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Miscellaneous - 98 FULLER ROAD 4/30/2018 (2)
N OO Q IlCl w 0 0 0 0 0 haps llnp Fhudo•e a vkapalXdpld mml3) e[wds121081 p - j�'Electriral Penh[ 421081- V... XLA Town of North Andover, MAA,Q Search... Q - 21009 *Electrical Permit - IN conjunction with a Building Permit (Commercial or Residential) TIMELINE Submission received Aug 10, ZOt6ar 1Z38pm Electrical Review In Progress Opermit Fee Pay- -o Permit Issuance Ox —> Wednesday, Aug 10, 2016 12:39 PM Your request is in progress We'll letyou know of any updates via email. Feel free to check the status at any time by coming back to this page. ,ny Pctue Sent to\ls-4ALOMDEV_RICOH fl Capy Numhal ESC i'y Fent r AppBcanc Lamlon Joe Vaccaro 98 FULLER ROAD, NORTH ANDOVER, MA ow,e� DAMOUR MICHAEL W. Attachments I Upf . d r„ e -OT5WA81001F Wed Aug_10_2016_16:38:.PDF Ur,b—d,d A:, ur. 10, 701£ ny Joe Jn:rar; It. ^3 t� ® e)% N I4I 8)10(201612:39 PM M.,: �--\ C'ommonweahk of Maaaack aetb Official Use Only ' c7 n Permit No. 2epartment 4 ire S ndcea 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPfrad ALL INFORMATION) Date: `b 1 A City or Town of: o/hndo✓� 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) R'% 'Fol) t -t- (Zd Owner or Tenant lAi ke- icmolir Telephone No. q -n - y -1 3 — 1-h 3y Owner'SAddress 9% 'f -A4 -r U. 1Ucn,-� A, -,d oar, Is this permit In conjunction with a building permit? Yes ET No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Eiechical W : - v .1 Cnnrnlolfmf nfJ/,n fn//ntvino lah/p Dtav be Wa[Ve[ibV ttt¢ LtSDeC101'OIYYtJeS. No. of Recessed Luminaires No. of Ceil: Sus . addle p (Paddle) Fans o ota TrKVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimmin Pool Above ❑ n- ❑ g rnd. rnd. o. o Emergency Lighting Batterl Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o ete and Initiating Devices evvices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: .„um er ons ........ o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW al Local El Connection ❑ Other No. of Dryers i'Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent o. o Water Heaters KW o. o o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a No of Devices or Equivalent OTHER: $ q S 016-'r I Attach additional detail 11 destrea, or as required ay tae tnspecror oj wires. Estimated Value of Electrical Work: ?— 000 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Rr BOND ❑ OTHER ❑ (Specify:) 1 certify, under the pains and penalties of perjiny, that the htforntadon on this application is true and complete. LIC. NO.: 1wbEb14 g LIC. NO.: Tel. No.:7%%-V0-4& Tel. No.: I *Per M.G.L. c. 147, s. 57-61, security work requires Departmcht of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner owner's a eat. Owner/Agent PERMIT FEE: $ Signature Telephone No. CERTIFICATE OF LIABILITY INSURANCE DATE1/1 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 certificate holder Is an ADDITIONAL INSURED, the policy(tas) must be endorsed. if SUBROGATION IS WAIVED, stiNect to the terns 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 Ileu of such endorsement(s). PRODUCER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 326 OWATONNA, MN 55060 CONTA&T CLIENT CONTACT CFNTFR mr, we Exa • 9 F No : 50 DISs., C C INSURERS AFFORDING COVERAGE NAIC 9 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 297-673.6 NORTHEAST ELECTRICAL INC 1 NORTH AVE BURLINGTON, MA 01803 INSURER a: INSURER &. INSURER 0. INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 0 REVISION NUMBER: U THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE R POLICY NUMBER POLICY POLICYEXP LIMITS rA GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMSMADS ❑X OCCUR rN N 9884054 12/31/2015 12131/2016 EACH OCCURRENCE slAwpO( D RENTED $100100( MEOEXP (OM alapasall) EXCLUDEC PERSOfM & ADV INJURY :11000,00( GENERALAOOREOATE $2,000,OOC OENI AOOREOATE LIMIT APPLIES PER: X POLICY ,°leo- CT F1 LOC PRODUCTS 6 COMPIOP AGO $2,000,00C AUTOALL AUTOMOBILE IM LIABILITY YAUTOBODILY IUTED eAMEODUlEO HIRED AUTOS NON -OWNED AUTOS N N 9884085 12/31/2015 12/31/2016 MBI dED eINOLE LIMIT $1,0001000 INJURY (Par parson) BODILY INJURY (Per aeddent) OPE TY AMAOE A X UMBRELLA LIAR EXCESS LIAO X OCCUR CLJUMSMADE N N 9884087 12131/2015 12/31/2016 EACH OCCURRENCE $2,000,00& aeomoxa $2,000,000 DED I I RETENTION A WORKERS COMPENSATIONWCST{QSJ- AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTPA OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yar, describe under DESCRIPTION OF OPERATIONS below NIA N 9854066 12/31/2015 12/31/2016 DTH' )C TORY u 8 ER E.L. EACH ACCIDENT $1,000,OOC E.L. DISEASE • EA EMPLOYEE $(,000,00( I.I.DISEASE • POLICY LIMIT $1,000,OOC DESCRIPTION Or OPERATIONS I LOCATIONS 1 VEHICLES Wbdl ACORD lot. A40onal Remarks SdAMs, H more space is roquIred) THIS COPY IS NOT TO BE REPRODUCED FOR ISSUANCE OF CERTIFICATES. 00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED It ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 1989-2010 ACORD CORPORATION. All rights reserved ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD a- The Consntonivealth of Massachusetts ' Deparlutent ofInrkrsttlal Aecidenls Office of IIIyestigadotls it 1 Cottgtess Street, Srtlte 100 Boston, MA 02114.2017 wipJV.nI1 ss gov/illi$ Worlcers' Csnpelsation Insurance Affidavit, Bulldet's/Contracts'slElectr[cians/Plumbers An pl_icaut luforrnation Please Print Leeibltr Name (Business/Organization/lndividuat): Northeast Solar Services Inc Address: l North Ave Suite A Burlington/ MA/ 01603 Phone, #:781.270 - 6555 Are you an employe'? Check the appropriate box: 1.0 i am a employer with 12 4. Q 1 am a general contractor and I employees (Rill and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I ata a homeowner doing all work myself. [No workers' comp. insurance required.) $ have hired Ilio sub-catttraetors listed on the attached shoot. These sub -contractors have employees and have workers' comp. insurance.$ S. ❑ We aro a corporation and its officers have exercised their right of oxomption per MOL c. 152, 61(4), and we have no employees. [No workers' tomo. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1113 Plumbing repairs or additions 12.❑ Roof repairs 13.❑✓ OtherSolar PV •Any applicant HIMchecks box 111 must also fill out it% section Wow ahowingthett moskere con►peasatton policy 100101010111.t Homeosruus svho submit this affidavit Indicating they are doing all nrodc and then biro outsideconlractars must submit a now affidavit indicating such. $Contractors that check this box must attached out additional sheet showing the name of t e sub.conlrectors end state Whether or 1101 those entities have employees. If thesub•contractors have employees, they must provide their workers' comp. policy number. I our au ea1ployer that is provlethig $porkers' eosnpesrsallass lsssrrrauce for lily employees. Below is 11re policy anrd job stle htjora►ailon. Insurance Company Name:_FederatedMotual Insurance Company Policy # or Self -ins. 1,1c. ►1:8884086 Expiration Dato:' 12/33/2016 - — Job Site Address: �� � �c>f /0t , oy�Lyty/StatolZip: 4 Attach it copy of the worlcers' compensatlon policy declaration page (showlog the policy number and explradon date). Failure to secure coverage as required tinder Section 25A of MOL e. 152 can lead to the imposition of criminal penalties of a fine tip to $1,S00.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of lite DIA for insurance coverage verification. 1 do lrereby certUy s�rr r the pair ad penaltles of perjury Ilia! lite N rrrrrrtlotr provided above h trite nail correct 781.270.4888 OffJcial rise only. Do scot write In Bels area, to be completed by cl(p or town ofJlelid City or Town: Pertnit/License # Issuing Authority (circle ono ' 1. Board of Health 2. Building Department 3. Ctty/rown Clerk 4. Eleetrical Inspector 5. 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CD c _ A A _ � 8 z a fl CD A y A o ' 0 wt T y ' V W 2yNm ' T�FOKOym O� zA`Z m DMpm Hg Dz�z 422 66 A .sm�oo=z mr��3�PDO 'O <Z 0 �] j § ! r >z P�Mi _ gp A ii �tOR7f( o+ • a O 9 ,SSACMUSE� Date . .... ..1. `. . t.ATO1WN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... ... ... °... ............. ...... . has permission to perform . '-'�� plumbing in the"buildings of . .... ................. . at ......... ,��..... . , North Andover, Mass. Fee `-' • ... Lie. No. -7!% ' 3 . /f I .� �/ .............. . PLUf�b{91L. G INSPECTOR Check # 7934 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date �l 9 `n Building Location 9k lUllelp e1j. Owners Name JO e �� % /(r'/ y Permit #46— T— AmountV� Type of Occupancy Newrl 13Renovation Replacement ® Plans Submitted Yes1:1 19LJ No &' I Zi Wm =:: `B1t D►I --MM-M--MM---------M-----E •s' mmmmmmmm-m-mmm-mmm---m--.m W 1 • I ' MMM---M--M--------MMMM--- -5 ' ------------------------- • � • 1 • *:' ------------------------- l -MM--------------M.M---- 1 • �:' --..--.----------------- MA 1 I 10 01:' ------...---------------- 1 � �:' --.-------------.-.-M-.--1 (Print or type) p Installing Company Name H4Z z o tf, 1 Address P 0, 00'-y Check one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber: T /til %M C I- C) /<' #4 /U Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® 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 ❑ Agent ❑ 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By ignare oL 1-1censeG Flumoer Title 'Type of Plumbing License Ci /Town y S33 City/Town 1cense INUMDer Master ❑ Journeyman APPROVED (OFFICE USE ONLY UNJ MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FiITING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Y Building Locations Permit # ��' ��� Amount $ —Joe- r -I 14HL�� �y .. Owner's Name Ci New ❑ Renovation ❑ Replacement © Plans Submitted ❑ (Print or type) CSC one- Certificate Installing Company Name T -il—d L L O YCI--1 ❑ Corp. -JO Partner. '? Firm/Co. Date .. / .- o — ,, ,"° 10 TOWN OF NORTH ANDOVER A PERMIT FOR -GAS INSTALLATION This certifies that . ... /7`.-r 20-�-d '� Y 17 has permission for gas installation . �• -� .... . in the buildings of ..�_ r;�% at ���. ..� - /4 l% ................... North Andover, Mass. Fee.: ...... Lic. No:� , . (( Check # (1 y12 6640 No ❑ Bond ❑ rewired by Chapter 142 of the Agent ❑ application are true and accurate to the Issued for this application will be in [42 of the General Laws. Gas Fitter 1ST. FLOOR Mai (Print or type) CSC one- Certificate Installing Company Name T -il—d L L O YCI--1 ❑ Corp. -JO Partner. '? Firm/Co. Date .. / .- o — ,, ,"° 10 TOWN OF NORTH ANDOVER A PERMIT FOR -GAS INSTALLATION This certifies that . ... /7`.-r 20-�-d '� Y 17 has permission for gas installation . �• -� .... . in the buildings of ..�_ r;�% at ���. ..� - /4 l% ................... North Andover, Mass. Fee.: ...... Lic. No:� , . (( Check # (1 y12 6640 No ❑ Bond ❑ rewired by Chapter 142 of the Agent ❑ application are true and accurate to the Issued for this application will be in [42 of the General Laws. Gas Fitter Date .... - 2......1—.....el.'7 .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. -- ... . .... ..V ................ has permission to perform ........................... .................................................... wiring in the building of ....,/............................................. at ..... 2? ...... . ..... ...................... . North Andover, Mass. Fee ... :tX� ... . ... Lic. No-;-n4?-� ................ ELECTRICAL 1; 4SPE(JR Check # v2 tl 7548 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7-31-07 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives no e of his or her i ention to perform the electrical work described below. Location (Street & Number) Owner or Tenant _ J v Owner's Address s;¢ 93 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building La stcht c ,e 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: (,qty—t of /10 # i'.mmntotinn nftha fn/ln,.d».. r.,/.L„ --A.......:.....J r._..r-_ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) „ I certify, under th ai s an a alties of er' ry, that the information on is application is true and complete. FIRM NAME r,(/Yf— /N(NJ LIC. NO.: Licensee: r-� s �r N� Signature LIC. NO.: E-21�;9J7 (If applicable, enter "exempt' in the lice number line.) „ us. Tel. No.•9' "fck -Q 3Y Address: / / GlrO ,gytt� d . oli`�Q p'itA ®f �_ Alt. Tel No.. *Per M.G.L. c. 1�7-61, 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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $�% - ---- -----.. - ..._ .......•••• •.........,... — u trm irta rctur u rrtrcy, No. of Recessed Luminaires No, of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- E] IN o. of Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number ...1. Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, Security No. of Water No. of No. of f Devic s or Equivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: r; Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) „ I certify, under th ai s an a alties of er' ry, that the information on is application is true and complete. FIRM NAME r,(/Yf— /N(NJ LIC. NO.: Licensee: r-� s �r N� Signature LIC. NO.: E-21�;9J7 (If applicable, enter "exempt' in the lice number line.) „ us. Tel. No.•9' "fck -Q 3Y Address: / / GlrO ,gytt� d . oli`�Q p'itA ®f �_ Alt. Tel No.. *Per M.G.L. c. 1�7-61, 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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $�% t ` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Y Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 0D1iC2nt Infnrma+inn Name (Business/Organization/Individual): S Address: City/State/Zip poa— nAA Phone.#. Are you an I ? mp oyer Check the appropriate box: 1. ❑ I am a employer with 4. [1 I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors I 2. am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] ;Any applicant that checks box #1 must also fill out the section below showin their Type of project (required):. 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. Building addition 10.❑ Electrical repairs or additions I LQ Plumbing repairs or additions 12.0 Roof repairs 13.[] Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside cont actors mus s bmtsation Policy ort as new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub contractoro and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' co mp. policy number. I ani an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of theD A� forinsurance coverar a �do her y e�rnfnd ains d lues ofperjury that teinformationprovided aboveistrue e• \ Date: I — d - use area, to or town officlaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Ir Phone #• I Locations No. --2/4 Date TOWN OF NORTH ANDOVER # Certificate of Occupancy $ '�b'•^•''t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check #�/ 1$587. /, `Building Inspec r 1.1 Property Address: IlLee 1.2 Assessors Map and Parcel v G Q Map Number Number: - ----06Y2 Parcel Number 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 RegWred Provided ReciWred Provided 1.7 Water Supply AGI -C.40. 34) 1.5. Public 0 Private ❑ Zone Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ bZU11UDI 1 - PKUPEKTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record _ Name (Print) 6?7e) Address for Service �2/ ,STtd Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si ture Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Lice sed Construction vervisor: Not Applicable ❑ dppg-tv Licensed Construction Supervisor: ZtV&f-kF, License Number oAddress rqT) 911— ' ®lt Expiration Date Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name t l Registration Number Address rgR) Expiration Date Si re Telephone MU M �o 3 z 0 v n M 0 z M 90 0 rM v r _r z 0 SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) Failure to provide this affidavit will result New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work-./ ,. 7D ; -Docwe 4^t^. fes=) SF.CT10N 6 - F,STTMATFD CONSTRITrTION COST5 Item Estimated Cost (Dollar) to be Comp ete permit applicant QIFICIAL USE ONLY ' I . Building s �,_ (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AG NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, // 6fy 1 L' as Own/Authorized Agent f subject property Hereby autho to act on My bell n all ma ive to worthorized by this building permit application. 9�� A�r Signa er Date I SECT40N 7b OWNER/AUTHORIZED AGENT DECLARATION I 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 Sig2ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS iST2 3 RD SPAN DUVIENSIONS OF SILLS DM4ENSIONS 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 ry Lot) A m m M m m YI mm • v y C m � d 'fl O CD 0 Z CO) � � O CL ' y aCC2 O CD o p CD O cr CD Sr CD Oww CD s COi CD CL O_ CO) I CD S v CO) O 'v Z CD oCD a C CD O A � Ct7 C1) n Cn C cn A.r E O ^O Z Cn b• rn Off' C 0 CO) O Q d mC2cl. ='dd� =r C d CL s v, O m m g m CO) -00 . O pN.CO'! . O may: a MAI O CL ... o � r O m H d y _� O. pm CCD . IE.5Cos m -,a N p !9 Z o CD M CO) = C. dm: : MF s 0 b! m 3 N y O O CD I It CO) C) m T Fri CO) _ z 0 N 0 H 0 9 o o w x n �.'d EL r ro M o O w O x a U C/)oil O x o � � 0 G a AN, The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street this Boston, MA 02111 ., www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Check the appropriate box: I . ❑ I am a employer with 4. ❑ I a 2. ❑ 3. ❑ employees (full and/or part-time).* 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone #: m a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs l3.❑ Other 'Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Expiration City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia 0 N Z fk 0 r M = n w n X cn cn D m - �mo -� D Z O N 0 0 a CL. �I w 0 Location %X No. a Date TOWN OF NORTH ANDOVER 9 e1 Certificate of Occupancy $ s'r0., <� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # - 'i666--') $ `Building In for TOWN OF NORTH ANDOVER BUILDING DEPARTMENT ISH A ONE OR TWO FAMILY DWELLING APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMyO�fL� g'l� BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: 001ing Commissioner to of Buildings Date SECTION 1- SITE INFORMATION a 1.1 Property Address: 19 Tuzz X'Of it 1.2 Assessors Map and Parcel Number: 6 _ O O V Map Number Parcel Number IV, 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.6.40 54)1.5. Flood Zone Infomution: Public ❑ Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 0 2.1 Owner of Record Yet/2 2�f %ZL4,119n,� ° iU L Z Tlt 90 MVOVA Name (Print) rAddress for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: - 5F971 Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Lic$nsed Construction Supervisor: j w" S � � � m -A , Addres' 7— - al /-/ // 2 0 Signature Telephone Not Applicable 0 License Number 0 0 Expiration Date 3.2 Registered Home Improvement Contractor z , J ��L����� Company Name "2-2-6LousR.Cl, S 7-�iL 1'it�9-t Not Applicable ❑ Registration Number �D?.Ll�'7 ���,-ate Addres Q [� '- (/� 7 �.� Expiration Date Si ture Telephone Ma rn X ic Z O v rn SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) 3 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 au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 400 � 0 llmw l Z Yip or I SECTION 6 - ESTIMATED CONSTRUCTION COCTfi I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFTCML USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) d 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> �J " Authorized A nt e- as Owne of subject property Hereby authorize ru L-ebzoL. / c o to act on My b f all afters to work authorized by this building permit application. Signatdre oYJwner 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 TIlVIBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DM,--NSIONS OF GIRDERS fff IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Y Location af'U /�� PC; No. C( */ Date &/�a ' l Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 30 r Foundation Permit Fee $ Other Permit Fee TOTAL 752 ( '(P I -- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT EEEM& RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Two seeti6rtE filr +(ice Use 0111 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: �. Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: �S ;:da 1.2 Assessors Map and Parcel Number: 65, _ �3 Map Number Parcel Number Vyv I( 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 Regaired Provided R red Provided 1 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information: Public ❑ private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT =' « ' S L I ''U L • '=5 2.1 Owner of Record Aagw r'or Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor if L. Cgl�-r s-uc77ark Not Applicable ❑ /-37-3-3o Registration Rumber Company Name / Add s /- '570 Expiration Daic Si re Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Sianed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Workcheck sU a li-ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ism ' /2 /y P, < dD >/ 774, p A,ct Vi 011ro I SECTION 6 - RSTIMATFn CONSTRUCTION COSTS I Addition Y_ Item Estimated Cost (Dollar) to be C2n jpfeted by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) Q 4 Mechanical HVAC S Fire Protection 6 Total 1+2+3+4+5 Check Number Cr SECTION 7a OWNEKnWn10KtZATION TO BE COMPLETED WHEN OWNERS AGEN R CON`TRACTO PLIES FOR BUILDING PERMIT as Owne Authorized Agent f subject property Hereby au ze 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 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 ofOwner/A ent NO. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR TDABERS iST SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Date SIZE 2' THICKNESS X Dec,. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** /APPLICANT LOCATION: Assessor's Map Number (06" SUBDIVISION STREET v PHON&06ec- C 17 5 PARCEL 93 LOT (S) (/ST. NUMBER **********OFFICIAL USE RECD IIMENDATIONS RF TgYVN AGENTS: Ai NSERVATION ADMI COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS TOR DATE APPROVED 7 I) DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT, RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm MORTGAGE INSPECTION BAY STATE SURVEYING ASSOCIATES INC. 100 CUMMINGS CENTER. SUITE # ajU SEVERLY.MA.. 01915 LOCATION :.. �ti,Qg✓ SCALE: In= 60 OATE • /0" /2-0/9 ......» REFERENCE: Z CES' 11615 M. TP'utT Mo,QTGAGe coR The location of the buildingtsl as shown. either compiled vwth the local zoning setbacks at the tkne of constructior. or,s ±zWs pt !tta Vft_t:�;,:.:�r.:saent a4on under Mass ML Title V11 Chapter 40A Section T jr 0 L'L' NOTES¢ 11 TMs is a mortgage Inspection survey and not an rnotftaneut srrrsey, tltsrafaa this plot plan is for mmtgmp gospsdloro pmposiss may, =i TMs eurxay is band an sm Vey marks of others 31 Bushew ahndi& fences and tree linea do not h Inilicame tom dose. 41 VYhrrnrer an edb t to 11 *• or lass. an Ina anent aerrsy Is raeooemsrdsd to dstensine property ft"W and any possible sror:oadsaents 6j O3fasts sbewo are. approarkn" and are to be tend only for tate dshmminadm of inning, motto be used to sataMsb property Iinse. 31 in mT Pvtm Mnd UN buiidinglsl are not located In the special flood hazard sane. as d&Mwd by H -IM MAPIP -Z /_ - �7_ca-2 N% To►s-� Douai r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print 9 arm Location: ` Cily I)/i4 Phone # 1 am a homeowner perforafing all work myself. 1 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 City: Phone #: Insurance. Co. Policy # Company name: Address City: Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment_as _well_as _civil..Renakies in ihe.form of-aS_T_OP WORK_ORDER..and_a .fine of _(.$1 DO.DD)_a jday -against.me. I understand that a copy of this st ent m y be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify ungerthe pains Print the information provided above is true and correct. � lei Phone #921 g,-21— 3—S-0 V. Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Licensing Board p Selectman's Office Contact person: Phone A- Health Department F-1 Other m m m m CO) m mm CIO C � S- d '0 O CD 5ZZ y CL 90 0 CL y aCc o -N O v CD CD o CL Q� =r CD CDo C O y CL a) y —• o cc C S v CO) O '0 CD O CD O CD m o Ry C C?�0 m 2 F- a _Go 0Q N a r CO S CL y G O C2 CL es n z �v O Oil m �0 m � y o > > m w m 0 0 w 0 GOD C r �: g m CIL. .....: CD m ,om: = d C o ti y m N ad�cr _IL ;� C o CA °° � r 7 C Wan mCD W H � V 9 CD W ao OD moi z �16 Co ri s Is moC: dmA oIO n 0 C3 c o o = o c� m o Ry Cl F- a F. a r Cj7 111o G I? y n ►n C w O Oil GOD o z 9 y 0 c Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: r %�614Z X/r— Q City N kni 100 rof,/ L-- Phone # QI am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rry employees working on this job. 16 Address. �, 4 L ar,,,•,riLC �-- — 6"S3?_a G,6!g'o Companv name: Address City: Phone # Insurance Co. _ Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal �� one � penalties of,a fine up to $1,500.00 years•'mprisorunentas welLas_civAlpwakmjnihelmnjcfaS7S2P111t9RKDMERand_afine-Gf_($1JD0-W)-aAW agaiostD1-- I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / ob hereby eeifify unthe Signaturel� 0 Print name Y&L ��> '�F�/'Z Pine.# Z - Official use only do not write in this area to be commleted by city or town official' Uy or Toon icensing El Building Dept C] Check if immediate response is reguked ❑ licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other r N- A- North Andover Building Department Tei: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is -that. the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A.. The debris will be disposed of in: (Location of F A�/ Ir Sign ure ofrmit Applicant - ��-03 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector 11 Q 0 � r'/� "(OO�lLhtp�y�� �✓�a�ciCuaerC4 - = Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before'the expiration date. If found return to: Registration: 102467 Board of Building Regulations and Standards Expiration: 7/2/2004 One Ashburton Place Rm 1301 Type: Private Corporation Boston, Ma. 02108 NEW ENGLAND CUSTOM DESIG fiat"Lanza 226 LOWELL ST. — – WILMINGTON, MA 01887 _ Administrator Not valid ithout s' re ;;a'::a;: �ite '(OO�ltinur�zcuect� o�✓�dac�ttcJeirr.G BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 008828 Birth date: 04/20/1951 Expires: 04/20/2004 Tr, no: 20132 Restricted: 00 VAL J LANZA 34 BIXBY ST L•E.�e 6 REVERE, MA 02151 Administrator H O 0 z "¢ o .0 O w ' V)u v cn 04 u � or- p u. O w v U - io C w a 0 U a p w G w a O W U w W p w U cn coC w Oa z ¢ to w C w W a w a w v W 2 cn v -� O cn CD O E co O v z O CO3 O D O I CCD om_ CO2 Q A O O �r m m CD 40 co � O.a 3� O G O R O a CL CM< C O CIOC CJ � CO) Z Q cv � R C .0 C C. y Lli _0 U) U) w W W ui U) c r- o m c C V O ` C H � C C O C3 V CL. c Cc eo c �z o o 43 43 N � o D e o a •• N om :� v$ u cm cE :mom .�m a N N ��3 = c �' J N A O -v E m ®o aC m L L O o1 C O m C3 -y O v -;Z O r c C O C c H m h = m m .�.. p N COD 4— ymo� m L W c �. N MD 19 O C oc -E CZ m is Z o ui L3 m om�c g COD CL m � C3 m H .O C = R C =�a�m� CD O E co O v z O CO3 O D O I CCD om_ CO2 Q A O O �r m m CD 40 co � O.a 3� O G O R O a CL CM< C O CIOC CJ � CO) Z Q cv � R C .0 C C. y Lli _0 U) U) w W W ui U) 3;5O Date. —4 A.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... .Id..,. ..... 5.fC ........ haspermission to perform ........ 7 ....................................... wirirt4 in the building of ........ / . ................................. 6 ........ at ........... ./:x ..... A.. ... ........ North Andover S. . ...... .... Fee......�.. Lic. No.C/5,�3.,� ........ ......... ELEMICAL INSAECTOR Check # w r Commonwealth of Massachusetts Official Use Only, m Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (M.W) 527 CMR 12.00 (PLEASE PRINT IN INK OR T AL INF RMATION) Date: �� City or Town of: - To the Inspe for of Wires: By this application the undersigns 'yes no o his orlher in t' n 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 ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Q Location and Nature of Proposed Electrical Work: _Installation of Security system Completion nfthe fnllnwina mhla —, t,,, it,,, -r No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above [I In- ❑ rnd. rnd. o. o Emergency Lighting Batts Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump 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 E uivalent No. o Water KW Heaters No. of No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) �- Estimated Value of E ectrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: -Qjnspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thefpaW hndpenalties of perjury, that the information on this application is true and complete. FIRM NAME: nllT SeCiiri tv Corvi roc JA t`1 i/Qr tion hlr _ Hnl l i c tiH LIC. NO.: 1 533(: LIC. NO.: 1533C Licensee: John S. Bassett Signature (If applicable, enter "exempt" in the license number line) g-7� Address: OWNER'S INSURANCE WAIVER: I am aware that the Lic see does required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature Telephone No. Bus. Tel. No.. 608 594 5928 Alt. Tel. No.: not have the liability insurance coverage normally I am the (check one) ❑ owner ❑ owner's agent. PERMIT FEE: $ ,