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HomeMy WebLinkAboutMiscellaneous - 98 LYMAN ROAD 4/30/2018 (2)1 Date .............. .......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that -&-A j )E P � (}v. ! p....................................................... has permission to perform w4ett c wiring 'n the building of........'P... ........................................................................................ j at y-. v�!i +-!.......... ......... , North Andover, Mass. Fee. �� r Lie. No. �1 .......................... ..................................................................................................... ELECTRICAL INSPECTOR Check # 1210,123-1 — 26 \�o vh I Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. )T� 11 Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: I a 11 I is— City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. �l L t' & N b 00 oca On (Street um er) L V I'Y►GN JS 4 Owner or Tenant ALl dy U 2e ay� �O Telephone No. 78 �- 70�/ -%7S�I Owner's Address Is this permit in conj unction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 0109c) (o83_j__ - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service ,bb_ Amps '12V /a Kt7 Volts Overhead � Undgrd ❑ No. of Meters „ r Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: New ��� Cmmnletinn nfthe fnllnwinu table may be waived by the Inspector of Wires. SSS` No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- El rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW No. of Self -Contained , Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local.❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritNo. o Dedies or Equivalent No. of Water KW No, of No. of Data Wiring: Beaters Signs - Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as regidred by the Inspector of Wires. Estimated Value of Electrical Worki u I3 Bc) (When required by municipal policy.) Work to Start: I 11b 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: _ t Licensee: Signature (If applicable, ente exempt" in the license number line) Address• _ LIC. NO.: 1001-7 3 _ LTC. NO.: a p Bus. Tel. No.: Alt. Tel. No.: 5111-1(01- 0788 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safet r "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 ❑ owngfs agent. Owner/Agent PERMIT FEE: ' Signature Telephone No. ❑ 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 A, 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 deemed by the Inspector of Wires abandoned and invalid if hei or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written 1 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: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: I Inspectors Signature: Date: SERVICE ECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: G PARTIAL ROUGH INSPECTION: Pass Failed ($.) ❑ Re- Inspection Required9 Of Inspectors Comments: o& I' Ito Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: )FINAL INSPECnO3e Pass M ilFailed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com N The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): TSraj Lot I 1 1) fn t C4,y Address: cga S,1yter &bek IR c\— Q� G�-e' ,l[� (O'2q City/State/Zip: Are you an employer? Check the appropriate box: Phone #: C17k- -) 7 — 074V- 1. ❑ I am employer with employees (full and/or part-time).* 2. i am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.FJ 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): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 E] Building addition 11.❑ Electrical repairs or additions 12.E] Plumbing repairs or additions 13. Fl Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -con'tract'ors have employees,they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: M R Ql pkfr}S :ENS!aCq TAC. p —W Policy # or Self -ins. Lie. #: 190P q c)q IO 40q Expiration Date: 7 IOS7 t 1 p Job Site Address: 0 �T/)Y�lA 1t cV City/State/Zip: Q��S Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 ofperjuty that the information provided above is true and correct. Signature: Date:Phone#: 97t--7&7 -0-711- Official -O'?41 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 apaitmv§'and whoxiesides•therein, or the occupant of the dwelling house of another who employs persons to.do maintenance, consQ'iion or repair work on such dwelling house or on the groundsf (;r build ipg app urtenant'there'torsballrnot because of•such empjoymo. be deemed to be an employer." MGL chapter 15_214`§251C(6)•also-stdfes than"eery state or local licensing agencyAshall withhold tN,,issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 Departmentlhas rovided`a space at the bottom of the affidavit f'or you -to fill out in the event the Office of Investigations h'as �oggont� 'You i`egarding the applicant. Please be sure to fill in the,pennit/license number which will be used as a reference number. In addition,, an applicant that must submit multipl "permitJlicense applications in any given year, need` -o' sril init one of idavit ndicating 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 Department's address, telephone quid fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia MONWENS LTH 0 BOARD OF ELECTRICIANS ,*SSUES THE FOLLOWING LICENSE AS REGISTERED MASTER ELECT RICIAN- 3RAIS, D KELLOWAY 25 SLIVER BROOK RD 1,0 I SUES A 00, A P* E G ELECTR I C 1 ANS THE FOLLOWING LICENSE JOURNEYMAN ELECTRI,CtA AY pop wE 1 1 1: FXPIRATION OAT mm m Location f 0 Z (i k-),7,dj No. i Check # , iUa ? Date /'% 13 2-0/6 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee$ "- P"TG) . Foundation Permit Fee ' $ Other Permit Fee $ TOTAL $ Building Inspe or Commonwealth of Massachusetts Sheet Metal Permit Date: - WN4 31, 2016 Estimated Job Cost: 66 00 Plans Submitted: YES NO Business License # � Business Information: Name: fn,04 C�-��c�` Street: 12, G #NjftjfLjo t Permit # U Permit Fee: Plans Reviewed: YES NO Applicant License # i Property Owner / Job Location Information: Name: Q`f®t e, / tA o t Street: City/Town: � �lj S -f-) City/Town: Telephone: 60- 590%?) 1+9 Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: -/ . Renovation: HVAC Metal Roofmg Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes P'-N'o ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy [ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box)j, I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date Progress Inspections Comments Final Inspection Inspector Signature of Permit Approval Comments Signature of Licensee License Number: Check at www.mass.gov/dpl E 4 0 Type of License: By ❑ Master Title ❑ Master -Restricted City/Town ❑Journeyperson Permit # ❑Journeyperson-Restricted Fee $ Inspector Signature of Permit Approval Comments Signature of Licensee License Number: Check at www.mass.gov/dpl E 4 0 Sheet Metal Commercial Guidelines / Life Safety / Critical System_ s Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios :Eire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm. testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) G-rease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper 616;Wances, fire rated enclosures and pressure testing required. rRt inStalle ?h11Ezi I�qulreCl 011 egli` ment and Duct penetrations in f-ke'iatU tvall:3 and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nips installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -off) 4 - Sheet Metal Residential Guidelines / Inspection Checklist Yes No NIA Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumayperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) _ t 4 - Sheet Metal Residential Guidelines / Inspection Checklist Yes No NIA Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumayperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) 611/2016 IMG-2963.JPG ff#j COMMONWEALTH OF MASSAC't'Hus S 'E "AtTAL WORKEx-R$ Ni�-,T--.-'\ ISSUE.SgTHE FOLLOW144`6 AMASTf,,P.��rUM�R�'ESTR.I-CTED,.-" > . .... �Ils c 0 RGO A FRAN "'n x - yS A 021 22 50 3 1 0 9 /:-2-1811 https://mail.google.com/mail/u/0/Mnbox/155Oc8Oe98t75e52?projector=l 1/1 l® CERTIFICATE OF LIABILITY INSURANCE ACORDZ DATE (MM/DDIYYYY) �! 5/16/16 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Metro Boston Insurance Agency, 96 Central Ave Chelsea, MA 02150 CONTACT NAME: Chris PHONE FAX (617) 884-5480 / No: (617) 884-6487 AIL ADDRESS: cmatarazzo@metrobostoninsurance.ocm INSURE S AFFORDING COVERAGE NAIC # INSURER A: Nautilus Insurance Com an PREMISES ISE (Ea occurrence) $ 100,000 INSURED INSURER B : Eddys Heating & INSURERC: Cooling Services INC D: 12 Carroll St SUITE 2 -INSURER INSURER E: Chelsea, MA 02150 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER! 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF M/DD/Y POUCY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE I—XI OCCUR NN672708 4/7/16 4/7/17 EACH OCCURRENCE $ 1,000,000 PREMISES ISE (Ea occurrence) $ 100,000 MED EXP (Arty one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'LAGGREGATELIMITAPPLIESPER POLICY PRO LOC JECT .PRODUCTS - COMP/OPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL 0 WNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS OMBINED SINGLELIMIT (CE Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Peraccident $ UMBRELLA LIAB EXCESSLIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED. (Mandatory in NH) Ifs describe unS,describder DRIPTIONOFOPERATIONSbelow` N / A WC STATU- OTH- I FR E.L. EAC HACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT I $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regui red) Town of North Andover 120 Main St North Andover, MA 01845 N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE z C 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORE( ' CITY Qe_ a/ -e MA DATE L PERMIT # =�r — �' JOBSITE ADDRESS OWNER'S NAMEL iV POWNER ADDRESS TEL —FAX E - TYPE OR I OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT CLEARLY NEW: RENOVATION: © REPLACEMENT: Ell FIXTURES Z FLOOR--, BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 2 1 3 1 4 5 1 6 1 7 WATER HEATER ALL TYPES I=-rI E _ ) _ i IF WATER OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the RESIDENTIAL PLANS SUBMITTED: YES Q NO 8 1 9 1 10 1 11 1 12 1 13 1 14 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 01 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are and that all plumbing work and installations performed under the permit issued for this application will be in coi Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAME L�Se y� --IILICENSE# IVIP 2,-- JP Q CORPORATIOND #PARTNERSHIP COMPANY NAME Nl E G /�( _ ;ADDRESS c� CITY - -._____--...._._..._i STATE [�-ZIP (y (_ 1 II TEL Li FAX L , E CELL .---- .. _._ EMAIL -C--fit .-4-- he best of my knowledge nent provision of the SIGNATURE LLC a.'�N on z N ❑ tii w LL 't4 LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER F INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES D NO _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ® BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT I® SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 complia ce wit a anent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME :� LICENSE #i f, /I SIGNATURE MP ®BJP Q CORPORATION D# } PARTNERSHIP ® ( LLC LatE COMPANY NAME ni G �v( _; ADDRESS CITY _�' /�- __..... -.._C STATE C�_ZIP 2 ( _— TEL F�;7� '2 — U J C FAX CELL EMAIL _dZ..__i� J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11 cqoj CITY Il%� y� j1 c/? MA DATEZPERMIT #�U'4 JOBSITE ADDRESS L OWNER'S NAME POWNER ADDRESS TEL FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL ��— PRINT CLEARLY NEW: RENOVATION: © REPLACEMENT: Of PLANS SUBMITTED: YES Q NO FIXTURES 7. FLOOR--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE. DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM _._.� _ _ � . 1 I _..__� I ._._! f II I _I DEDICATED GRAY WATER SYSTEM I ._- [ _ [ _ I __- _j _ _J DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN__.3 __-.__ ._ f ._..__...._I FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK I .- [ f ( __._.__i _._._-..._ ____[ _---- I L_111- _--i----� LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER F INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES D NO _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ® BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT I® SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 complia ce wit a anent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME :� LICENSE #i f, /I SIGNATURE MP ®BJP Q CORPORATION D# } PARTNERSHIP ® ( LLC LatE COMPANY NAME ni G �v( _; ADDRESS CITY _�' /�- __..... -.._C STATE C�_ZIP 2 ( _— TEL F�;7� '2 — U J C FAX CELL EMAIL _dZ..__i� J U1 ❑ ui LU LL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Dy' e)✓-O� MA DATE Z2 f _ PERMIT#2 " JOBSITE ADDRESS J_ _ : �-iii-,�YJ'�/ OWNER'S NAME l/� �v U GOWNER ADDRESS ITE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: M--' RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES Ej NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER(-� -.._-1[::j[- _. _ BOOSTER - - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER 1 DRYER FIREPLACE FRYOLATOR I I FURNACE - v - - - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS_��C- MAKEUP AIR UNIT I OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER - OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LJ OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia ce iti i all P inent provision of the Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. I-,' (� PLUMBER-GASFITTER NAME J /1t. LICENSE # [ IGNATURE MP MGF EJI JP 0 JGF a LPGI CORPORATION ©# PART RSHIP[I# _ LLC R14= 17 COMPANY NAME: 8--' _fi/ ADDRESS CITY FAX CELL~_ EMAIL /V�C�rZ lc>✓ _ vl OF� FI O H U W 7P-4 A ' Z z°❑ O W O� a � U w �* W � � w Cl)C0 Ix LLI O �+ w U) a g a, a U J E., a a. Q < S w x w I-- LL H °z z O H V W L�7 W s' Y r The Commonwealth of Massachusetts n Department of Industrial Accidents terms : a 1 Congress Street, Suite 100 Boston, MA 02114-2017 `t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): (Jl.cl ld Address: 2,6 City/State/Zip: C c S L> /a` /�'L�1' d2G� Bone #: �, tib `alt 2 Are you an employer? Check the appropriate box: Type of project (required): 1. am a employer with , ! employees (full and/or part-time).* 7. [] New construction 2. ] I am a sole proprietor or partnership and have no employees working for me in 8. [ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 ❑ Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12: �bing repairs or additions 5. n I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs These sub -contractors have employees and have workers' comp. insurance.# 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 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 showing their workers' compensation policy information. i Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must�attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X ant an employer tfiat is piovidiiag workers' compensation insurance for my employees.' Below is the policy and job site information. / Insurance Company Name:` i 4- - (D- e, 41,0—� Policy # or Self -ins. Lie. Expiration Dater C� Job Site Address: �75�1✓� City/State/Zip: Attach a copy of the workers' compErnsation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine tip 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. A copy of this statement may be forwarded to the Office of Investigations of the DIP, for insurance coverage verification. X do hereby ce y under�e pain�d penalties of perjury that the information provided above is true #d correct. Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): i 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&'boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees 'other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Depaftment of Industrial Accidents foi- 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 bur leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Y DateJ�...Z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that........................................................................�............... has permission to perform ..., C�,,�-- wiring in the building of ................. `, . V. e n ................ at....VY1.'.................................... t Fee.."..........:. Lic. No. i0 ... .................. Check # 4 b 1290771 ....... , North Andover, Mass. ............................................. ELECTRICAL INSPECTOR —Us Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 17A61— Occupancy and Fee Checked [Rev.1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL .INFORMATION) Date: X211 � ► r City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) �j r L,Y, an [(,8aa Owner or Tenant Nt'Ax& 2c t'ero Telephone No. 7?1 • — oq - (p-] Owner's Address Is this permit in'conj unction with a building permit? Yes No (Check Appropriate Box) �{+ Purpose of Building -reM P Sera,—CQ Utility Authorization No. a1 0C[D (000J5 y 7 - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service bbd Amps a /My Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Temp serfll a e -- Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number . .. .... ........................... ,Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Dr 3' Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Hydromassage Bathtubs No. of Motors Total HP WirinNo. Telecommunications No. of Devices or E u valent OTHER: 19, 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: I a 11 11,C 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 coverage is in force, and has exhibited proof of same to the permit issuing office. �CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) i X certify, ander the sins tend penalties of perjury, that the information on this application is true and complete. FIRM NiME: ,rVIA 4ttlpwetv LIC. NO.: I MO 1-7 Q Licensee: M&a KA, IL452 p/ Signature LTC. NO.: aOr+l3all4 (If applicable, enter "exempt" in the lice Ase number line.) Bus. Tel. No.7A Address: as $,Iver &aA a l , S bl'arn iV }i 03q2q Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $,� — Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the per' 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 deemed 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 isrto,promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic fourtyear-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. { x } i- ❑ Rule 8—Permit/Date Closed:<` -**Note: Reapply for new permit ❑ rti ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection s 14 .. Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: , Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: PASS0 ' `' �` � -.�,�; : Failed 0 Re- I ectiota R? ^"lnspecfors Comments. ,' '•tx y' , 3� ; , .�-...ti.7 Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com r? ^1 ski The Commonwealth of Massq chusetts Department of IndustrialAceldents m n ; 1 Congress Street, Suite 100 Boston, MA 02X142017 www mass.gov/dna Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: r � �1 V�l( na-n.,,l'• S6N-e t ' A& 03021 City/State/Zip: Are you an employer? Check the appi'oPriate box: Phone #: q7t" 1 to Z — 4>7qg�_ 1.❑ I am employer with employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have na. employees. [No workers' comp. insurance required.] Type of project (required): 7. New construction 8. 0 Remodeling 9. ❑ Demolition 10 [] Building addition 11.0 Electrical repairs or additions 12. F] Plumbing repairs or additions 13.0 Roof repairs 14.0 Other *Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such whether or not those entities have tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state employees. If the sub-coniractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. (� Insurance Company Name: M i` D�S �N_--� aG✓ �' — Policy # or Self -ins. Lie. #: dQ q gg LO QOq Expiration Date: 7 ��S jD 7obSiteAddress: !S' L�r�n tZ 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 thepains andpenalties ofpeijury that the information provided above is true and correct. Phone #: L –077 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License #, Issuing Authority (circle one): i , 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: .ia 0 � IIWJ a 4 \RX M I T a. ■. ;..� TOWN OF NORTH ANDOVER Office of the Building Department 0* NORTH q LEC , 1 Community Development and Services F ` . p 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 7,9 +ArEo V's us Gerald Brown, Inspector of Buildings January 12, 2015 To: Mariona Malloy Nancy Vavak Jacob Vavak From: Gerald Brown Re: 98 Lyman Road, North Andover, MA 01845 THIRD NOTICE Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on January 7, 2015 it has been determined that although the doors are now secured and there is no evidence of rodent or vermin infestation outside or around the structure at this time. During an earlier inspection on May 5, 2014 the building was unsecured but that issue has been remedied with doors now locked and secured. However, the roof on the barn/structure is still in deteriorating condition. Please accept this letter as the THIRD official notice under the Massachusetts State Building Code (780 CMR) section, Notice 116.3. You have fourteen (14) days to contact this office so that we may begin the process to remedy this in a timely manner. I may be reached between the hours of 8:00 am to 10 am Monday through Friday and 1:00 pm to 2:00 pm Monday through Thursday at 978-688-9545. Sincerely, Gerald Brown Inspector of Buildings Cc: File TOWN OF NORTH ANDOVER Office of the Building Department NORTH q Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 '' 70 North Andover, MA 01845 �9SSACHu5v. h Gerald Brown, Inspector of Buildings January 12, 2015 To: Mariona Malloy Nancy Vavak Jacob Vavak From: Gerald Brown Re: 98 Lyman Road, North Andover, MA 01845 THIRD NOTICE Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on January 7, 2015 it has been determined that although the doors are now secured and there is no evidence of rodent or vermin infestation outside or around the structure at this time. During an earlier inspection on May 5, 2014 the building was unsecured but that issue has been remedied with doors now locked and secured. However, the roof on the barn/structure is still in deteriorating condition. Please accept this letter as the THIRD official notice under the Massachusetts State Building Code (780 CMR) section, Notice 116.3. You have fourteen (14) days to contact this office so that we may begin the process to remedy this in a timely manner. I may be reached between the hours of 8:00 am to 10 am Monday through Friday and 1:00 pm to 2:00 pm Monday through Thursday at 978-688-9545. Sincerely, Gerald Brown Inspector of Buildings Cc: File January 8, 2015 Mariona Malloy Jacob Vavak Nancy Vavak 98 Lyman Road North Andover, MA 01845 RE: 98 Lyman Road, North Andover, MA 01845 Third Notice Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on January 8, 2015 it has been determined that although the doors are now secured and there is no evidence of rodent infestation outside or around the structure at this time, the structure is in an unsafe condition because of roof failure which may result in injury to anybody utilizing the structure for its intended use. Please accept this letter as the THIRD official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1. You have fourteen (14) days to contact this office so that we may begin the process to remedy this in a timely fashion. I may be reached between the hours of 8:00 —10:00 am at 978-688-9545. Respectfully, Gerald Brown Inspector of Buildings N January 8, 2015 Mariona Malloy Jacob Vavak Nancy Vavak 98 Lyman Road North Andover, MA 01845 RE: 98 Lyman Road, North Andover, MA 01845 Third Notice Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on January 8, 2015 it has been determined that although the doors are now secured and there is no evidence of rodent infestation outside or around the structure at this time, the structure is in an unsafe condition because of roof failure which may result in injury to anybody utilizing the structure for its intended use. Please accept this letter as the THIRD official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1. You have fourteen (14) days to contact this office so that we may begin the process to remedy this in a timely fashion. I may be reached between the hours of 8:00 —10:00 am at 978-688-9545. Respectfully, Gerald Brown Inspector of Buildings SECTION 114 VIOLATIONS 114'.1 Unlawful acts. It shall be unlawful for any person, firm or corporation to erect, construct, alter, extend, repair, move, remove, demolish or occupy any building, structure or equip- ment regulated by this code, or cause same to be done, in con- flict with or in violation of any of the provisions of this code. 114.2 Notice of violation. The building official is authorized to serve a notice of violation or order on the person responsible for the erection, construction, alteration, extension, repair, moving, removal, demolition or occupancy of a building or structure in violation of the provisions of this code, or in viola- tion of a permit or certificate issued under the provisions of this code. Such order shall direct the discontinuance of the illegal action or condition and the abatement of the violation. 114.3 Prosecution of violation. If the notice of violation is not complied with promptly, the building official is authorized to request the legal counsel of the jurisdiction to institute the appropriate proceeding at law or in equity to restrain, correct or abate such violation, or to require the removal or termination of the unlawful occupancy of the building or structure in violation of the provisions of this code or of the order or direction made pursuant thereto. 114.4 Violation penalties. Any person who violates a provi- sion of this code or fails to comply with any of the requirements thereof or who erects, constructs, alters or repairs a building or structure in violation of the approved construction documents a or directive of the building official, or of a permit or certificate issued under the provisions of this code, shall be subject to pen- alties as prescribed by law. SECTION 115 STOP WORK ORDER 115.1 Authority. Whenever the building official finds any work regulated by this code being performed in a manner either contrary to the provisions of this code or dangerous or unsafe, the building official is authorized to issue a stop work order. 115.2 Issuance. The stop work order shall be in writing and shall be given to the owner of the property involved, or to the owner's agent, or to the person doing the work. Upon issuance of a stop work order, the cited work shall immediately cease. The stop work order shall state the reason for the order, and the conditions under which the cited work will be permitted to resume. 115.3 Unlawful continuance. Any person who shall continue any work after having been served with a stop work order, except such work as that person is directed to perform to remove a violation or unsafe condition, shall be subject to pen- alties as prescribed by law. SECTION 116 UNSAFE STRUCTURES AND EQUIPMENT 116.1 Conditions. Structures or existing equipment.that are or hereafter become unsafe, insanitary or deficient because of inadequate means of egress facilities, inadequate light and ven- SCOPE AND ADMINISTRATION 1 tilation, or which constitute a fire hazard, or are otherwise dan- gerous to human life or the public welfare, or that involve ille- gal or improper occupancy or inadequate maintenance, shall be deemed an unsafe condition. Unsafe structures shall be taken down and removed or made safe, as the building official deems necessary and as provided for in this sectionCAva ant`stnicta_re7_ rthat is not secured aga-mstentry shall be deemed unsafe 116.2 Record. The building official shall cause a report to be filed on an unsafe condition. The report shall state the occu- pancy of the structure and the nature of the unsafe condition. 116.3 Notice. If an unsafe condition is found, the building offi- cial shall serve on the owner, agent or person in control of the structure, a written notice that describes the condition deemed unsafe and specifies the required repairs or improvements to be made to abate the unsafe condition, or that requires the unsafe structure to be demolished within a stipulated time. Such notice shall require the person thus notified to declare immediately to the building official acceptance or rejection of the terms of the order. 116.4 Method of service. Such notice shall be deemed prop- erly served if a copy thereof is (a) delivered to the owner per- sonally; (b) sent by certified or registered mail addressed to the owner at the last known address with the return receipt requested; or (c) delivered in any other manner as prescribed by local law. If the certified or registered letter is returned showing that the letter was not delivered, a copy thereof shall be posted in g conspicuous place in or about the structure affected by such notice. Service of such notice in the foregoing manner upon the owner's agent or upon the person responsible for the structure shall constitute service of notice upon the owner. 116.5 Restoration. The structure or equipment determined to be unsafe by the building official is permitted to be restored to a safe condition. To the extent that repairs, alterations or addi- tions are made or a change of occupancy occurs during the res- toration of the structure, such repairs, alterations, additions or change of occupancy shall comply with the requirements of Section 105.2.2 and Chapter 34. 009 INTERNATIONAL BUILDING CODE® � 9 SECTION 114 VIOLATIONS 114.1 Unlawful acts. It shall be unlawful for any person, firm or corporation to erect, construct, alter, extend, repair, move, remove, demolish or occupy any building, structure or equip- ment regulated by this code, or cause same to be done, in con- flict with or in violation of any of the provisions of this code. 114.2 Notice of violation. The building official is authorized to serve a notice of violation or order on the person responsible for the erection, construction, alteration, extension, repair, moving, removal, demolition or occupancy of a building or structure in violation of the provisions of this code, or in viola- tion of a permit or certificate issued under the provisions of this code. Such order shall direct the discontinuance of the illegal action or condition and the abatement of the violation. 114.3 Prosecution of violation. If the notice of violation is not complied with promptly, the building official is authorized to request the legal counsel of the jurisdiction to institute the appropriate proceeding at law or in equity to restrain, correct or abate such violation, or to require the removal or termination of the unlawful occupancy of the building or structure in violation of the provisions of this code or of the order or direction made pursuant thereto. 114.4 Violation penalties. Any person who violates a provi- sion of this code or fails to comply with any of the requirements thereof or who erects, constructs, alters or repairs a building or structure in violation of the approved construction documents or directive of the building official, or of a permit or certificate issued under the provisions of this code, shall be subject to pen- alties as prescribed by law. SECTION 115 STOP WORK ORDER 115.1 Authority. Whenever the building official finds any work regulated by this code being performed in a manner either contrary to the provisions of this code or dangerous or unsafe, the building official is authorized to issue a stop work order. 115.2 Issuance. The stop work order shall be in writing and shall be given to the owner of the property involved, or to the owner's agent, or to the person doing the work. Upon issuance of a stop work order, the cited work shall immediately cease. The stop work order shall state the reason for the order, and the conditions under which the cited work will be permitted to resume. 115.3 Unlawful continuance. Any person who shall continue any work after having been served with a stop work order, except such work as that person is directed to perform to remove a violation or unsafe condition, shall be subject to pen- alties as prescribed by law. SECTION 116 UNSAFE STRUCTURES AND EQUIPMENT 116.1 Conditions. Structures or existing equipment that are or hereafter become unsafe, insanitary or deficient because of inadequate means of egress facilities, inadequate light and ven- 2009 INTERNATIONAL BUILDING CODE® SCOPE AND ADMINISTRATION I tilation, or which constitute a fire hazard, or are otherwise dan- gerous to human life or the public welfare, or that involve ille- gal or improper occupancy or inadequate maintenance, shall be deemed an unsafe condition. Unsafe structures shall be taken down and removed or made safe, as the building official deems necessary and as provided for in this section: A vacant structure that is not secured against entry shall be deemed unsafe. 116.2 Record. The building official shall cause a report to be filed on an unsafe condition. The report shall state the occu- pancy of the structure and the nature of the unsafe condition. 116.3 Notice. If an unsafe condition is found, the building offi- cial shall serve on the owner, agent or person in control of the structure, a written notice that describes the condition deemed unsafe and specifies the required repairs or improvements to be made to abate the unsafe condition, or that requires the unsafe structure to be demolished within a stipulated time. Such notice shall require the person thus notified to declare immediately to the building official acceptance or rejection of the terms of the order. 116.4 Method of service. Such notice shall be deemed prop- erly served if a copy thereof is (a) delivered to the owner per- sonally; (b) sent by certified or registered mail addressed to the owner at the last known address with the return receipt requested; or (c) delivered in any other manner as prescribed by local law. If the certified or registered letter is returned showing that the letter was not delivered, a copy thereof shall be posted in a conspicuous place in or about the structure affected by such notice. Service of such notice in the foregoing manner upon the owner's agent or upon the person responsible for the structure shall constitute service of notice upon the owner. 116.5 Restoration. The structure or equipment determined to be unsafe by the building official is permitted to be restored to a safe condition. To the extent that repairs, alterations or addi- tions are made or a change of occupancy occurs during the res- toration of the structure, such repairs, alterations, additions or change of occupancy shall comply with the requirements of Section 105.2.2 and Chapter 34. Gerald Brown Inspector of Buildings October 6, 2014 Mariona Mallory Jacob Vavak NancyVavak 98 Lyman Road North Andover MA 01845 TOWN OF NORTH ANDOVER Office of the Building Department Community Development Division 1600 Osgood Street — Suite 2035 North Andover, Massachusetts 01845 RE: 98 Lyman .Road, N. Andover MA 01845 FINAL NOTICE Thank you for meeting with Brian Leathe, local inspect inspection on Monday, September 29, he found the ban He also observed that the structure still presents an unsc failure and rodent infestation, which may result in injul children or anybody utilizing the structure for its intend Telephone (978) 688-9545 Fax (978)688-9542 Please accept this letter as the FINAL official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116J )f 780 CMR, except any specialized code referenced herr ;ian $1000. Or by imprisonment for not more than one 18.4. Each day that a violation exists shall constitute a self j As discussed with y( �- $ the roof has been rep proceedings. Respectfully, r` Gerald Brown Inspector of Buildings` ' 'ore November 1, 2014 to see if our office will begin court Gerald Brown Inspector of Buildings October 6, 2014 Mariona Mallory Jacob Vavak NancyVavak 98 Lyman Road North Andover MA 01845 TOWN OF NORTH ANDOVER Office of the Building Department Community Development Division 1600 Osgood Street — Suite 2035 North Andover, Massachusetts 01845 RE: 98 Lyman .Road, N. Andover MA 01845 FINAL NOTICE Telephone (978) 688-9545 Fax (978)688-9542 Thank you for meeting with Brian Leathe, local inspector, the other day. After Mr. Leathe's inspection on Monday, September 29, he found the barn/structure on your property to be secure. He also observed that the structure still presents an unsafe condition because ofpossible roof failure and rodent infestation, which may result in injury to abutters or abutter's property, local children or anybody utilizing the structure for its intended use. Please accept this letter as the FINAL official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1. Whoever violates any provision of 780 CMR, except any specialized code referenced herein, shall be punishable by a fine of not more than $1000. Or by imprisonment for not more than one year, or both for each violation as per section 5118.4. Each day that a violation exists shall constitute a separate offense. As discussed with you, Mr. Leathe will re -inspect your property before November 1, 2014 to see if the roof has been repaired. If the work is not completed by that date our office will begin court proceedings. Respectfully, Gerald Brown Inspector of Buildings TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street North Andover, Massachusetts 01845 Jerry Brown Inspector of Buildings May 5, 2014 Mariona Mallory Jacob Vavak Nancy Vavak 98 Lyman Road North Andover MA 01845 RE: 98 Lyman Road, N. Andover MA 01845 Second Nonce 6t- JNL � J (d teA\4 C'4 4 �31,ly Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on March 21, 2014 it has been deemed that the structure is in an un.rn£P r���'-=��—' froof failure and unsecured doors, and i abutters property, local children or Please accept this letter the SECOND offici` CMR) section Unsafe Structure 116.1 Con CMR, except any specialized code reference than $1000. Or by imprisonment for not moi section 5118.4. Each day that a violation exi You have fourteen (14) days to contact this o3 this in a timely fashion. If you do not contact need to initiate court proceed--- 978-688-9545. �, J� Respectfully, -a-r�-�-�- Gerald Brown Inspector of BuildingsIs rs or (780 780 more per edy ire will [ at TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street North Andover, Massachusetts 01845 Jerry Brown Inspector of Buildings May 5, 2014 Mariona Mallory Jacob Vavak Nancy Vavak 98 Lyman Road North Andover MA 01845 RE: 98 Lyman Road, N. Andover MA 01845 Second Notice Telephone(978)688-9545 FAX (978) 688-9542 Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on March 21, 2014 it has been deemed that the structure is in an unsafe condition because of roof failure and unsecured doors, and rodent infestation, which may result in injury to abutters or abutters property, local children or anybody utilizing the structure for its intended use. Please accept this letter the SECOND official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1 Conditions: Whoever violates any provision of 780 CMR, except any specialized code referenced herein, shall be punishable by a fine of not more than $1000.Or by imprisonment for not more than one year, or both for each violation as per section 5118.4. Each day that a violation exists shall constitute a separate offense. You have fourteen (14) days to contact this office so that we may begin the process to remedy this in a timely fashion. If you do not contact me within the fourteen (14) day time frame we will need to initiate court proceedings. I may be reached between the hours of 8:00 —10:00 AM at 978-688-9545. Respectfully, Gerald Brown Inspector of Buildings t : 1 ACH115ES•(`' 16000sgood Street Building 20, 2035 North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION 7,v �-gde- DATE: 30ell Tel #: FROM: 6 Aee-oj 4/ � 7C !/� rn.4..) V ADDRESS: 9P- /e Complaint Against: ELECTRICAL: PLUMBING: GAS: BUILDING CONTRACTOR: PROPERTY OWNER: OTHER: A0y. y 1� %. i Gd�l� v�4,-4_� "l— a� I North Andover MIMAP March 20, 2014 r ,r q Interstates —I SR Roads C. r EasementsE NOR7M q Oar«ao C3 MVPC Boundary 3? e ❑ Parcels 0 F >F np 1" = 39 ft ^�° t4fY Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION North Andover Board of Assessors Public Access I f NORTH O tt�eo a •yC t +F �SS^CHU`�ES Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 Im roperty Record Card Parcel ID :210/020.0-0035-0000.0 FY:2014 Community: North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to ss Location: 98 LYMAN ROAD Owner Name: MALLORY, MARIONA Owner Address: 98 LYMAN ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.30 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2288 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 323,200 323,200 Building Value: 156,500 156,500 Land Value: 166,700 166,700 Market Land Value: 166,700 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=2432346&amp;town=NandoverPubAcc 3/20/2014 North Andover Board of Assessors Public Access Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 Tzroperty Record Card Parcel ID :210/020.0-0061-0000.0 FY:2014 Community: North Andover Location: 94 LYMAN ROAD Owner Name: KILEY, COLLEENE Owner Address: 94 LYMAN ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.07 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1203 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 243,000 243,000 Building Value: 108,700 108,700 Land Value: 134,300 134,300 Market Land Value: 134,300 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkId=2432373&amp;town=NandoverPubAce 3/20/2014 TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street North Andover, Massachusetts 01845 Jerry Brown Inspector of Buildings March 21, 2014 Mariona Mallory Jacob Vavak Nancy Vavak 98 Lyman Road North Andover MA 01845 RE: 98 Lyman Road, N. Andover MA 01845 Telephone(978)688-9545 FAX (978) 688-9542 Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on March 21, 2014 it has been deemed that the structure is in an unsafe condition because of roof failure and unsecured doors, and rodent infestation, which may result in injury to abutters or abutters property, local children or anybody utilizing the structure for its intended use. Please accept this letter as a official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1 Conditions. Please contact me so that we may begin the process to remedy this in a timely fashion, I may be reached between the hours of 8:00 —10:00 AM at 978-688-9545. Respectfully, �r- Gerald Brown Inspector of Buildings ki if aA alz div r4li TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street North Andover, Massachusetts 01845 Jerry Brown Inspector of Buildings March 21, 2014 Mariona Mallory Jacob Vavak Nancy Vavak 98 Lyman Road North Andover MA 01845 RE: 98 Lyman Road, N. Andover MA 01845 Telephone (978) 688-9545 FAX (978) 688-9542 Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on March 21, 2014 it has been deemed that the structure is in an unsafe condition because of roof failure and unsecured doors, and rodent infestation, which may result in injury to abutters or abutters property, local children or anybody utilizing the structure for its intended use. Please accept this letter as a official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1 Conditions. Please contact me so that we may begin the process to remedy this in a timely fashion, I may be reached between the hours of 8:00 —10:00 AM at 978-688-9545. Respectfully, Gerald Brown Inspector of Buildings Leathe, Brian Prom: Burke, John Sent: Sunday, August 11, 2013 11:07 PM To: Leathe, Brian Cc: Kilcoyne, Bob Subject: 98 Lyman Road Brian, The Fire Department went down to the area of 98 Lyman Road for smoke in the area tonight. While there, they noted that the garage at that address is in pretty bad condition, and seems to have a large number of raccoons living in there. I already notified the animal control officer about the raccoons, but they wanted you to know about the condition of the garage. Thanks. Any questions, contact Lt. Bob Kilcoyne at the Fire Department. John Burke North Andover Police/Fire Dispatch ease note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more irmation please refer to: http://www.sec.state.ma.us/are/preidx.htm. Please consider the environment before printing this email. `V?rr „ r kDD f DATE OF INSP)r>TI:ON SAM-• -. --�_ _ _ • < , PASS FAIL; Ct7HE� HON` ON -NP. -Ml 1NSPEGTI09COMMENTs l 4 I SER r � fl�TING�„FOUNLI,,1Tf t Y TIME OPT. OU TIME IN � ]DISE — r. INSP)rCTED Y - I ]=CTION: aM �sF P 55 FAIL OTHER i0 ' CO GTION NOTE/ INSF'6r[ON'COMMI=NTS: RI1T� o) FftNOT x ma: 3 E 1I3 -4; L; t, TING OUN-A'1'ION FRAME: IME IN TIMI OUT. 7REA1. SPE s `- �E k< DATE OF,INSPECTION _ _ - - - PASS' OTHER_.- � FAIIs )NE - �� --- �_ - 6 lFGTfON NCOt INSpI_cT1%l COMMENTS; f I'm tIrlI T.� °< OFFIGi �NoiE _ _ a.v. �►�s•, ,k 4 j 2 cr1oN`P,) ►) 5r� `>=st�lEoa°ilntG F0>�N-00 FAME TIMEIN _ TIME011T. N� /�► NSPFCTED BY: DATE ofINSPECTION: PASS FAIL OTHER . } CCtZNECTION NDiE/ INSPF-CiION GOMMENTS. c `� O)sFICENOE _CTfbx:iW EsT� sG/FOo71Nc F011NAATfflN F=RAME r i �H+ 'Flt HE TIMEIN: TIME OUT! — _ r ,.�. r- v� VAA r � r SPECTEp.BY: QST !Z� i t • ' DATE OF INS -ECTION: r OTHER i „. _ _ _ < __x . PASS FAIL c-_ coRR);CTioN NOTE/ JNSPEcTID cflMMENTS: 1 .y OFFJ.'E NOVF F - �7ION REgtTS7. [=c1FQDT[NG EoUNDArIoN f PArAE - -- Y. :- -;. it _ _ -- —. -- a .. -X , CTIM SERVIGE- LOG ADL._ .S i.� ����' INSPECTED NAME�'C.� �"-•rs� GTiON: . PHONE PAS FAIL. OTHER 'ERMIT# GORREcy ION NOTE[ INSPECTIOAi COMMENTS: ' OFFICE NOTE. NSPEGTION REQUEST: ESCIFO07lNG FOUNDATION FRAM ,,E��- ROUGH FINAL OTHER [��t IN: TIME OUT: f a �- DURESS r NSPECTEDD WE -f%JLii� •� e D SPECTION: TONE PASS FAIL OTHER. :KNIT# RR EGTloN NOTE/ iNSP)=CTfON COMMENTS: OFFICE N07E: 3PECTfON REQUEST: ESCIFOOTING FOUNDATION FRAME OUCH ' 14 FINAL OTHER TIME IN: TIME OUT: 6 gr �R( T S' INSPECTED 13Y: TE OF INSPECTION: )NE PASS FAIL OTHER Tr1T CORRECTION NOW INSPECTION COMMENTS: � OFFici~ NOTE: 'ECTIQNR)=QUEST: ESGIFOOTING FOUNDATION ]FRAME JGH F1.N9L ;HER d Al TIME- � �+.??(I�E OUT: ...._.. --- -- .- ?ESS NSPEG 13Y: O 1(ON: �+ IE V®� AS5 FAIL OTHER _� ("T(' nrri G RECTIONNOIE[ INSPECTION COMMENTS: W&XL OFFICE NOTE' ?GTION REO••UEST. ESCIFOOTING FOUNDATION FRAME oo H FINAL OTHER TIME IN: TIME OUT: ri OFFICE NOTE: FION REQUEST: ESCIFOOTiNG FOUNDATION FPAME INSP) GTED DY:, er-cl-s O:t-- 'E' '!�IQ Le OF INSPECTION: k,:--Ztf o V &N aq L Ass FAIL OTHER RRECTfDN NOTE[ INSPECTION COMMENTS: uj�—J&o TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street North Andover, Massachusetts 01845 Jerry Brown Inspector of Buildings March 21, 2014 Mariona Mallory Jacob Vavak Nancy Vavak 98 Lyman Road North Andover MA 01845 RE: 98 Lyman Road, N. Andover MA 01845 Telephone (978) 688-9545 FAX (978) 688-9542 Please be advised that upon a visual inspection of the barn/structure at 98 Lyman Road on March 21, 2014 it has been deemed that the structure is in an unsafe condition because of roof failure and unsecured doors, and rodent infestation, which may result in injury to abutters or abutters property, local children or anybody utilizing the structure for its intended use. Please accept this letter as a official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1 Conditions. Please contact me so that we may begin the process to remedy this in a timely fashion, I may be reached between the hours of 8:00 —10:00 AM at 978-688-9545. Respectfully, Gerald Brown Inspector of Buildings Leathe, Brian From: Burke, John Sent: Sunday; August 11, 201 11:07 PM To: Leathe, Brian Cc: Kilcoyne, Bob Subject: 98 Lyman Road Brian, The Fire Department went down to the area of 98 Lyman Road for smoke in the area tonight. While there, they noted that the garage at that address is in pretty bad condition, and seems to have a large number of raccoons living in there. already notified the animal control officer about the raccoons, but they wanted you to know about the condition of the garage. Thanks. Any questions, contact Lt. Bob Kilcoyne at the Fire Department. John Burke North Andover Police/Fire Dispatch Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.see.state.ma.us/ore/preidx.htm. Please consider the environment before printing this email. Leathe, Brian From: Burke, John Sent: Sunday, August 11, 2013 11:07 PM To: Leathe, Brian Cc: Kilcoyne, Bob Subject: 98 Lyman Road Brian, The Fire Department went down to the area of 98 Lyman Road for smoke in the area tonight. While there, they noted that the garage at that address is in pretty bad condition, and seems to have a large number of raccoons living in there. already notified the animal control officer about the raccoons, but they wanted you to know about the condition of the garage. Thanks. Any questions, contact Lt. Bob Kilcoyne at the Fire Department. John Burke North Andover Police/Fire Dispatch Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. Date. ...... k I -V jr TOWN OF NOR ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . :4 i .D.. ...................... has permission for gas installation. n — ......... . ............................ in the buildings of . Am?. '/ . . . 11'e. r, x at .�,Y.AzriH �. . .......... No h Andover, Mass. Fee:}?.. .... Lic. No. . 2 �.. g . .... . ...... G INSPECTOR Check 444A MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date" NORTH ANDOVER, MASSACHUSETTS , Building Locations 1. 6 to 0� � l� Ky Owner's Name New Renovation Replacement Plans Submitted Permit Amount 6 , Cd (Print Name Addre BUS�M Name of Licensed Plumber'or Gas Fitter Check one: Certificate Installing Company 1-3 Corp. P rer. ' Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance polic or it's substantial equivalent. Yes No� If you have checked es as plee in ' Pte type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does_ not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sy,as CMe a" Chapter 142 of the General Laws. Title City/Town: PPROVED (OFFICE USE ONLY) �ipr(ature of Licensed Plumber Or Gas Fitter Plumber r9 2�E Gas Fitter License Number Master 04oumeyman v� r�zw �a vi w a a Oa F x Ze C w z C , ZU x z .. &03 z --t W 0 > LT., w E. UG W a x >> x a A d C7 o o° w O SUB-BASEM ENT .a U C > D C6 F BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR. 8TH. - FLOOR (Print Name Addre BUS�M Name of Licensed Plumber'or Gas Fitter Check one: Certificate Installing Company 1-3 Corp. P rer. ' Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance polic or it's substantial equivalent. Yes No� If you have checked es as plee in ' Pte type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does_ not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sy,as CMe a" Chapter 142 of the General Laws. Title City/Town: PPROVED (OFFICE USE ONLY) �ipr(ature of Licensed Plumber Or Gas Fitter Plumber r9 2�E Gas Fitter License Number Master 04oumeyman Date ...-1A..... //Z -.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...A. ��!.Jl .... A.:r./-J.m:� .................................................... has permission to perform ....... ...... t ....... .............................. wiring in the building of .....<r 0 A1.40 ... 4KiV-X................................................ at ........ q..,? ...... . . ............................... g North Andover, Mas. Fee...9.)... .... Lic. .......... ..... ELE ICALINSPI?TOR C-1 Check # / ) 11 . 8099 1-A' -C\- Commonwealth of Massachusetts Official Use Only Department of .Fire Services Permit No. dy �, `1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 11071 (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: City or Town o% NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) '� 1,%� M AtQ1 QC's/40 Owner or Tenant ] q R®®bJ tq MLLQ"� Telephone Nei ,_ Z 09q'Z Owner's Address fgtM2_ Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building!5;1 10 Utility,Autborization No. .442=11!j Existing Service1 QCj Amps X Z,© / Z `(QVolts Overhead Q Undgrd ❑ No. of Meters New Service ?mo Amps I1 -.C) / ZJLJ0Volts Overhead ® Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (zs-9LAC--L lZ1C+rRt► �i('r; t �N 6C�~ce�r-1lli ��-� aa'YIt� QJ -C% Comnletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaire 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- ❑ rud. rad. o. o Emergency Lighting Battery Units No. of Receptacle Outlets 2a No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches (o No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pomp Num..,_er Tons KW No. of Self -Contained No. of Waste Disposers 1 Totals: 1 ............ Detection/Alerting Devices No. of Dishwashers i Space/Area Heating KW Municipal Local ❑ Cyonnection ❑ Other No. of Dryers Heating Appliances KW ecuriNo of Devic s or Equivalent No. of Water KW No. of No. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNevicesr Wiringg• No. of Devices or Equivalent OTHER: Attach additional detail if -desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: b, ,Pn (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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F] BOND ❑ OTIIER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete FIRM NAME: A+5 Q7 -Q -!=9!:-t,4 SL3 Q"Z9-%y, St�l - LIC. NO.: Ib?',64 A Licensee: (` aRL &g=j P, Signature.C.-t— LIC. (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. Address: V) L 52�''C • - 3P*,QGQS --Mf4 0 VtQQ Alt. Tel. No..?` %- t� � s *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (chefPEMITFEE. one El owner El owner's a ent. Owner/Agent Signature Telephone No. ' i r 'Pitt- d� a r :^ www.massgov/dia Workers' Compensation Insurance Affidavit: BuflderslContractorsiElect dcions/Plambers A leant Information Please Print LS bly Name (Business/organization/Individual): Cit J /�,� 'i \� n -c i C Address: 171 � . - D- " ,1,1�Ps- 019�i� Phone #: Are you an emp!oyer?,heck the appropriate .hox: The Commonwealth of Massachusetts 4. ❑ I am a general contractor and I Departnwnt-of Industrial Accidents w- t Offke of Investigations 600 Washington Street These subcontractors have Boston, MA 02111 r :^ www.massgov/dia Workers' Compensation Insurance Affidavit: BuflderslContractorsiElect dcions/Plambers A leant Information Please Print LS bly Name (Business/organization/Individual): Cit J /�,� 'i \� n -c i C Address: 171 � . - D- " ,1,1�Ps- 019�i� Phone #: Are you an emp!oyer?,heck the appropriate .hox: 1. 1911 am a employer with 4. ❑ I am a general contractor and I __?_ employees (full and/or parttime)" have hired thesur contractors listed on the attached sheet' 2. ❑ 1 am a sole proprietor or partner- ship and have no employees These subcontractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required-] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c.. 152, § 1(4), and we have no insurance required.] t employees. [No workers' -,comp. insurance required.] Type of Project (required): 6. ❑ New construction 7. ❑ Remodeling S. Q Demolition 9. Q Building addition 10 .10, Electrical repairs or additions 17:❑ Plumbing repairs or additions 12-0 Roof repairs 13.❑ Other *Any apptkM that checks box gt mast also fill out the section below showing their workas' compensMion policy information. t Homeowners who submit this affidavit indicat" Ibey are doingatl�vorkand thea f►$aoutsidet onEeactoes musts"it s new$ffedmain liedingsuch. tContraclors that check this box -wig attadW an additional sheat showing the name of the sub -contractors and their workers' comp. polity infomration. lain an engrleyer that is prmigiag workers'radon hmraxce for my emy►loyM Below is the polity mrd job site infonnadeft /, SAc& Insurance Company Name: V- �� Policy # or Self -ins. Lic. #_ H 311 '2 1 Expiration Date: 1 G� Job Site Address: CIL�( V%/1 Ar_3 Flop Q City/3tate/Zip: i3"Iil A.P Q z lZ M P i Attach a copy of the wwuers' gompeuntion policy deeharatlonpnge_(showin_g the policy number and expiration date). Faihue 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 penaltiesi n -the form-ofa-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 fotwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hff* cerdfy und¢r theparm andpmaffin of perjury that the informadon provided above is true and correct Phone #: 7fI-�T53--):J-7 OJjrcial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health L Building Department 3. City/TownClerk 4. ElectricalInspector3. I%Mbing Inspector 6. Other Contact Person: Phone #: A* W- I oft'. I 5 I IN y `T �"z ? � e. e •i n w' � cc a '.�'r 9i .i�F?��c„.I.'�i.V ra �i:Yi. a....; a'.•:_,�.Oxx"u�.�_ ; :�rPd42✓ . .syr y 4 '� - ��'' � ems..' . ,} � I a � 1\ ' `# .r� � �- � r f�� a`,'e y' - _ _ �' �.y �� _ ' r 1 j r.. ` if , t� 3' \\ �� 1� �` �. i � Ste, ti %`� hiy'4 a4� rw�� �: SSS J Y 4 # 1 e,� :: s: �i e a � , e �`• ' �� 3 ' - .. �� k�..� 'A r arm � ',t ��1 .A, � � � . ,� �' _ �� ... _' +cr .._ _ ... ..y � '"� �.--�_. i A �v r� e S ; Location U K No. `/ y Date .,2 'joRTh TOWN OF NORTH ANDOVER Of �`•c ,•,yG 4111or war Certificate of Occupancy $ s�CNusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # `� 7 94(51 15241 Building Inspe for F *r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING EVEN BUILDING PERMIT NUMBER:^- - � DATE ISSUED: . , SIGNATURE: Building Commissim SECTION 1- SITE INFORMATION Date /'f r v 1.1 Property Address: SECTION 2 - PROPERTY OWNERSEEMAUTHORIZED AGENT 1.2 Assessors Map and Parcel Map Number Number: Parcel Number A10. _ o V e ✓, 1.3 Zoning Information: Zoning District Proposed Use Signature Telephone 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide Required Provided R red Provided Licensed Construction Supervisor: License Number 1.7 Water Supply M.G.LC.40. Public ❑ Private ❑ 54) 1.5. Zona Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSEEMAUTHORIZED AGENT r 2.1 Owner of Record Name (Print) Address for Servi f \ V Signature Telephone 2.2 Owner of Record: Name Prith Address for Service: 2, d P►���- --tya . 40,0 Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 R(eg�iste1r`edr Home Improvement Contractor Not Applicable ❑ Company Na e •J�' Z11(f) may` ( Registration Number ` VO Z- Address 1�50� Expiratio to Signature Telephone SECTION 4 - WORKERS COMPENSATION (KG.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 .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction E sting Building ❑ Repair(s) ❑ Alt w t I I Accessory B g. Ir Demolition ❑ Other ❑ Specify'_ 21 Brief Description of P�ropWorl Failure to provide this affidavit will result ❑ 1 Addition ❑ � 4-2 — Oor, r , A� 2R —5�-t`�!-s \'o eC.3C'(- I SF.C'.TION 6 - F.STTMATF.TD C ONCTRTTrTION VORTC I Item Estimated Cost (Dollar) to be Si ature of Owner/Agent Date NO. OF STORIES Completed by permit applicant (a) Building Permit Fee 1. Building 2 ND 3 RD SPAN DMIENSIONS OF SILLS . Multiplier DIMENSIONS OF POSTS 2 Electrical DIMENSIONS OF GIRDERS (b) Estimated Total Cost of HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING Construction MATERIAL OF CHIMNEY 3 Plumbing IS BUILDING ON SOLID OR FILLED LAND Building Permit fee (a) X (b) IS BUILDING CONNECTED TO NATURAL GAS LINE 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 O Check Number JGl,i1V1`I /a VWINAMAU1t1gJ f1fA11VP1 1V BE UUVMYLElEll WHEIN 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 71b OWNER/AUTHORIZED AGENT DECLARATION 1, C ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information o the foregoingapplication are true and accurate, to the best of my knowledge and belief Print N IZ]Z�a( Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1sT 2 ND 3 RD SPAN DMIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS — HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE .\ 0 a I I/ ,> FA 0 I North Andover Building Department Tel: 978-688-954.5 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 Facility) S� c� Signature of Permit Applic t Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector C/) m C Cf) 0 m CA .p a Z CD O wCL r W CZ a� CD o p CL Q CD O .. .. O tC CD CA 10 CD O O CA 0 CO) co C7 CD s CD Ma CD CA CD CA O CSD O CCD c n 0 z cn 0 z cn d b n: O t 0 O Z o. 00 m 0 m 0 c 0 J2 COm C 0 H C 0 CL h Vi C ?� O d �.y O Q y 4c CD 40 �d IS co CD C9 y sacr POOH O IE cco=r �o Z:SO N� n CD ay O CL = r m m H Q ma: CLO JE CAQ moo: �e m m m a H mom: 00 moo: a� CM o c!.1 o O .� co) CD d �` S m md o � CL 0 = eo cn o X, rD Cl) o o7 d noa " :n gv O b •n G as Go ?l w qo C oa O t!f 7f w () ` 7d G oc G 0 cn b O a. y O �J m omq 0 0 c i Date. . . TOWN OF RTH ANDOVER is �.,� _,.,_•. ��c \ PERMIT FOR PLUMBING • � �• a This certifies that ...3.'. D.�l.................. . has permission to perform .... lkc.& p.`- `............ . plumbing in the buildings of ............... at ...... �''f? `................ . v . North Andover, Mass. ` } L PLUMBING INSPECTOR Check # a Y 7753 Y I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building New rl �dl Date )wners Name �/� 6;14 % C% Permit Amount of Occupancy �'yl CZE Renovation b" Replacement El Plans Submitted YesNo 9 (Print or type)`�— Check one: Certificate Installing Company Name_ �J �� C vi t / Corp. Address a x0 � r-1 Partner. usmess elephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F1 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 Plu ' g Co d t y: �. �il� of the General Laws. Title Type of Plum"i License APPROVED icense u ef6�—' Master Journeyman APPROVED (OFFICE USE ONLY O