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HomeMy WebLinkAboutMiscellaneous - 99 BEAR HILL ROAD 4/30/2018N AMERICAN CLAIMS SERVICE MULTI -LINE ADJUSTERS BUILDING COMMISSIONER OR BOARD OF HEALTH OR INSPECTOR OF BUILDINGS BOARD OF SELECTMAN 1600 Osgood Street North Andover, MA 01845 RE: INSURED: John Conaton PROPERTY ADDRESS: 99 Bear Hill Road, North Andover, MA POLICY NUMBER: PHOO100803210 LOSS OF: 9/3/12;Property Damage FILE/CLAIM NUMBER 30081 PD Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please -direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim file number. Tim McLaughlin Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. September 5, 2012 Date 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 • FAX: (781) 245-1077 Date�Aaz- ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that -0I........... . . . .......... 7PAV -rA�10A-- I - has permission to perform ..... ....... . . ......... wiring in the building of ...T I., ..... CA. ................................. at ..(9.9 ..... /5W ......... North Andover ass. .... ............... . .... .... Fee...6� ......... Lic. No.,X/.Mo-� ....... Check# 5�)q I ELECTRICAL "INSPE 10843 Commonwealth of Massachusetts Official Use only og- Department of Fire Services PermitNo.0BOARD OF FIRE PREVENTION REGULATIONS Occupancy andFee 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 (NEC), 527 CMR 12.00 MA (PLEASEPAWTMUNKORTYPEALLINFORTIOA9 Date: J57— 16 1�— City or Town of NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noti of his or herr ii tet, n to er rm the electrical work described below. Location (Street & Number) `C I9 L r Owner or Tenant Telephone No. Owner's Address S 4/h-�e- Is this permit in conjupxl pn with a buil ing ermit? Yes No ❑ (Check Appropriate Box) Purpose of Building i(":111 j 4.1 Utility Authorization No. Existing Service Amps / Volts ew Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion DI ollowin table m be wai d b th I W' No. of Recessed Luminaires ve ens ector o ares. No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Fool Above ❑ In- ❑ o. o mergency Lighting rnd. rnd. Batter Units No. of Recept9cle 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 No. of Air Cond. TotTons No, of Alerting Devices No. of Waste Disposers Heat Pump Number Tons ..:.- KW No. ofSelf-Contained Totals: - Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances RW Security Systems:*• No. of Watero. No. No. of Devices or E uivalent Heaters KW Bal as Si s Ballasts signs Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: Nn_ of TIAVIPae —W—A-1." .,,A-1." OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Q7 (When required by municipal policy.) Work to Start: <!F- /7. /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 liabiliENDEI urance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coves m force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER ❑ (Specify:) I certiiII under a pains and pena 11es.o perj�Cat the information on this application is true and complete: FIRM NAME: / LIC. NO. - Licensee: f /}c, is /L Signature LTC. NO.: (Ifapplicable, enter empt' in the i se num 'ne.) Address: Vt ( (, ��-� Bus. Tel. No.: 9 ® Ic -'Per c. 147, S. 7-61, security work requires Department of Public Safety 11S' License: Alt. Lie. No. 66.16-1'%— S�¢¢ CG2"t'// 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/Agent [I owner's agent. Signature Telephone No. PERMIT FEE: IS _ TLE CTR][CA�1��y.�(y �P(E���1yyy��[��•'eN. o �� /• �p �� �I��'�����T�P�?��': v _ .•.Jc-.Jl.(L.�•W ��.L�V�®.L0. moi• • .. ._ ^ — • �_ R kassed•—X 7 Sailed—I I ?fie ins ecizottxequixec ($50.00) [ J Inspectors' comments: (Sxaspectoxs'Signature-•3.oinitials) Pate r 4. J'R+7SPXCITON—uE�t, CW,: .DA � 1, CAL -TURA ply TONAL. GROW: Passed— [ Z Snspectbxs' eo�um.ep�is: S'afled— (Xnspectors' i9ignatuxe - io f �. DQ7S�'D+ CTXOS�7 •- OT�Sir" ' Le-inspection r Data 'assed �- [ � S+.'azled �• I )_ ' ate-xnsp ection xec�uized ($50.0 D) -• [ � asp ectoxs' cv�oam.enis: (Snspectoxs' Signaiwre •• no initials) —. — Date D 0 O TAGO AM TO DE FAMED Oi7T, A" IEFT OX SITE IF TM A=A TO BE INSPECTED IS NOT A.00ERSIBLE AND ,A. R USIECTION OF $50,00 IN TO BY, CB"GED. . The Commonwealth of Massachusetts Department of IndustrialAccidihts Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl, Name (Business/Organization/Individual): T. E&C441c- �C Address: ��� (>6�i1 V e� City/State/Zip: 1), 4\y 1 I VL , �+' C? 391 Phone #: 603 3&)—?D CD 4 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. 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.] r employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. F1 Remodeling 8. ❑ DeMolition 9. ui1 ' g addition 10. lectrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Job Site Expiration City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required -under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I do hereby c jryy under the pains and penalties of perjury that the information provided above is true and correct. Sip -nature: ` Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 TO, # 61.7-72.7-4900 ext 405 or 1.-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdla Date. .414�11Z ...... . roll" 0 f. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Vo 7 This certifies that ... 147 ;e4. ................... has permission for gas installation ........ in the buildings of ... � t,'•Jr ?'/j ,-7 ...................... ....... I North And Mass at ..... I Fee.,:,Iq?. Lic. No.. GAS INSPECTOR Check 8162 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY — ,4µe{F.� _ - - -^' MA DATE 5 • Z Z- 12, PERMIT # (� JOBSITE ADDRESS q �l�/M2. c�i1 trt - OWNER'S NAME � J ,,[ ( r,Oi 7-4,u l� OWNER ADDRESS ��{'Q e,--P- TYPE OR PRINT 'FAX OCCUPANCYTYPE COMMERCIAL __ EDUCATIONAL RESIDENTIAL! CLEARLY NEW:. _ ; RENOVATION: i ] REPLACEMENT: ` PLANS SUBMITTED: YES t + NO _ APPLIANCES -1 FLOORS--+ BSM 1 2 34 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 1 CONVERSION BURNER COOK STOVE, DIRECT VENT HEATER DRYER FIREPLACE 'YRM M�'lJ3. FRYOLATOR FURNACE._ I ' GENERATOR — •--�;---� GRILLE INFRARED HEATER - LABORATORY COCKS`r--•--- MAKEUPAIRUNIT OVEN POOL HEATER .�..,:-� .x., -, . �..1�,... .._ .,.!,,I►—m-1._. - -;�. -- }. �.. i ...,... „j ..._.. I } ROOM ISPACE _HEATER -----3—N.—!-.«•------ - _--...I�-=_ ._.. I _. ..-_ 1 t 1.- _ ROOF TOP UNIT i - � � __ ; .---W-�—_„�. . �. TEST I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ I INSURANCE COVERAGE t have a current tiabili 'insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES (VINO I IF YOU CHECKED YES; PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNRY €, - 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 ortthis permit application waives this requirement. CHECK ONE ONLY: OWNER -I-- AGENT ?� � SIGNATURE Of OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best.of my knowledge and that all plumbing wdrk and installations, performed under the permit issued for this application will bei ante wi all P n t provision of the. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFiTTER NAME . Fke►l�itc Go�+dEIA - _- . LICENSE # 1b2Zo SIGNATURE MP , `!1MGF JP , _ � JGF LPGI CORPORATION. �;74 _,2 '}B 1 C PARTNERSHIP #m _~ - LLC -T COMPANY NAME: FB AIc1 tC Ga �JdE A r- _ 1 i ADDRESS (9S �Qlt•1CgTr� N' Sa: ; CITY 1.l • c 0 t �k-ts Po i STATE , MA ZIP • ohi6 TEL Q 6 • 2 t - t $ oa FAX q18-251 _IS01; CELL _ _ _ EMAIL F+¢•At; M le-B�F4PLd1-t$1vuG . Cort W W F 0 z z 0 F V W a z r.. a 7_. w �o z O w WO } r `r 1 o G a F o z ¢ tsl > acn w W C7 a co z � a a P. c i � I Q U J CL Q to CD S F- w LLI ti 9453 Date..............19..:................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. ........ 4- ....................... has permission to perform .......... .......... 6 ... L. ..................................................... wiring in the building of ...'T.yAn ...... .............................. at' -?7..... ........ ......... .... t...1 .., .., ..N..o...r..h Andover, Mas. iy A-�Fee .......Lic. No....Ok...................E EerRICALINSPECT0 Check # l..ommortu�eaC��i o� //laea(a�elivaeil� 21"Parim#41 015ire Serviced BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.s� 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 IN INK OR_ TYPE ALL INFORMATION) . Date: (c: � C111 1 U City or Town of: %01P -'Th 130 w de E 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) q C1Sep-A- 14, Owner or Tenant 3SC��1 p Telephone No. Owner's Address Gamt i rir 1, I1 4( Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building /1J6t2QLi,..,Q oAl i T -E Pte_ Utility Authorization No. Existing Service o`1130 Amps v)YO1 12c Volts Overhead ❑ Undgrd No. of.Meters New Service L)� Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W IZrF 1A)612co iUG'U,,►lTls SW i M th 1-16(6 1A�(� . llei % AN I t'm/elinn nfthe fnllnwlna table mat, be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus (Puddle) Fans P (nsformers of ran Total TNo. INA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires ove Swimming Pool nd. ❑ rnd. �' No of o Emergency ig ng Bsttery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No, of Gas Burners o. Initiatiin t on No. of Ranges Tl No. of Air Cond. Tan No. of Alerting Devices No. of Waste Disposers P eat Pump Totals: um -er ons _ o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Munical Local 13 connection ❑ Other No. of Dryers ry Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water, Heaters o. o o. o Si ns Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunica ons Wiring: No. of Devices or Equivalent OTHER: Attach additional detail tf desn•ed or as required by the Inspector of Wires. Estimated Value of Electrical Work: .2606 � (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEG 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 KL BOND ❑ OTHER ❑ . (Specify:) I certify, under th ains and penalties of perjury, that the information on this application is true and complete. FIRM NA /�, �" / 2 C LIC. NO.: ,2 .s8 %9 Licensee: alp V �%,✓CC1QP S Signatur LIC. NO.: �/7y3 (Ifopplicable, enter ..exempt" in the lice a number line.) Bus. Tel. No. ry 7 Address: F.6- 9O X S7-3 UnJ /`yf a3o33 Alt. TeI. No.: 9.�r *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, l hereby waive this requirement. I am the (check one) ❑ owner ❑ owner§ agent. Owner/Agent Ir.nnwlRT nn m ���� Signature Telephone No. I rZAJVAAJ r,,E :.p ,,,5 �J Date ... l '...... . NOFTN Of TOWN OF NORTH ANDOVER • - 0PERMIT FOR GAS INSTALLATION This certifies that'—'—A ... has permission for gas in the buildings of ..................... at ..1� - s ?! ...... .. , North Andover, Mass. Fee .;�.O.. Lic. No) . ��� ......... . GAS IN XC OR Check # �Z Z v 69/8 .1 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) - NORTH ANDOVER, MASSACHUSETTS Date �( - _ Q Building Locations L lyc-c./ Ar Permit # lode Amount $ / Z -z- New y� N C O a. G r O .v Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or Name— I- Ve f_j f t.4 : ri Qf_", j =O/v f Check one: Certific'We Installing Company � p Corp.` " .. Address a �_64 T U4-, A.. iiJ� a �a e �t ❑ Partner. /Clew 13q:&,j 1,114 C7 30 79 B mess lee ep one C 0.3 .,_ Sas---gid 7 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter Te- %.. y INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy , Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ t nere°y cemry mat an or me aetans ana mrormatron 1 nave subrmtted (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 Massachuse tate Gas Code and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Getter ❑ Plumber P[ - -1( rc-17�--� ❑ Gas Fitter License Number Master ff Journeyman U n z O W p z v Gx w d x z o a w F z F Q W p W U a CW7 a w F ., H > �a > z O F z O H W W x of a( x o w 3 o C7 ° a > SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR FLOOR 15TH. 6TH. FLOOR 7TH. FLOOR 8TH. - FLOOR (Print or Name— I- Ve f_j f t.4 : ri Qf_", j =O/v f Check one: Certific'We Installing Company � p Corp.` " .. Address a �_64 T U4-, A.. iiJ� a �a e �t ❑ Partner. /Clew 13q:&,j 1,114 C7 30 79 B mess lee ep one C 0.3 .,_ Sas---gid 7 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter Te- %.. y INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy , Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ t nere°y cemry mat an or me aetans ana mrormatron 1 nave subrmtted (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 Massachuse tate Gas Code and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Getter ❑ Plumber P[ - -1( rc-17�--� ❑ Gas Fitter License Number Master ff Journeyman 1� t t u�nweaft of M=adwseft f. f DPpartmet�zt of fna�icstrial Acciderus l Q cce i,C to of .Invz6gadonv i r 600 05rchi r.&H Street Boston c`7 ,MA 02111 Workers' CamPensatioa Iasiran �iince •Mdavi~ -vW/dein /C, aaaion mtraeorsEectrici$g/PiQmbers Na>sie Address: t .w , , 0' J Are you an ea►ployer? Check the a PPraP�� •hoz: 1 Q I,aru a employer with 4. Q I azti 8 gemeral Type of Pro�eot n (required): �PIoY� (foil and/or p � ,* I CaotT. Ctw and I have hired the sub -contractors 6• Q'Now corisbl=6oit am; a.soie I�Pn� or Pier- ship and have no em 1 P listed ars the attached sheet 3 Thome suis-eontracfors have . 7. Q' Remnde}iag working for me th �' SP Y• [No workers' comp, iasraarsce .. '"avers' Coro insurance, 5. [] VJt are a co osaiion g Q Demo"tiom 9• Q BW7ding addition ie.quired ] 3 • ❑ i am a homeowner do and its °ff tea's have exercised their 10•Q .Blectrrical repairs mg all work myself [NOw.erkrrs' comp, right of eoceinption'per MDL 2, § 1(4�,'and•we have or additions 11. Q Plumbing rep=or additions gid-] .t no .=PjCryews. [No worms' I2. Roaf .. fn's coni`Anyappiicmthat P• in�susanctmquireci] T etrecics bm'}� f must Oleo fin out the rection below airuwiag KOmeDt �€ n� 13.s .Cqi= G.,., ,4,�, f . theirworkot>' b who submit this affidavit indj�g They are doing an pe8ruion _ =Coatracfars that check this baa murtata� sn add Baas] sheatsiw end fhen hhe outaitie canuae{ors �' rite policy infnmsat;oa Halal sobmit a afridavit name of the soh• M' Cla iia; such.' I tom ad emir aR E pcoyer t%tat td it work=' w°'t='cc-r pri:c; mfnn�ton. i aFnpEi.Sijt.turQllCefOT �lr7rttl�lL my End *=. A�P!oN�. Insurance Car PaI Name: Poli # or Sett -ins. Lie. #: Job Site A idress: pa ion ,4tiachh a COPY of the workers• co �rt3'/Sta%2ip: mPeasaSon policy dedarafioo showin, Failure m se=M Covera a as P ( e the poky number and e t; required under Szc6on 25A of MCiL c. I52 its Iced to cite Imposition of Aprs�ftoa daie�. . fine up to $1,5DQ00 and/or one-year imprisonnierrt, as well crvtl �iaai P�4es of a • of up to 5250.00 a day agairist.the virriatot. Be wised penattim in the -form of a S'TOp V�ORK O Investigations of the DIA -for insRD a copy of oris statement m a fins urance coverage verifrr�tion, ay be forwarded to the Office of do i1crEbY car* under the pains and periarlfies of pErjrcr, firm the infnrmalioa provided above is aW and eorrrc Date: 4fflcirrl use only. i)o not write lir this asp, tm be mnipte�� by iaitj or town offuid City or Town: Issuing P ermit/Liceuse # m Authority (cirrfe one): I. Board of Iiesitb L gunning Dep$r•Jueut 3. C.4/T",u Cleric d teal las actor C. Other P S. Plumbing Iaspec(pr Contact Person: Phone #: twormanon a- jac.1 instructions, Massachusetts General Laws.chaptcr I S2 requires all amp I oyers to provide worked' omnpeTmtion for ffi . oir =ployecs. Pursuant to this statute, an mpivyac is defined as "...'everlypersm in the service of another under any contact Aire, express or impiimd, oral or writtzm" An effflayer is defined as "an individual, pmtncrihip, association, corporafion or other Ito entity, or zrry two or more of tine foregoing capgad in a joint eitzrprist, and includi"g- the IcgEd MPIT .. SUZI VMS of a 86—lzmd employer, brlht - rtc-miyar ort=kw-of an individual, partnership, associaticwn or other lep! aitity, =pioying employees. 'Howewthe owner -of a dwelling house having not more then thr—_ spaLl-trnerft and who resides thrsa9n, Or the DCCUPW Of the dwelling house of another who employs parsons to do naLi-mtenance, construction or I epi wcirk an such dwefthouse or on the grounds or building spurimneat th=tn shell na't be of such employment be deemed to be an cmpioy=." MOL chapter 15Z §25C(6) also states that "every state v`w- local sedusing agency sham wkhboid the inmunmor renewal of a license or permit to operate a business or *e construct boiklings in the commeoweaft for any applicaut,whe bas out produced acceptable evideuee.Dk mmprmnce with flieJasurance. . coverage required." AddWomlly, MOL chapter I a §25C(7) state -Neither tiro commonwealth nor any 'of it polifical subdivisions ha enter into arty acand for the jcr farnan. Ce, ofpublir. worse undil-acceptabla cvidmict of =npHm6= with the inmmce- requirzaimits of this d . mpter have bezopresunted to-tho acitTygra . cting suffix r4." Pleast, fill out the woricere.compensation affidavit complmtely, by checking the boxes flud apply to. your situation and, if necessary, supply.. sub-cotttractpr(s) PRIMA RddMKc9):W1nd phonernumber(s) along with thari certificates) of insurance. Limitedtiabffity Companies (6LC) c Limitma Liabl-lity pWt=SliipS (LLP).With no-omployces otherilum the members-orpartners, am not requked'10 csnY-wOrkM'M(n1-TnP=s8fi= insuato ce. Van LLC orUP does -hive MupiDYM, a policy is required. Bt advised that this afficl*L* may be submitted to the Department of Industrial Accidents for confirmation of insurimot coverage.. Ala'13.e sum ID sign and -date the jiffi&vit The affidavit should be returned to the 'city. or town thatthe application far tbm ped or 1i=1n is being requested,notateDepartmentof Industrial Accidents. Should you have -any questions r*Mr-ding the law or if you art required to obtain a workers' compensation policy, please -ed the Dqustment it the ntxmbw. fisted below, Self insured ournpitnies -should er= their self�msu number on tfiz*appropiiaft Ii City or town Offnials Please be sum that tiro affidavit is campieft and printed 6-W-bly. The Depaytneit liss provided a space at the bo'tw of the affidavit for you to RU out in tiro event the Office of Investigations has to contact you regarding file applicant Pien't be sure to fill in the permitflictnse n=bw which w -J-11 be used as a. reference number. In addition, an zopikvit that must submit multiple pmmit/licenSC applications in any giv= year, need only submit one affidavit indicating-mrrant policy,in.'JU1111stion (if necessary) and under "lob Site Addz-c=" the aPpiic= should write "all locations in _(city or town)." A copy dliie affi&vit that has been officially stamped or marked by the city or knvn may be provided to the zpplicarrt as proof that a valid affidmkis on file for fix ' ftre. Permits or licenses. A now affidavit must be Med out =h year. MM . VAa homeowner or citizen is obb& im-& a 1irW'MM: or permit not related to any business or commercial vmt=e (i.e. a dog H6011M Or pMrMft to burn leaves ear,.) said pms&n is NOT.requirtcl to -complete this affidavit. The Office; of os Investitiom would lflm to dmk you in ad-ww= 1 for your cDopbratin andshould you have any questions, p1mm do not. hesitate to give us a call. The Dopattment's address, telephone aria fax number, The Commorrwmalth of Massachmw= Depart nent Of 1xidustial Accidmt office Of. ruvesfigations 600 Wadxinggton &7�t Boston, MA 02111 TeL W 617-72.7-4900 i= 406 or 1-8.77-h4,kSSAFF_ Revised . :5-26-05 Fax 9 61 7-727-774� W-MMass.gov/dia Date.. . ?. A9 ...... ,AORT#q pf 4��io^.1 40 0 TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SACMUSE� This certifies that .... � �' . �! e G:.. ......... ....... . has permission for gas installation in the buildings of ........................... at .... ........ North Andover, Mass. Fee. 3 ?..... Lic. No.. L/'!/ 36. -�'-' :.�. �........ . GAS INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATON FORPERNIlT TO DO GAS FI TING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS I I � o Building Locations �Bear ` 1"� L t � CJ Permit # .Amount $ � L Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ (Printor type) �� )1e� n _ _ & Check one: Certificate Installing Company Name "4-13 El. rp. Address 01 X-G)—w—m ! o 1 to C : &1,42") ❑ Partner. Lowly ji « /Lc ussiness Te ep one G) 7 cX A� _ % ', ® Firm/Co. Name of Licensed Plumber or Gas Fitter Sohn�"1 1Pi'!� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity 0 Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i ncrcoy cerary mat an or me aetaus ana mrormation 1 nave 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 SAate Gas0o je and Chapter 142 of the General Laws. (OFFICE USE ONLY) eer e of Licensed Plumber Or G s Fittj� lam. Gas Fitter 71—ce—ns—e—Rumber Master Journeyman o cw7 a a w O zp x z O A F Z d ]" a W W W F" x C4 U z-< w W > F a 9- W Q� C7 r° �¢ >z o z U o WD x x O w x z x 3 x 0 ¢ a o v o a> w ., A w H o SUB-BASEM ENT BASEM ENT - 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH.. FLO O R 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. - FLOOR (Printor type) �� )1e� n _ _ & Check one: Certificate Installing Company Name "4-13 El. rp. Address 01 X-G)—w—m ! o 1 to C : &1,42") ❑ Partner. Lowly ji « /Lc ussiness Te ep one G) 7 cX A� _ % ', ® Firm/Co. Name of Licensed Plumber or Gas Fitter Sohn�"1 1Pi'!� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity 0 Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i ncrcoy cerary mat an or me aetaus ana mrormation 1 nave 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 SAate Gas0o je and Chapter 142 of the General Laws. (OFFICE USE ONLY) eer e of Licensed Plumber Or G s Fittj� lam. Gas Fitter 71—ce—ns—e—Rumber Master Journeyman <, . • ^d' r . _it ofAf=arhuse#s i U,. D4P�nt of Ir�icstrial Arrident�• i tce •Q ;1;,, fir' • of'Im►estcd oiwnv tisk 600 1rashin',jnn Street Boston c� ,M462111 Workers' Compenafion 1wil aneeenv us.�gav/din , �4 ficant Information . A€ $$vi f wldem/Contractors/Eiecfx iciaUslPiQmbers Name Adc]ress~ - Cityl,State/Ztg; Phone k. Are you an employer? Check.the appropriate bo= [: F1 I'am a employer Type with 2111employees (foil and/or pm t_time). 1 MM 4. I► a gemerai cotftssetoi end I have j�d the sub- of project (regnitmdj; 6 ❑ hfew can strucEion ,11301eprcptietar ar partner. ship and hevc no employees listedad�ots 7bes °n the attached s}zcet 3 sub-coaftamm have . 7. []:Remodeling working liar me in any caP=ify. [No workers comp, ins MM. workors' camp. insurance. S. [] Wz areaorafi- 8' [] Deccntihtion 9• � Building addition required.] 3 • ❑ I am a homeowner doing and its lffi� have exercised their 'exam. 10.[] .El=trical repairs all work Myself .[No,w�, Mmp insta'ancr..regninrd_] •t ' 1n of ptian per MOL .G t�2, § I(4),'and,we have m' additions I I Q Plumbi pa anor'additions no -OPIUM_-& [No work=' Roof . pain ;Any "Purer fiuet checks `9P• nrrsurance rociuirsdj I3.Li .OmMT t bo><# I most ciao fiR oet the 2r -'Ohm below aho�g thei'.warkerd' co iiomeow> who submit this e'ffffi-+ indicating fh acs �eetion poiicy in&",fion, Cantraemn that cheek- this bar musts an add Enna? doing h wos{� end fh= hire onside canasctats moist sheetshowJEW the name ofd ru .cooasc� submit anew Affidavit indiaeiin� Ruch.' . I t:f1: crit enFpeoyer fk r ���a a►le rparC � , .. wortcs6 col i J n OIl rafarr T � ���R �rrsarcn�ee�or�' e�lm►es; Below .ir Fm midiabr Insurance Company Name: Polity # or Sw--ins Lic. # Sob Site Address, Date: Address: . Attach a copy of the workers' ------------ _7 coin CstylSt�elZip Faffi= in Peosation Policy declar-ation showiee secure rev=,age as P ( b the poky Dumber and e g required under Section 25A of MOIL c. Ir- can lead to true i Apit�ioa date). . fine up in S-1,500.00 and/or one-year imprisonmzrrt as well as civil penatfim in the farm of$o ora of ccuninal Of up to 9250.00 a Ferta}ties of a - Of up day' againsttrue violet r. Be advised 1}sgt a c MP W0U ORDER mad a fine gations of the DIA •for insurance cov v opy of this statement may be forwarded to the Ofiim of . crags erifir�•tioti: . . as aereay certify ander the Pte' andpaRaifi� ofper3r"3' rifts- the uafnrmWonm • . SiPrrattm- p traded cbwe dice and Coad WACi& use only. do Rat wale in this area, to he rx►t>;ate�� �, or town �� Cky or Town: Issuing ,qathori{y (ciP�itlLiamse # m I. Board of fieatt6 Z rcle one): Bunding Dew 3. CttylT"'V .Cleric 4. Eleatricai Inspector 6 Other S. Plumbic b luster Contact Person: Phone#: iniormanon aL na instructions, Massachusetts GWWRI LaWS Chapter I S2 enquires all emj:x I oyers to provide workem' compensation for fficir employees. Pursuant to this statute, an mplayre is defined as pcmor in the service of another under any contract Airy,- =qx-mrz or implied, oral or written," An z"Flpyar is defined as "m individual partnership, Rl&c:Kciaticn, corporation or other legal entity, or arty two, or More. Of tht'ibmping capgad in a joint enterprise, and includi"S. the legal of a d6ccasmd employer, briht receiver artufte-of an individual, parinership, amociaficxin or other legal mt . ity, employing employe= 'Tiawewthe owner- of a dwelling house having not more that time apaLrtincrift and who resi&s thcrein,or lint occWznt of the dwelling ho= of anothe:r who employs persons to do msamteniinm, construction orrepair work''m such dwel[linrhouse or on the grom'ds or building RPPurtrm= thereto shall 110T bccmis: of such cruploymair be d--med to be IM =piD3=_- MOL C*tw 152, §25C(6) aim states that 'every state oar- low licensing agency shall Withhow the imanumor renewal of a Ii—no or permit to operate a business or tax construct b"zop in the commonwealth for any appriciint who has nut produced acceptable vvideuce.ojr compannee with the.insnraocecoveraze, required." Additionally, MOL chapter I52; J25C(7) state "Neither tbe, communweahfi nor any of it polifiad subdivisions &M eateriTU, any contract for the k'afalmar ce of public work untu-SICCISPiable evid== of =Mplizinct witb rico= instm- requirtmonts of this grapier have, been presented tollit =:x . ritr=ling authaft." Applicants Please fill out the workers' ,compensation. affidavit cOMPI-e--tely, by checking the boxes that apply to your situation and, if n=MswY- MIPPIY sub-cot>ttacfa*) name(s), Rd&M*e9):ftMd phone number(s) along with fhzi =n:ifi=*s) of insurance. Limitril'Liabik Companies (LLC) or Limitul Liability. Partnerships (LLP)with no employees othardum the members qrpmtn=, are not re;qu:irrd,.to cm-ry work=' c�rnpensafim hmugan = Van LLC orUP doft-hm employees, a policy is required. Be advised that lifis affidavit May be submitted tD the Dqwiznmt of . Indizstrial Aim -date Acciderits for confinm9icm of m*=`a"c C*v=29f— Eye 51am to sign and the affi&VIt The affidavit Should be returnmd tD the: c4 or town that the apprics6OM fur 1116 Peimif Pr Tic anse is being requested, natthe Do-partrfisa of Industrial Acaid=tL Should you have any quesliam rcMrxiing the law or if you are required ip obtain a warkcr;` OD14PISTIBIRtion policy, picast-ca][I the Department at the-mamber. listed 6law. Self-insured 00_ it, chauld t salf-insm== ficci= BuxnbW on thz,appropiiattli City or Town 061c iRls Please, be sum ffw the, affidavit is complete and printed hg;jb)y. The Department ims a space tat batm provided at of the affidavit for you to fin out in. the: event the Of"= of InVMS0gRfiCW has to con= you regarding the applicant Plem be SUM to fill in tl�lc permit/license number whidb W11-11 be used as z. r::fc:rm= number. In addition, an opficad that must submit multiple peirinitfficz= appii=tions in RnY given yzar, need only submit one affidavit indicating -current - policy information (if necessary) and under "lob Site Address" file zPPH=It should writt "all locations in or t0w.n)." A wp'y of the affidavit that has b=,officiak stamped or marked by ffie city or Own may be provided to the zppikkintasproof that valid affidaVit.is an Me for fdir-e.parmits or H=nr-eL A row affidavit must be framed out each year. WhMM R home, owner or citizen is obtaining a H=m= or pexmit not relate=d to any business or commercial vmlt= (i.e: a dog li6mist or pennift to bran leav--s etc.) said is NOT required to complete this zffi Pelson davit. The Office; of Investigations would like to thank you in ad-.rw=fid. for.your cDopbratim an. -should you have any questions, please do not. hesftate: to give us a call. 71z: Dalmirtmew's. address, telephone and fax ntanban. The Commonwmmith of Massachusem Dcpartrnentt of Industial Accidents Mee -of Euvwfignfiens 600 Washington Stj=t Bost=on, MA M I I I .TeL 4 617-727-4900 i= 406 cr 1-977-MASSAFE Rz- . vised 5-Z-05 Fax 9 61 7-727-774� WWWM.,::;Iqq Clovidia 11M LUlVvylULY 1'Yr A1" [I Vr lrVsa VIL'" UOLM i u DE PART 310Vf OF PUBI K SAFEI Y BOARD OF FIRE PREVF1 MON (W121W Permit No. /�CJ Occupancy & Fees Checked 0 APPUCAHON FOR PERMIT T AMORM ELEC MCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH TYM MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date LL Town of North Andover The undersigned applies for a permit to perform tti Location (Street & Number) q G Owner or Tenant Owner's Address ('l `1 &,.,- �, < \ l AJ work described below. ,l< a A To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes � No (Check Appropriate Box) � Purpose of Building w � \ _ , c,, Utility Authorization No. Existing Service -,4-01J� Amps �o�3((o Volts Overhead Underground 7 No. of Meters New Service Amps/ Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work U{<V-0 Sao ( r 0 Q n No. of Lighting Outlets No. of Hot Tubs SW L4 - 14 - C- S No. of Transformers � E' Val $ofE �Wclk $ Total Pfflalfiesafpa;uy. I.;oaeeNo. p - V1 . KVA No. of Lighting Fixtures Swimming Pool AboveBelow Limwm Generators `` _ KVA `'( -�'6 -31) - SV)-) round and S� s-39�-CtY�22 I --,,.,,,49CSMURANCEWANER;IamawwdutheIedoes_rtothmetheirmramanuageoritssbgUdNtrivala asmgmredbY CalmWLaws ardthatrrlysgrlatiaeentt�spemlitappHcadotlwaivesthisregtmarlalt No. of Receptacle Outlets '`� �d No. of Oil Burners Agent,. No. of Emergency Lighting Battery Units No. of Switch Outlets Telephone No. PERMIT FEE $ Signature of Ownergen i No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and of Disposals No. of Heat Total Total Pumps . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal ED Other No. of Dryers Heating Devices KW Connections a o. of Water Heaters KW No. of No. of Signs Bailasis o. Hydro Massage Tubs No. of Motors Total HP St- �',A tvtsuaa o tIe rec}merlaas or tv t�ale�llaws tYhartc�Rcyirlc]tldrlgConlpltie orflssub�larialequivak�lt YES NO IptoofofsarnelodleOf= YES ryouhT�edreiadMplemirrfi *dxtypeoi Ew b SW L4 - 14 - C- S �Regll�d Rough � E' Val $ofE �Wclk $ i i )J- 00 Pfflalfiesafpa;uy. I.;oaeeNo. p - V1 . Limwm AJCQ `` _ Busk=TdNa `'( -�'6 -31) - SV)-) A1tTdNa S� s-39�-CtY�22 I --,,.,,,49CSMURANCEWANER;IamawwdutheIedoes_rtothmetheirmramanuageoritssbgUdNtrivala asmgmredbY CalmWLaws ardthatrrlysgrlatiaeentt�spemlitappHcadotlwaivesthisregtmarlalt (Please check one) Owner Agent,. Telephone No. PERMIT FEE $ Signature of Ownergen i n 0 Location 7&4'0 a NoDate A Check # 1—�td-3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ (i Foundation Permit Fee Other Permit Fee TOTAL Building Inspector 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number /V0 /� v�G 1.3 Zoning Information: Zoning District Proposed Use Signature 1.4 Property Dimensions: Lot Area Frontage tt 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided t Not Applicable ❑ pe"k ;/ --Zl� Licensed Construction Supervisor: 1.7 Water Supply NCO.L.C.40. 34) Public ❑ Private ❑ 1.3. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT C Ui" t(! Ct: ",,'ra 2.1 Owner of Record Name (Print) Address for Service Signature Telephone 2.2,Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ pe"k ;/ --Zl� Licensed Construction Supervisor: �� License Number j , 4e to ,/LC Addre 2 igTture 9,- 9)6 Telephone / 9A 0 0 Expiration Date 3.2 Registered Home Improvement Contractor Company Name Not Applicable ❑ !y�—® Registration Number / Qe Aaor s Expiration Date i nature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 8 25d6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Worktdh—mk aH applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description/ of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY .. 1. Building ye 2 (a) Building Permit Fee Multiplier 2 Electrical ,��o d (b) Estimated Total Cost of Construction 3 Plumbing o a o ' Building Permit fee (a) x (b) — 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 ,�00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT I. as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief / Print tcure of er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1Yr2ND 3 SPAN DM ENSIONS OF SILLS DMIENSIONS OF POSTS DB ENSIGNS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CH ANEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE H Ml Z 11 E 1� O FM4 C 0 .mC C �1 O i O C VO V .a� a� 0 o m Ea o • 0 YID N C � t O 'r .00 m C o► f ` m C `ems, o a � eri c � � • '� 2- W m o 3 : CL m LA O ; r C =CD O C1 0 p m IS 0 2 o0 0 cm CL c `mc = 0 =0 3 F' $ amok m W CO �=;Z w F. .erJ EL= A C Z LO a �m�C 5 a �� > o m a�= F- t 2asm 5 O U 0 Z O U Cf) cm y O O m m C ~ Za a� CD o O d C. C Q 00 C !O O. 42.2 CO2 Z C3 C CD CL V H O C C c CO) LU U) W W 19 LUW U) o a a c9i w° a°G U w cn 0 cn 1� O FM4 C 0 .mC C �1 O i O C VO V .a� a� 0 o m Ea o • 0 YID N C � t O 'r .00 m C o► f ` m C `ems, o a � eri c � � • '� 2- W m o 3 : CL m LA O ; r C =CD O C1 0 p m IS 0 2 o0 0 cm CL c `mc = 0 =0 3 F' $ amok m W CO �=;Z w F. .erJ EL= A C Z LO a �m�C 5 a �� > o m a�= F- t 2asm 5 O U 0 Z O U Cf) cm y O O m m C ~ Za a� CD o O d C. C Q 00 C !O O. 42.2 CO2 Z C3 C CD CL V H O C C c CO) LU U) W W 19 LUW U) The Commonwealth of Massachusetts Department of Industrial Accidents Ofte of /nvesdgadons Boston, Mass.. 02111 Workers' Compensation ►rlsumfce Affldwl Nlarrte Please Print ai am a homeowner performing ail Ymm myself. FA I am a sob proprietor and have no one working in any capacity I am an employer pmovidrig workers' compensation for my employees working on this job. Comply name: Address City: Phone: Irtstuance. Co. Potisv Comoanv flame' Address CX: Phone InsLuw= Co. Potiry ! Fdkxe to secure coverage ar regdred order Secdon 26A or MOL 152 can load to thek *=Won d cA ninal pwmNlae d.a Ana up to $I.SW.W andfor ono yen' ImPrYanrieN.aa Wd.n.CbA4 MMM10lbsIM d A STtaP.V.K=OROEP-MdA.f ue d.($IQDAM-nAW agmiM ma I understand that a copy of this stdwnw t may be forwarded to tM Office of Inveelgakm of U» DIA for coverapa vwftg&m. I do hereby cwdY under ar;dp@nmfgpofpwJwy that the k*mwffim provided above h he and can Signature Date ys-/ -- Print name .� ��6 /7N �'T� Phone e Official use only do not write In this was to be completed by city or town affk d' city or Town Permits ��+ ❑ Blj#d V Dept []Check If Immediate response As requked ❑ ►xerwkg Board ❑ Selectmen's Ofte Contact person: Phone ❑ Heath Department 13 Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: Location of Facility) Si nature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector r� y N- ° L v 6 4 Date........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ a l 1, i? ........................................... has permission to perform A- .<.1.........V" `` Derr lrl e ......................................................... wiring in the building of .....« .�.�.. �. /?,.............................................. 7 f r 1 /� n Gi ....... worth Andover, Mass Fee...3.7..vv.. Lic. No..�. 1.�/..... � ..c� ..1/.:...G%` .Q.. 1rLEcT CAL INSPECTOR Check #L WHITE: Applicant CANARY: Building Dept. PINK: Treasurer --------------------- eornmonwea& o f //ladaac utealfa Official Use Only Permit No. 1J part`nranf a`,�ira �sruicas - BOARD OF FiRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev, 11, 99] (Ica:ve 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 LV INK OR TYPE ALL INFO.AVL,ITION) Date: % —,5;9 J _ d o City or 'Town of: a j9_ ora U To the Inspector of Wiles: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 9 )O ,Cr �% /1 p% Owner or Tenant Owner's Address Is this permit in conjurrctiori with a building permit? Yurliose of Building Existing Service Antps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. Yes ❑ No UU. '(Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: Srl �On S'7 P No. of Meters No. of Meters. Completion of the 1ollowine table ntav be waived he• thr 12F.a»crml- n( INir"T No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Farts ! o. of otal Transformers KVA No. of Lighting Outlets No. of I -lot Tubs Generators KYA No. of Lighting Pictures Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency ig tting BatteryUnits No.�bf Receptacle Outlets No. of Oil Burners FIRE ALARMS TiNo. of Zones No. of Switches No. of Gas Burners to. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Dis osers p Heat Pump Totals: i_ umber Tons -- �V -' �- No. o Self -Contained Detection/Alerting Devices No. of Dishivasbers Space/Area Heating .KW Local ❑ Nluntcipa ❑ Other Connection No. of Dryers Heating Appliances Key ecurity Systems: No. of Devices or Equivalent No. of Water KWo. of No. of Data Wiring: Heaters Sims Ballasts . No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications 'irtttg: No. of Devices or E uivalent OTHER: Attach additional detail if desired. or as required by the Inspector of Wires. INSUR,kNCE 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. T'Ihe undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OThIER ❑ (Specify:) -' U ' (Expiration Date) Estimated Value of Electrical Work:* (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with iv1EC Rule 10, and upon completion. 1 certiry itrrder theprutt.* and penalties ofper jurr. that the infort ration on is application is trite and coninfele. _ FIIZNI NA}1IE: /4 - C /' c LIC. NO.: ft -5 Licensee: �%ox - tj o Signature- - L1C. r0.: �' !�� 7Z (If applicable. eater -exempt •' in the license number line.) Bus. Tel. No.• 5!'7 -9 Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. FPj,-Rj11IT FEE: $ ,3 5 3 L 2 7 Date. /; ... :?.. . ... . Ci 4 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLAT14 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer This certifies that ... . ,� -amu.-- : .......g. . has permission for gas installation��'�`•` `�! .. • ... in the buildings of . ..... �'.:.'...':..� a� .F.................... . f j at ................................... .,,North Andover, Mass. Fee. 2 ti . � . Lic. No. �?:3..... ......................... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer RN MASSACHUSETTS UNIFORM APPLICATOR FOR PERMIT TO DO GAS FITTING or print) Date tvUK I H ANDOVER, MA33A4—HU3J1 I L3 Building Locations �>C Permit 9 Amount S Owner's Name New / Renovation ❑ Replacement ❑ Plans Submitted ❑ 11, 19 6 (Print or type) Check one: Name �F AS -fit d1. Corp. Certificate Installing Company AddressT _ _ ❑ Partner. K.- ness // ((�� a -Name of Licensed Plumber or Gas Fitter /\ G—� `, � 1` ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, pleas indicate the type coverage by checking the appropriate box. Liability insurance policy R Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i herebv 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 Gas Code and Chapter 142 of the General Laws. By: Title City/Town PROVED (oHr•icp USE ONLY) Signature of Licensed Plumb r r G<er ^ �^ ® Plumber l Gas Fitter Licen&e Number i'vlaster ❑ Journeyman f� 3R 0. FLO OR (Print or type) Check one: Name �F AS -fit d1. Corp. Certificate Installing Company AddressT _ _ ❑ Partner. K.- ness // ((�� a -Name of Licensed Plumber or Gas Fitter /\ G—� `, � 1` ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, pleas indicate the type coverage by checking the appropriate box. Liability insurance policy R Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i herebv 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 Gas Code and Chapter 142 of the General Laws. By: Title City/Town PROVED (oHr•icp USE ONLY) Signature of Licensed Plumb r r G<er ^ �^ ® Plumber l Gas Fitter Licen&e Number i'vlaster ❑ Journeyman Date. ` ....... G.. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies tha't-- �.-!,..... ........ has permission to perform ........ ..-r4 plumbing in the buildings of ............ .at .. I. �l-J!.............. . North.Andover, Mass. Fee ?�%.. Lic. No/ -7V !�C......... . . PLUMBIN�� ,ECTOR Check # 4/:4/,3 0 6427 MASSA/0 �SESIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) 6 �'� / M E v rT N Mass. Date J 1S 2D Os!5rPermit #-44;W' Building Location Owner's Name Type of Occupancy �� h New ❑ Renovation 5? B.P.n SFWFRx Repladement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES CFPTTC Installing Com ©R0 Business TelephoneO Name of Licensed Plumber 44 -op + Check one: ❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate 7jr' INSURANCE COVE E: I ttave a current I' ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate type coverage by checking the appropriate box. A liability insurance policy Other tvDe of indemnity n Rnnri 7 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ jl=lzuy -xrurythat aii or the details and information I have sub ' r entered) in above application are true an accurate to the best of my knowledge and that all plumbing work and installations pe ed un r the permit issued for thi pplicati e ' .cern pertinent provisions of the Massachusetts State Plumbin de apte 42 en S. all E3y. Title Sign a of Licensed Plumber �(f� •r/ City/Town Type of License: Master 9'0 y Journeyman ❑ ' "--�� APPROVED OFFICE USE ONLY) License Number z � a 0 P X C to N ra l � i S-4 v i 1 W N Y Z .N1 Q¢ w ¢_~ z O 2 a Aj 4j W W o d h J Z a ¢ OJ [xa W Sr~ tu_ O o J G 1- Q Y O ¢ O L- U 14 � ~ Q Q = N N OJ 't7 •- Y .� + m Q Q D I Q d ¢ ¢ 7 Q C sus—BSMT, 7 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR n Installing Com ©R0 Business TelephoneO Name of Licensed Plumber 44 -op + Check one: ❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate 7jr' INSURANCE COVE E: I ttave a current I' ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate type coverage by checking the appropriate box. A liability insurance policy Other tvDe of indemnity n Rnnri 7 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ jl=lzuy -xrurythat aii or the details and information I have sub ' r entered) in above application are true an accurate to the best of my knowledge and that all plumbing work and installations pe ed un r the permit issued for thi pplicati e ' .cern pertinent provisions of the Massachusetts State Plumbin de apte 42 en S. all E3y. Title Sign a of Licensed Plumber �(f� •r/ City/Town Type of License: Master 9'0 y Journeyman ❑ ' "--�� APPROVED OFFICE USE ONLY) License Number z � a 0 _T Z D r Z N T m n O Z N N - 7C m n TnN r c O D .v m m mr. rn r_ 0 m A. 77 ? = p O m m O m c r O d �= m 37 z m A Z r 0. A C r a z I m O Q d O r a c Z A -� Date../-/.-/ 111'2- 6-6 -... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This —certifies that !1.... . has permission for gas installation �"� ......................... in the buildings of ................. at .............. North Andover, Mass. Lic. NoI4 GAS INSPECTOR Check Check# z.13 5692 fo A ORM (Print or Type) J G a Installing Building Local APPLICATION FOR PERMIT TO DO GASFITTING Mass. Date Permit%a- Owner's Name Type of Occupancy_ New &! Renovation ❑ Replacemeri p Plans Submitted: Yeso No p Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership ❑ Flrm/Co. Certificate # INSURANCE COVERAGE: I have a currentjw5ilKy Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 6T No ❑ If you have checked Yes, please Icate the type coverage by checking the appropriate box. A It Itabllfty Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and Information I have submitted (or entered) n above app icatlon are true and accurate to the best of my knowledge and that all plumbing work and Installatlons performed under the per It Issued for Is applicatioAvdiln compliance with Ali pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th General s.T cense: JALberSrg al re o cense um etiter Title _ Gasfitlor 01Y/Townaster Ucense Number IA -3 Journeyman u'f1xrvrn—%RteU.U.o i MINE NEW ISTFIL06iMMENEENEEN 01 No INEWENINNINNIN MUMEEMEEMEM IMMI MEN JIMM MEN Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership ❑ Flrm/Co. Certificate # INSURANCE COVERAGE: I have a currentjw5ilKy Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 6T No ❑ If you have checked Yes, please Icate the type coverage by checking the appropriate box. A It Itabllfty Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and Information I have submitted (or entered) n above app icatlon are true and accurate to the best of my knowledge and that all plumbing work and Installatlons performed under the per It Issued for Is applicatioAvdiln compliance with Ali pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th General s.T cense: JALberSrg al re o cense um etiter Title _ Gasfitlor 01Y/Townaster Ucense Number IA -3 Journeyman u'f1xrvrn—%RteU.U.o v r C i w m a 0 a 0 D Z D r N v m 0 0 z v m a A � m D x -i m 0 0 D :S N vhf O v m A v r C i w m a 0 a 0 D Z D r N v m 0 0 z Date.� .'�20- 0-5- ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ... ......................................................................................... has permission to wiring in the building of ........................................ at ................... .North Andover, Mass. ........................................ .�' e -fl - - Fe;e-:J6 ..- .............. Lic. No ................'......'/ ........................................ ELEcTRiCAL INSPECTOR Check # 5710 11W I.U1V1iV1U[v r►ri"n Ur 1 L3- y DEPARTflIDYIOFPUBLICSAFETY Permit No. B0ARD0FFWPREVEM0N.527CM12.W Occupancy &Fees Checked APPLICATION FOR PERMIT T PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH T MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform tth Location (Street & Number) C Cl e Owner or Tenant Owner's Address Cl`1 G"r �,c \ l A'v work described below. (< a To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes IZI No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Servicea0� Amps0-) �40 Volts Overhead Underground M No. of Meters New Service Amps�Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work iR<w, da ( &-kil ry o w• No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming PoolAbove Below Generators KVA round and No. of Receptacle Outlets 3 No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal ID Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- i e �I:.W , S Jc- n T Irtsttta=C0VW,W Pt»attlDfhete4merrlat4CfNIaMadWSMCmaAlLaws IrrawaameritLmbkyhsnanaeib5cymditC nVlei NCDVMWGHISSLJrrial0c}rivalat YES EZr NO IliaresubmiMdvaWFC faf=W1D heOffice YES j�i� Y)uuWwdmdWYES,plemmdcmthegpeofeoymvpby INSURANCE BOND OrIF�Rremslimy) BTirafirnDate Esfan&dVatleof 3Bcbiral Wade $ 1, t WodcmSM L ` l cc -(>S hspecfimD&Regtlesldd Rough `k- )-y - o Final ? Sigrledu xkrTEPftkesafpajuly. -� p RRMNAME 'r1 "' `o `� �e� r c- 1 ^ LioacseNa Liter T o,U l S sigro �I��� /V� Iioa�eNo 3 t 31 C Air-C3 � nn j Busa=TeLNa °(7'S-11 Ad lraca 65 A i c c1 t�� {���/ Q� , ,(Vl t^ l TS AL Tel Na 12"6 - "> 5- - Ci 1212 OWNER'SINSURANCEWAIVE?4IamawarethatdrLio wdoesnothavetheirmaarloeaNwd zorilsslbsWUegtrivalaitasrequitedbyMassadu9eltsCoaleralLaws andd atmysgrla mendzperi[appbcabmwaivestrism merrlat (Please check one) Owner 1:3 Agent a Telephone No. PERMIT FEE $ signature of Owner or gen