ed for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chap 1 t era] Laws. By Title Signature o t e sed mber - Ciry.?own APPROVED(OFFlCEUSEONLY) Type of License: Master ❑Journeyman Z NN Y z N to Of >- O = ¢ I— z z z > w tz N UJ to iJ¢— to 2 N }' V w N U) p= u- z .-. 13. to z � F�- w O H I- w¢ .W o= ¢ w �- °' Q z a b w ~Q 2 V ¢ O ¢ O -' ¢ 7i ¢ .� U tz = 'S m to 0 in g z to u_ Q (D ¢ mLU _Q O SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TTH FLOOR 8TH FLOOR # { li Installing Company Name A— tr , .r.. Business Telephone_ ( 1�V'?Q ) y"jl-j -!�t.A-Z -.A Name of Licensed Plumber or Gas Fitter Check one: Certificate [�Orporation -Z_(., Vic, (�L 0 Partnership 0 Firm/Co. INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 142. " Yes 0 No.❑ If you have checked Ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond 0 OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent O I hereby certify that all of the details and information I have submitted for ente n abo application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the per it ' ed for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chap 1 t era] Laws. By Title Signature o t e sed mber - Ciry.?own APPROVED(OFFlCEUSEONLY) Type of License: Master ❑Journeyman Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.:.� �............ ., jr has permission for gas installation .... P �? �' .`/ . ............ in the buildings of .......................... at ... r., ."w ! , North Andover, Mass. Fee. Lic. No..IZ). '! :.. .. CE .... �....... . % GASINSPECTOR Check # 3803 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Z- �--- P Al-"XAQno-erg. , Mass. Date /O -- 3 O Permit # �y 3 IC Building Location PD Owner's Name 4L ,A -7(;ee .L� ••��+c)/v! Type of Occupancy New ❑ Renovation C Replacement 9I FIXTURES Plans Submitted: Yes ❑ No Installing Company Name Check one: Certificate Address GST Y Lv T Corporation a v-2, I -PA '.i - Partnership Business Telephone 92e. ,F r-, -i 3 `/-3— � zc. Firm/Co. Name of Licensed Plumber or Gas Fitter Pf, C� 2 /J c) /�-.a INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of ,MCL Ch. 142. Yes-, No C If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy _ Other type of indemnity _ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required b\ Chapter 142 or the tv1ass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner = Agent C I hereby certtiv that all of the details and information I have >ubmitted for entered; In the above application are true and accurate to the best of m+ kro+vlecge and that al: plumbing .-.ork and insiallauo- perormed under the permit asued for this apnhcanoo ++ill be in compliance ++itL ali pe eminent pro+tston of the ,\tassachusens iia:e Ga= Code and Chapter 142 of the General Lars. Ga,imer � W Z H i(, ate,ter Signature or Licen>ed P!umber or Ga. Fitter Cita.Tu++n loumel man License `:umber APPRM ED 1)FF CE L!SE U%U'; U Z O C< 61 Q c z= O a z O z hW- UU W— z w O T W LA LnQ C n W U Q ~ C W r C W ~_Ln 6W z ii- e-611 Q W J Q C F_ F} Q Ln Z O Z C 0 ii soui��l3 c`�5° > ° o SUB-BSMT. I BASEMENT 9st FLOOR / 2nd FLOOR 3rd FLOOR 4th FLOOR I 5th FLOOR 6th FLOOR I 7th FLOOR I I I 8th FLOOR Installing Company Name Check one: Certificate Address GST Y Lv T Corporation a v-2, I -PA '.i - Partnership Business Telephone 92e. ,F r-, -i 3 `/-3— � zc. Firm/Co. Name of Licensed Plumber or Gas Fitter Pf, C� 2 /J c) /�-.a INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of ,MCL Ch. 142. Yes-, No C If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy _ Other type of indemnity _ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required b\ Chapter 142 or the tv1ass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner = Agent C I hereby certtiv that all of the details and information I have >ubmitted for entered; In the above application are true and accurate to the best of m+ kro+vlecge and that al: plumbing .-.ork and insiallauo- perormed under the permit asued for this apnhcanoo ++ill be in compliance ++itL ali pe eminent pro+tston of the ,\tassachusens iia:e Ga= Code and Chapter 142 of the General Lars. Ga,imer Title i(, ate,ter Signature or Licen>ed P!umber or Ga. Fitter Cita.Tu++n loumel man License `:umber APPRM ED 1)FF CE L!SE U%U'; Date l. 5?.9 ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... ........ I�Aofol��;FW .5 .............................................................. has permission to perform ........ ...... S�15 ................... z ..... wiring in the building of .................. .................................... .... ...... .....%Vf ....... ... .te A ................. North Andover, Mass. Fee ..T..' .... Lic. No. .............. . I ........ELECTRICAL INSPEc-roR . Check # 9,109 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed, form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of.ongoing construction activity, and may'be-deemW-by-the .Inspector_of _Wires abandoned-and_invalid.if he—_ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or.the installing entity stated on the permit application. . ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. Rule 8 — Permit/Date Closed: /, Jj * Note: Reapply for new per 0 Permit Extension Act — Permit/Date Closed: � Commomvealth: f Massachusetts Official Use Only Permit No.� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. 9/05] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEYl, 7 CM 12.00 (PLEASE PRINT IN INK OR TTPE ALL INF RMA770N) Date: a 5P City or Town of: /'Vex- To the Inspe or of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant / 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: Completion ojthe ollowin table may be waived by the Ins -r -f Wires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of Total' Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires A Swimming Pool g ove ❑ - E3o. d. o Lighting Batte Units Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. , of Switches No. of Gas Burners � o. oand D Initiating Devices No. of Ranges Total No. of Air Cond. Tons � - No. of Alerting Devices . No. of Waste Disposers- eat ump Totals: Number- Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent o. of Water KW Heaters No. of _ _. o. of signsBallasts Data Wiring: No. of Devices or uivalent No. Hydromassage Bathtubs No. of Motors Total HP ecommunicahonsinngg No. of Devices or uivalent OTHER: .lttach additional detail ifdesired oras required by the Inspector of tfrres. Estimated Value of Electrical Work: f y®. (� l� (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 co a is in force, and has exhibited proof of same to the permitissuingoffice. CHECK ONE: INSURANCE ( BOND ❑ . OTHER ❑ (Specify:) I certify, under the pains and�'ett ,operjury in at theontt°n on this app[icn is true and complete - 0 �Lh�fe1a� B�/f�`G T LIC. NO.: Licensee: v/d Signature LIC. NO.: 6� ,f (If aPPlicabl� t" in the license numberline // Bus: TeL No.• �.s � O// *Security System Contractor License for this work; if applicable, enter the license number here: 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 requitement I am the (check one) ❑owner ❑owner's agent. Signature gent Telephone No. PERMIT FEE:. $ Q h ..:: .a .� The Commonwealth gfMassachusetts Deparmrer_t orindustrid Accider,* •' - Office oflnvestigadons 600 washington &-reef Boston, Ali 02111 1�'�~,.eCS' Compensation; +.l�l.rarl:c A19davit: Buitdt�rs/i ouYraetors/Electricians/Plumbers Name , � �4!�'/� Address: i.�Cwoaa/ �os� /��� .���4,, 7o 17f City/State%Zip:.6lG°-7 Phone #: Arc you an employer? Check: the appropriate box: 1.0 1 am a znploy=- with 4- 0 t am a $nerd contactor. and j, , bt ees (W and/or pari-tilae).* have hired the sub•oaniraptors �.,� 2. L'! i � a sole proprietor or partner- listed on the atached sheeL , ,�x ship and have no eatplovees Thm hric worldag for me in any c2.ltacity. emloyees and have worlmets' [No workers' comp. insurance comp•a1suranceJ requirta) S. [� We are a corporation and its 3.0 I am a ltomeow= doing all work ofi5etxs have exemsed their mysd£ [No workers' comp, right of exemption per ?SGL itmMu a rcquhv&l t c. 157, § 1(4), and we have no employees. W -o worlmrs' Type of project (required): 6. 0 New construction 7. 0 i modeling & 0 De moMon 9. 0 Bzw,&Ig addidon I0.93�9ecuieai repairs or additions 11.0 Phwbing npaits or wididons I2.[] Rw f repairs 13.0 Other +Ail! appfit ml that diCC m box #1 mw alsoSU oat do Ludw below shwiog thcirwod=3' cmnpmsWop poky taftmadfm- t fiontoowoers who a6wit this df}iJwk inion dwyam doing a➢ wakand dim bite of W& cmtnctm zeal submit a now &OUbvk h4coUng such. tCantactas filet diode ibis box must auedW an adMond Art dww%g the acme ofdte tab.aoattwtomt rad state whelbaorno: aodties We ewpboyom r dw sub-oDndoabata bm employees, toy meat pvW dwk wad=* rump. pahcY lam an amploper that riapmvidirrg workers' compensation bmrance for my employees. Below is the pollcy acrd job site infonnadon. . Insuranoe Company Namc: — Policy # or Self -ins. Lic. M Expirador, Date: Job Site Address: 0W- State.'Zip: Artach a cops of the workers' compensatlon policy declaration page (showing the policy number and expiration date). Fnihm to rectae covcwl;c as required under Section 25A of MGL c.152 can lead to the imposition oftxim nal penalties of a fipo up to $1,500.00 and/or ono -yeas impriamment, ss yell as civil pcWties in the form of a STOP WdzX ORDER and a rine of up to S250.00 a dkv against the violator. Be advised dmf a ropy of this statemsent may be forwarded to the OMM of — Invzsriations of sill: DL4 for itlsluatxx coverage verification. I do Iserehy cerujj, under tiro pains anti piaiaUks ofpajury that the iri IPnuadonjumided abae - true and correct. S' 1 iate A z D ` Phone #: OfflaWmeor;4% Ds cwt write & fids ureic, m be azWcW lg RR or town oJjreW City or Town.- Pleroldi icense # Issuing Anthortty (dr'e1e one): 1. Board of Health 2_ Building Department I City/Fown Clerk 4. Veeftical inspector 5. -Plumbing Inspector ti. x"Iiha' Contact Penen• Phone A .. Date./K.-..6- l �'<:<•ti TOWN OF NORTH ANDOVER 100 PERMIT FOR PLUMBING - ^ r 7 This certifies that X/cf..I!.f. e/- ... ? .//.............. has permission to perform .... fi.7/! � � . 1 ............. plumbing in the buildings of ....FY .............. at .. e -7 e! ... , North Andover, Mass. Fee. .3.`...Lic.No. ..�/I.`.�`.......� ..!r!?.:...... w Y -, LUMBING INSPECTOR Check # 5005 A MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO _ .� LUMBING (Print or Type) �►^.nrlr, rlL_ Mass. Date rQ •`a IL6 4i � �i ', Owner's Name�ls�,� �o A� 0:vs Building Location ra Type of Occupancy 0Plans Submitted: Yes C3 No .( New ❑ Renovation ❑ Replacement . FIXTURES Installing Company Name /yA / L/C. `L to/ M -- !� "��G Address /f7 (AA S Gc.1-v Gc L`� J �` Check One: ❑ Corporation ❑ Partnership Certificate Business Telephone $7r�- ��� 3.3 -VY— (� Firm/Co. Name of Licensed Plumber /✓ f� �� �- cS �� ✓ -- INSURANCE COVERAGE.: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142• Yes W No ❑ 11, you have checkedLes. please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ 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 Mass. General Laws. and that my signature on this permit applIcation waives this requirement. ck Owner p Agent ❑ Signature of Owner or owner s agent-- I hereby certify that all of the details and information 1 have submitted (or entered) in above 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 provisions of the Massachusetts State Plumbing Code andCh err 11142 of the General Laws. Signature of Licensed tum ar� Title Type of License: Master .Journeyman ❑ CityrCown %3 7 t r U NIYJ License Number % zy - w New Schedule - Plumbing - Effective date May 1, 1.994 Residential - Pen -nit $ .=. + 1_ per fixture Commercial/Industrial - Permit $35.00 + $10.00 per fixture Municipal - no charge (churches no longer exempt) Re -inspection -Residential $10.00 Re -inspection - Commercial/Industrial $15.00 Inspector approval must be obtained before a meter will be installed Pennit(s) shall be obtained prior to commencing work, installers found to be performing work without obtaining permits will be charged double the permit fee These fees shall apply to all plumbing work (new, replacement, renovation) r 1 x N -o_ r a Date .. 35/_ TOWN OF NORTH ANDOVER PERMIT FOR WIRING ".1 (� (+` c f✓l, c �, r This certifies that ......... C. v k a, C < 10A. q.".1 ....... ......................... ......../................. has permission to perform ....-r.. ?...%.r..! .M ............. v(..R..u... . ......... wiring in the building of ...........5 ....�? �.�''... S ........................................ G.:. orth Andover, asg.' Fee / Z�3. LECrR1CAL INSPIGCTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r� (,-{t01nnw/twea44 old/}i Ja�jaciiwejb 2eparl'nzenl al irB Servic,j BOARD OF FIRE PREVENTION REGULATIONS _�^-- Oi)icla! Use Outy 33 7 �- Pernui No. Occupancy and Fee Checked_~ [Rev. l I/99] �lcave vlank)�_�' 1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W All work to be: performed in accordance wills tine Massachusetts Electrical Lode (,'BICC) 527 CNJ"2 12.00 ��� (Pl EASE PRINT 1N INK Olt~ TYPE ,•ILL INI"ORM,1770N) I3:Itc: IV ID � City or "i'oivtt of: /�b"Ad .� To the hispet;tor. of lVit e By this application the undersigned gives notice or(lis or her itfterttioa to perform the electrical work described below. Location (Street R Number)`16M1 0 tiv trer of Tenant Owner's Address 7'clepilone No. Is this permit JIi conjunction with a building permit' Purpose of Building _ Existing Service Amps / TVults New Service Amps t Sults Number of Feeders and Anipacity Locatiotl�and Nature of Proposed Electrical Work: Yes ❑ No ❑ (Check Appropriate Box) Utiiity Authorization No. Overilead ❑ Undgrd ❑ Uverlicad ❑ Undgrd ❑ r....... I...: _.. .. r. i - r.r No. orbleters No. of Dieters No. of Recessed Fixtures �. vrrr it err V,f V/ me: ju fVllly 1(rotenra J o)v uvail.c I by t/rc lns� c�cto_r�o_/'ltr7 /'uf. No. ofotal No. of Ceil.-Susp. (Paddle) Fans t I ransformers KVA Na. of Lighting Outlets No. of blot Tubs Generators XVA No. of Ligttfing Fixtures Strisntaing Poul Above ❑ In ❑ o. o �inergency Ig r Itlg rud. rnd. Batte Units, No of Receptacle Outlets .. , o. of 0i1 Burners FIRE AIARMS No. of.Zones-. No. of Ser•itcltes No. of Gas Burners No. o l)etectiott an w _ h ritfltin Devices No. of Ranges No. of Air Cond. Tonsl ,. No. of Alerting.' Devices No. of Waste Disposers Feat I'um P Nun er ions K� _.N ....... No. o Self- ontuined Totals: Detection/Alerting Devices No. of Dishw2shers Space/Area Heating Kiv Localtin►ci a Connection ❑ ®flier No. of Dryers Heating Appliances KNV Security systems: o. of Water t o. of Co.of No. of Devices or Equivalent Heaters KNVData No. Hydrornassage Batlitubs Sins Ballasts No. Wiring: No. of Devices or t uivalent. Telecommunications Wir•iiig: of 1lotors Total III' ,�. Nu No. Of -Devices orE"ivalent_.__ OTHER: 4ttach additional detail if desired, or as 1'equired by the Inspector of Wires. INSURAINCE 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 sach coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURt1NCC L2--_DOnND ❑ O'fflER ❑ (Specify:) Ev tiivated Value of Elcctt•ical Work:' (When required by municipal policy.) (Expiration Date) �Vork to S(art: /ryynyj Inspections to be requested in accordance with MEC Rule 10, and upon completion..... T eelrifl', tutder the jiains nasi pelralries ofpeijug,111111 tilt' ittforttralioti nit this al)jilicativtt is Irtte:a>tti ro»tplc'tc'. I Iltill NAhIL:- J.IC nO39 Li.ccnsce: cS� �4�iy�/� Sibn fore (Ifopplicabie elite;' "c.rciupt"Ili the ilccrz a nuanibertirle I3us. Tel: No 3 2� l/7 Address:��I 1� �7 %�! �� A% Alt: Tel. \o OWNER'S INSURANCE WAIVER: I am ati' arc that fisc Liceltsee doe's not have the liability insurance coverage normally ;. required by law. By my slgnaturc below, I hereby waive this requirement. I aln the (check otic) ❑ owner ❑ o«•rcr's a`ter,t. Oivner/Aaeti( '^'' Signature Tolepttone No. LPI'RAH I X1:1:, SY J7. O U 01 MAO= C11 1 /11 M MA^11 _nlr1c Location t O No. %d� v Date TOWN OF NORTH ANDOVER s ; ; Certificate of Occupancy $ tis' • Eta' Building/Frame Permit Fee $ s�cNus Foundation Permit Fee $ Other Permit Fee $ .- r�✓ TOTAL $ l�S Check # 150501�l � ``building InspeVe` a 0/ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ti r„�','�,�”` ..,. __ .:->,... „`�E.<w .. � _,� ,�.;, �..3<�:�....n..�+�a "''.'."fv- _ n$��dP1�^��$'�4,��„e. .�, ti.....: ,_ __'..: •=ai<i a.�._:, e> _:q.:� s "�•xx'�s�ie�s�'ai YeJfi} , ?..L.s BUILDING PERNIIT NUMBER: DATE ISSUED: /® ) — I SIGNATURE: C Building CommissioneLq for o'f Buildin Date Nr 4- 11UN 1- SITE IN FORMATION 1 1.1 Property Address: % S %^ gam ©g �fi �oe 1.2 Assessors Map and Parcel ®(� Map Number Number: ©/S Parcel Number 1.3 Zoning Information: eS roning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft i.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide R ed Provided R red Provided tAj N /u .7 WaterSupply M G.L.C.40. 54) 1.5. Flood Zone Information: ublic �� Pnvate ❑ Zone Outside Flood Zone 1.8 Municipal Sewane Disposal System: �� On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSI3IP/AUTHORIZED AGENT A Owner of Record ed �-e rT - l rvMqOlk..s ame (Print) ignatuti e 2 Owner of Record: Name Print Telephone 96 Address for Service: 3935 Address for Service: WTION 3 - CONSTRUCTION SERVICES I Licensed Construction Su rvisor: Not Applicable ❑ sensed Construction Supervisor: / 04 ff V l D - C -V/- - `3 A-Ia' Nq Z>g^/ Vj�IC /VQ��J License Number dress Expiration Date oe5� nature Telep one Registered Home Improvement Contractor ► ? w P r -r 1 C Oo s7r V G %/GW npany Name Iress ature Telephone Not Applicable ❑ %,A9,%-7� Registration Number /®/f(Olz 00 e— Expiration Date SECTION 4 - WORKERS COM-PV..NSATION (M r- i r tc' s ic,.rc� 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 build unit. Si ned affidavit Attached Yes ....... No ....... ❑ SECTION 5 Descre tion of Proposed 'Work (check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other Specify o �' C X;,5 7_," T��jPN S✓ ��. i�eT.S SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be _'-V' 3 I1G?�JSE�1' { Completed by t applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbin / Gip® Building Permit fee (a) x (b) 4 Mechanical tmuAPI 5, Fire Protection (® 6 Total i+2+3+4+5 67 aG0 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I' as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I' 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/Agent Date NO. OF STORIES L SIZE BASEMENT OR SLAB SIZE OF FLOOR TH,4BERS 1 Sr 2 ND 3 RD SPAN DIMENSIONS "OF SILLS w f4 DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION N THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND eJ IS BUILDING CONNECTED TO NATURAL GAS LINE V e—s' i �- ��e "�arzzmzo�n�aerzlff �/��,a�racl:uae�la BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 048810 £` Birthdate: 08/03/1963 i Expires: 08/03/2003 Tr. no: 1456 Y -Restricted: 00 BRADLEY E POWERS JR _ 22 WYMAN`S LANDING DANVILLE, NH 03819 Administrator ✓iie �oorzrrza�uveal�ir. af'✓l�arrrl�taelld �! Board of Building Reguiatons and Standards HOME IMPROVEMENT CONTRACTOR Registration: 122775 Expiration: 10/16/2002 Type: INDIVIDUAL BRAD POWERS CONSTRUCTION BRADLEY POWE,iS JR , 22 WYMANS LANDING DANVILLE, NH 03819 _ M �'w " -_ ✓fie i�a��vntaouvecr�f� a �.lrautrluael�d BOARD OF BUILDING REGULATIONS - License: CONSTRUCTION SUPERVISOR t Number: CS 048810 Birthdate: 08103/1963 z Expires: 08/03/2003 Tr. no: 1456 —.Restricted- 00 BRADLEY E POWERS A _ 22 WYMAN'S LANDING DANVILLE, NH 03819 Administrator ✓ILN /e iaa�nmza�uoecr�. a�.��,a.�rtar�uae%ld Board of Buildin_ Reguiations and Stt3ndards HOME IMPROVEMENT CONTRACTOR Registration: 122776 i Expiration: 10/16/2002 Type: INDIVIDUAL BRAD POWERS CONSTRUCTION BRADLEY POWE,Rs,,JR ; 22 WYMANS LANDING. I744VlLtE, NH 03819 rliinnistator U#1 AC D CERTIFICATE OF LIABILITY INSURANCE OPID B DATE(MM/DD/YY) -OR WEBR2 06/26/01 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Y +JOSEPH ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE THE S. HILLS AGENCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 129 MAIN STREET, PO BOX 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PLAISTOW NH 03865-0300 PRODUCTS - COMP/OP AGG $ 60 0 , OOO Phone:603-382-9211 Fax:603-382-3387 INSURERS AFFORDING COVERAGE INSURED INSURER A: National Grange Mutual INSURER B: Bradley Powers, Jr. INSURER C: 22 Wyman' s Landing INSURER D: Danville NH 03819 INSURER E: LIABILITY ANY AUTO COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER P LI FFECTIV P LIEXPIRATIONLIMITS LTR DATE MM/DD/YY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ 300 , OOO A X COMMERCIAL GENERAL LIABILITY MPJ63691 01/20/01 01/20/02 FIRE DAMAGE (Anyone fire) $ 50,000 CLAIMS.MADE FxI OCCUR MED EXP (Any one person) $ 5,006 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY CARPENTRY- RESIDENTIAL- DWELLINGS CERTIFICATE HOLDER N I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN TOWN OF NORTH ANDOVER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL DEPARTMENT OF PUBLIC WORKS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR BUILDING DEPARTMENT 27 CHILD STREET REPRESENTATIVES. N ANDOVER MA 01845 AUTHORIZEDRESENTATIVE 1 n ACORD 25-S (7/97) TION 1988 PERSONAL &ADV INJURY $300,000 GENERAL AGGREGATE $ 600 , OOO GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 60 0 , OOO POLICY PRO- JECT 7 LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) Q GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR F-1 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY CARPENTRY- RESIDENTIAL- DWELLINGS CERTIFICATE HOLDER N I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN TOWN OF NORTH ANDOVER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL DEPARTMENT OF PUBLIC WORKS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR BUILDING DEPARTMENT 27 CHILD STREET REPRESENTATIVES. N ANDOVER MA 01845 AUTHORIZEDRESENTATIVE 1 n ACORD 25-S (7/97) TION 1988 12" 12" 161" 24" ... -�— 97" �— � 24- 27- - 2V 70" T 24" —7L 26" v 50" 253" )-- 30" 36" -- 15" /---- 36" 24" --/- 17•• 24" W2436- ..........._....._._......{.... W1D(24 15 L.DIIADR B17 -RI (D c1 co EL a m a LU U _. 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O O CiCD p H. m pp �/ Er : ♦ � AAN D m C=D N CDco C7v n_ mN 0 N z y cl cr cn ��j�J 41 tv''' m� C CD ♦yam O -j n m �H� o FW O -- O o z O cn y z m o :: � o CD CD O � 46 d d d rL a� qb o: co CD 51: F.. r -D, ^ p G ^ .fir z zm O OCG � �= W' � z O OCG � � n m� N O OCG � r� r Z COD 1-0 m p= n � z or OG ::r- G 7 CL 7 r ,b �. T =- rD x 4 0 c 0 Date.. 3.M a i TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... 0 , , , , rAI A cam... 12,!-pI (,[1N I' has permission for gas installation .. in the buildings of ...m?.. vh ' a... ......................... at .. .... ? .: j�2�,� a � ....... , North Andover, Mass. - Lic. Noq�R�..Fee.. . GASINSPECTOR Check # /q'73 9 1082 MASSACHUSEM UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations PERNIlT TO DO GAS FMING Date , 6ecl/7 "! � e C Permit # Amount $ -��- ,Owner's Name New ❑ Renovation ❑ I\4lacement Plans Submitted ❑ x � x w o U x x w o c °z o 9 4 F• 9U oW Q GV z a 9 Oa x G4 P U 0 1 SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type)— Ch ck one: Certificate Installing Company Name ' k/J\ ��� 1 y V _ Corp. Address��� ✓� ❑ Partner. usiness Telephone [:] Firm/Co. 1Name of Licensed Plumber'or Gas Fitter (> �i � .47^ INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes JZ No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy � 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and mtormauon i nave best of my knowledge and that all plumbing work and instal compliance with all pertinent provisions of the Massachuset )wn DVED (OFFICE USE ONLY) ciltc►cu� ui au vc aFyii�auvi, cuc uua. uui, .,.,,,.u�., led under P t Issued for this applic ion will b in e a-H-UthaDter 142 Qf 1he Gener w - Signature of Licensed Plumber Or Gas Fitter ❑ Plumber �� Ole �'- ❑ Gas Fitter License um er Master Journeyman 3553 This certifies that Date..F• . ?? . e.-. z ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION has permission for gas installation 71c ............ in the buildings of .......................... at ..f'.. , f �..t`"'e.f:�rl . ,tea: i/North_Andover, Mass. Fee.,.?./c 1. .. Lic. No. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 0 ✓IA.SSA t APP CATON FOR PERMIT TO DO GAS F=( or print) PARCEL Date a twxTH AND" Building Locations ? (1-7 y /-- U c% i 'S i rn d yy 'Ns Owner's Name New ❑ Renovation ❑ Replacement R Plans Submitted ❑ Permit # 3 J 3 •� Amount S ate. i (Print or type) Address Business Telephone " " x/17 -<— Name of Licensed Plumber or Gats Fitter S Check one: Certificate Installing Company ❑ Corp. ❑ Parmer. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ED 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 ❑ Agent ❑ I hereby certify that all of the details and information I have su itted (or entered) in above application are true d accurate to the best of my knowledge and that all plumbing work and install ions performed under rmit Issued for this ap tcation will be in compliance with all pertinent provisions of the Massachuse hap42 / the Ge I �ws. / By: Title City/Town APPROVED (c>fr(cl. USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber Gas Fitter License i umoer Nlaster Journeyman Mal REMI (Print or type) Address Business Telephone " " x/17 -<— Name of Licensed Plumber or Gats Fitter S Check one: Certificate Installing Company ❑ Corp. ❑ Parmer. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ED 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 ❑ Agent ❑ I hereby certify that all of the details and information I have su itted (or entered) in above application are true d accurate to the best of my knowledge and that all plumbing work and install ions performed under rmit Issued for this ap tcation will be in compliance with all pertinent provisions of the Massachuse hap42 / the Ge I �ws. / By: Title City/Town APPROVED (c>fr(cl. USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber Gas Fitter License i umoer Nlaster Journeyman