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Miscellaneous - Bingham Way
J cn 3 1 I It North Andover MIMAP 018.0-0058 018.0-0069 018.0-0070 59 WAVERLY RD / January 28, 2014 018.0-0045 018.0-0059 60 WAVERLY RD 37 FIRST ST 109 MAIN ST 63 WAVERLY RD 018.0-0046. 109 MAIN ST 109 MAIN ST 109 MAIN ST 115 MAIN S 64 WAVERLY RD ¢,� 109 MAIN S 018.0-0047 CJ��¢ 109 MAIN S 018.0-0060 �4{S� \ 029.0-0048 018.0-0048 4�BINGHAWAY? 018.0-006172 WAVERLY RD 6 BINGHAM INAY Rg -113 IGE A"M{WAIf' F 10 BINBI„� GHAMIWAV FIRS S,Te 12 BINGHA�WlM WA' ��- � a' ;1,�'B�IN�GHA;Mj1NAl'� .�� 96 BINGHAMtV11 3'IBINGHAMjWAY' 019 0°0001 �BINGHAMMWi4Y' 9BINGIiA�M WAY f 19NBINGHAMWAY' rr4'MAPLE AVEj g]BINGFiAM}WAY 2 BINGHAMp1tVAY] 6,IMA�PLE�Y g glNGtiAM WAYt 5;0 CONNO, f T P BAl HA'M WAAAAA& /° ti 1�1yBINGIi�AM)WAY¢ / 2 0 C:ONNO HTS) km PIP E �1BINGHAM WAS f; 401MAPLE+AU] / 030 0 0005 15�BIN'GHA WAAAAAj 019.0-0015 112 MA_Pi IM 5 MAPLE AVE �:141MAPLEAVE� zz, 6AMAPLEAV 18MAPLEIAVE 019.0-0003 45 SECOND ST 019.0-0064 019.0-0008 019.0 -0016 -AVE 13 MAPLE 98 WAVERLY RD Al 22 MAPLE AVE e 019.0-0007 15 MAPLE AVE 102 WAVERLY. RD 019.0-0023 019.0-0017 30 MAPLE AVE 019.0-0005 019.0-0004 53 SECOND S 019.0-0024 019.0-0065 019.0-0006 019.0-0018 21 MAPLE AVE 57 SECOND \ST' — Rail Line Interstates Hodwntal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack I t NORTH q Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Roads p �t�ao •s O� Environmental Affairs/MassGIS. The information depicted on this map is {; r Easements 3r ' O� for planning purposes only. It may not be adequate for legal boundary 0 MVPC Boundary — definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER h — 9 MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING C3 Municipal Boundary * * THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY D Parcels f i * OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT CS Hydrographic Features M �o�q _ `� • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION =w Wetlands �9SSAtFWSQt� C . Exempt Lands 1"=76ft ° a A"a Date ...fj .. ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... .......4 f.l. .... �✓..pJ-/�!4..Sh� has permission to perform ....'d .....!.v.......&/..................................................... wiring in a building of........ e......=r-e..............................:................... at ........................... ..` .. ..'�.:......'..`'......................................... , North Andover, Mass. Fee � Lic. No. �j� ELECTRICAL INSPECTOR Check # �0- 100 �1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 12-1 `;2 'I 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 (MEC), 527 MR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION Date: p City or Town of. NORTH ANDOVER To the Insp ctor 6f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1 etc W Owner or Tenant Owner's Address Is this permit in conjun tion with a buildipermit? Yes ❑ Purpose of Building s/O Rae r zre, Jf1G Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. a'IY- 69a-353_?— No 9a -3c132 - No W (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ce% 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- El rnd. rnd. 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 of Detection and No, 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 Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectr'cal Work: !Z�QU�C (When required by municipal policy.) Work to Start:�} �p /J 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 El BOND ❑ OTHER ❑ (Specify:) I'certify, under the p ins and penalties of perjury, that the information on this application is true and complete. FIRM NAME: _ cx�tL— LIC. NO.: q19 -JR Licensee: W\ Signature LIC. NO.: (If applicable, enter "exempt" in t e license nz5 ber line) Bus. Tel. No.* Address:C11 ; uni r e(. f P i G �(oa j" Cys .11C' Alt. Tel. No.: *Per M.G.L c. 1 7, is. 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 ERMIT FEE: $� Signature Telephone No.— 1 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§ Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the r P 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 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 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP CTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: /1 —13 -15— DEB WEINHOLD ... TOWN OF MERRIMAC, NIA........dweinhold@townofinerrimac.com N The Commonwealth of Massachusetts Department ofIndustrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 �r www mass.gov/dia 7 QTM SV. V9 Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/j'lumbers. TO BE FILED WITH THE FERMITT VG AUTHORIT Y- ' Please Print Legib A ' licant Information Name (Business/Orgariizationllndividual): Address: City/State/Zip:- Are you an employer? Check the appropriate box: Phone #: 1. Q I am a employer with employees (frill and/or part time).* 2. ❑ I am a sole proprietor or partnership and have no employees Working for mein any capacity. (No workers' comp.insurance required.] elf [No workers' comp. insurance required.] t 3.❑ I am a homeowner doing all work mys 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. insurauce.t 6.F1 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. ❑ NeWdonstruction 8. [J Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 124n :pjqnbing repairs or additions 13-1] Roof repairs 14. [] Other *Airy applicant that check's box 41. must also fill out the section below showing their workers' compensation policy information Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such Contractors that check this box muse 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. I am an employer that is pro vidingworkers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: City/State/Zip: Job Site Address: Attach a copy of the workers' compepsation 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,o as'Well as civil penalties in the form of a STOP WORK y of this statement may. be forwarded to the Office o Inveestigations of the DIA. for insurance ER and a fine of up to $250.0 0 a day against th coverage verification. Ido hereby certify under tlzepains and penalties of perjury that the information provided above is true and correct. Date: Si ature: Official use only. Do not write in this area, to he 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 htie, 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 enferprise, and including the legal representatives of a deceased employer, or the receivetbr, 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 b6 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 xequuiired " 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 cerdficate(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. B e 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' compensatiorit 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department ofIndustrial 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 wwwmass.gov/dia Ipp+ ivo�pNO�'" OP ID: TD :.."%411L " CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/21/2015 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 DeSanctis Insurance Agcy, Inc. 100 Unicorn Park Drive Woburn, MA 01801 CONTACT NAME: PHONE FAX AIC No Ext): A/C No E-MAIL ADDRESS: PRODUCE CUSTOMER ID #: JUPIT-1 INSURERS AFFORDING COVERAGE NAIC # INSURER A:Harleysville Insurance 26182 INSURED Jupiter Electric, Inc. Salisbury, MA 011952 Lafayette R Sal INSURER B: Technology Insurance Company42376 INSURER C : INSURER D: A INSURER E: INSURER F: KCVISIL)N NUMtJtK: 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 PLICY LTR TYPE OF INSURANCE BPOLICY NUMBER MM/ D/YEFF YYY MM DDmYY LIMITS GENERAL LIABILITY A X EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ AffA 100,000 COMMERCIAL GENERAL LIABILITY SPP00000076460P 12/23/2014 12/23/2015 CLAIMS -MADE OCCUR MED EXP (Any one person) $ 5,000 X XCU Coverage PERSONAL & ADV INJURY $ 1,000,00 X Contract Liab GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 3,000,00 POLICY X PRO_Cj LOC IDEDUCT. $ 0 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,00 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ A X SCHEDULED AUTOS BA76461 P 12/23/2014 12/23/2015 PROPERTY DAMAGE $ X HIRED AUTOS (PER ACCIDENT) X NON -OWNED AUTOS $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,00 A EXCESS LIAR CLAIMS -MADE CM600000078286P 12/23/2014 12/23/2015 AGGREGATE $ 10,000,00 DEDUCTIBLE X RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC STATU- OTH- X IWC IMIT X ER B OFFICER/MEMBER EXCLUDED? ANY ECUTIVE YIN N / A TWC3442671 12/23/2014 12/23/2015 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,0 0O (Mandatory in NH)MA,ME,NH If yes, describe under and DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Replacement of Master Boxes at Four Sites - Fountain Drive -667-1 Bingham Way -667-2 Foulds Terrace -667-3 O'Conner Heights -667-4 North Andover MA 01845 DH 'D FISH #196040. "ADbITIOI` INSUREDS LIMITS ARE NO GRtATER THAN THOSt REQUIRED BY WRITTEN CONTRACT." Town of North Andover, North Andover Housing Authority and the Department of Housina and Cnirnmi initu Develo PC0TI0Ir%ATG Town of North Andover Electrical Inspector 1600 Osgood Street Bldg 20 Suite 2035 North Andover, MA 01845 raa.VKLJ ZO (LUU`J/Uy) NORTA-1 u 4. 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 EPRESENTATI E ©19862009 ACO The ACORD name and logo are registered marks of ACORD All riahts racarvarf i5.1.�j Date.N .... . .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................................................................. has permission to perform `) ............... I .................... I ....... ............................................ wiring in the building of4 --t-Vors, ...... ............. I ....................... 4 1 .......................... ....... 0a.Pkn,North Andover, Mass. FL ...o.......... Lic. No .. ..... ............... .................. ...... ...... ........... 1.0 .. ........ �eck# 2okk240 ELECTRICAL INSPECTORC *112 2-2 5 a C,ommonwea& o f Mama4wettb R 2epad.d o f -7im Service, BOARD OF FIRE PREVENTION REGULATIONS Offilve cialsOnl�✓ Permit No. '%e(•/� 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: 3-6-2014 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) Bingham Way & Maple Ave Owner or Tenant North Andover Housing Authority Telephone No. 978-682-3932 Owner's Address 1 Morkeski Meadows, North Andover, MA 01845 Is this permit in conjunction with a building permit?, Yes ❑ No ❑X (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps J / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Replace Existing Light Fixtures with New. 42 Units (4 fixtures in each) + Exterior and Common Areas Completion of the followingtable may be waived b the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 229 Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW .... ..... No. of Self -Contained Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances 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 No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 50,000.00 (When required by municipal policy.) Work to Start: 3-6-2014 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 [R BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: C lam'c Flartrir C mmnanv Inr LIC. NO.: 20457A Licensee: Todd Clemens Signature LIC. NO.: 37846E (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 401-253-4043 Address: 11 Broadcommon Road, Bristol, RI 02809 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 ❑ ow ent. Owner/Agent Signature Telephone No. PERMIT FEE: 600.00 V. q A M a The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations ' d 1 Congress Street, Suite 100 r Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Clem's Electric Company Inc. Address: 11 Broadcommon Road City/State/Zip: Bristol / RI / 02809 Phone #: 401-253-4043 Are you an employer? Check the appropriate box: 1. ® I am a employer with 15 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ 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. 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 -contractors 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: Beacon Mutual Policy # or Self -ins. Lic. #: 0000070952 Expiration Date: 1 /1 /2015 Job Site Address: Bingham Way & Maple Ave City/State/Zip: North Andover, MA 01845 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 l.Avestigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ab (?AM44Z4� Date: 3-12-2014 Phone #: 401-253-4043 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 #: '�O® CERTIFICATE OF LIABILITY INSURANCE 3/3/12014 ) 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER John Andrade Insurance Agency, Inc. 559 Hope Street Bristol RI 02809 CONTACTDonna Rodrigues, CIC, CRIS PHONE (401)253-6592 FAX 14011253-5070 ADMDRRSS! drodrigues@johnandradeinsurance.coin INSURERS AFFORDING COVERAGE NAIC lI INSURERA:SeleetiVe Of South Carolina 19259 INSURED CLEMS ELECTRIC CO INC 11 BROADCOMMON RD BRISTOL RI 02809-2758 INSURERB.Beacon Mutual 24017 INSURER C: INSURER D; IN SURER E : INSURERF: COVERAGES CERTIFICATE NUMBER.-CL1411014565 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 LIR TYPE OF INSURANCE A L UBR POLICYNUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAA E T ELATEDPREMISES (Ea occurrence) $ 100,000 A CLAIMS-MADEXO OCCUR S 1693991 /26/2014 /26/2015 MED EXP (Anyone person) S 1o'000 PERSONAL &ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEHL AGGREGATE LIMIT APPLIES PER: PROOUCTS-COMPIOPAGG S 3,000,000 S X POLICY PRO- LOC AUTOMOBILE LIABILITY EOMBIIN eDi SINGLE LIMIT 11000,000 BODI LY INJURY(Per person) S A X ANY AUTO BODILY INJURY(Peraccidenl) S ALL O ED SCHEDULED 1693991 /26/2019 /26/2015 T SAUTOS PROPERTYD E $ Per acddem NON-0'A?MED HIRED AUTOS Urd4sured motorist comNned $ 11000,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAR LAMS MADE DED ETENTION$ $ 1693991 /26/2014 /26/2015 B WORKERS COMPENSATIONVr'C SLATU- OTH- I AND EMPLOYERS' LIASILITyIMITS -- E.EACH ACCIDENT $ 500,000 ANY PROPRIETORMPARTNERIEXECUTNE L OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA 000070952 /1/2014 /1/2015 E.L DISEASE - FA EMPLOYEE $ 500,000 If yes, descrila under DESCRIPTION OF OPERATIONS belom E.L. DISEASE- POLICY LIMIT $ 500,000 A Contractors Equipment S 1693991 /26/2014 /26/2015 $75,000 anyla'I leased or rented equipment DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 10f, Additional Remarks Schedule, if more space is required) Commonwealth of Massachusetts MA Y1G19Lei 39911 I1v191 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Matron, CIC/SSD ACORD 25 (2010105) (9)1888.2010 ACORD CORPORATION. All rights reserved. INS026oninmoni THo annPin nomas onrl 1—aro ron10-1 m—t— of J1rnpn J P_ b A R2X 'A*'Yvw•e••f•M•vv o• ear.-.pyWnVv• o�:k• C';!).' BQAi� EI�EI�IC`IANSs ISSUES -THE FOLLOWFNG%-Lj"CE 45 Ex AURNEYt�ANrELECTR ICIAIV "a TQDD M CLEMENS 17 CASE=Y z fRtl 02809 45J :.R51$T01 b� 37846<.EQ'- o7/3z1/1 f 4187Q 0 SSUES fw nrr�` L L OW I N G �I� 16E N'S E "A MAST, R;,,E-LECTR.I C I A TObD ;M CLEMENS 'f 3 17 CASE : R f'STt}l z j.R l 02809-451' 2047,_<A ':z :.. 0%/3a1 /n1 .. y : 418, F eotir:titam H U.i!;� 'AORT TOWN OF NORTH ANDOVER 3t1 E t v..ti b •6 Q O Building Department 1600 Osgood Street 0 Building 2- Suite 2-36 Building Dept 3,�30 "T`°''�<�y gc►+us North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: �°0%/, p� a ✓ TEL #: NAME OF COMPLAINTANT: A� O.v y /h o c�j• - /0i its 44en G*119Y ADDRESS.:: G� i.d .S~�it' «r` COMPLAINT TYPE: (40pvoA1 S�t,rd Electrical: Plumbing: Gas: Building: Property Owner: Address: Other: 14AI dv IonOctS e'fl /tfX 0V,,4,,&1h 77ti s _ 0t*"e ra 6e Jew 7 7`0 %f/o� ��✓u- /�L; ems, �,rP�o,� �ih�,rrl;` Signed: Complaint Form - Revised 6.2007 ��.C)046 c/?/A'�c TOWN OF NORTH ANDOVER 32 bf nil .,.h., •6\ O Building Department 1600 Osgood Street Building 2- Suite 2-36 Building Dept "SSgCHUS ` North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION 6 / /0 V �.. DATE: � �/� TEL #: NAME OF COMPLAINTANT: ADDRESS. COMPLAINT TYPE: Electrical: Plumbing: Gas: Building: Property Owner: Address: G,)u ev,o , e /,s �r"e- 0 Other:u' 4423 f� Signed: Complaint Form - Revised 6.2007 .-S72)o e, 10 it I C'101 N � 03/19/2004 15:43 6033296234 ENVIROMENTAL RESTORA PAGE 01 Environmental Restorations, Inc. De!eading A professional approach to quality service Sandbiasting -asbestos Removal 16 Haiel Drive, Hampstead. NH 03841 Tel (603) 329-6101 • Fax (603) 329-6234 . FAX COVER SHEET thlr TO: Val". Z w ATTENTION: Qav1 pei,,, FROM: %--j C.1itw�le-ry DATE: 3-Iq- O REGARDING: 2 _ -- NUMBER OF SHEET'S: 5 (including cover sheet) MESSAGE: $C -4-O If you have any questions or pxoblems with this transmission, please call (603) 329-6101 ENVIRONMENTAL RESTORATIONS,.INC. FAX# (603) 329-6234 03/19/2004 15:43 6033296234 ENVIROMENTAL RESTORA P E? E R f O N A f f O C I A T E f C O N S U L T I N G E N G I N E E R S. I N C. January 17, 2004 Environmental Restorations, Inc. Invoice No. 20031218 10 Hazel Drive Project No: 04010 Hampstead, NH 03841 Attn: Brad Charters Re- 12 Bingham Way, N. Andover For professional services rendered for the period January 1, 2004 to January 17, 2004 forthe referenced project. contract % Work Amount Amount To Date Billed 1,300.00 100,00% 1,300.00 Total Fixed Fee Invoice Total Previous This Inv Billed Billed 0.00 1,300.00 1,300.00 $1,300.00 PAGE 02 125 G.S 1'. • QV is 1'. N1 0'11.4 • (1.171 472.:1100 • FAX 16171 472.1;1,50 03/19/2004 15:43 6033296234 ENVIROMENTAL RESTORA PAGE 03 P E T E R 1 0 N A f 5 o C 1 A T E S C O N 5 U L T I N G E N G I N E E R 5, I N C - January 2, 2004 Mr. Brian Charters Environmental Restorations, Inc. 10 Hazel Drive Hampstead, NH 03841 RE: Structural Review — Fire Damage 12 Hingham Way North Andover Reusing Authority Project No. 04010 Dear Brian: As requested, Peterson Associates has visited the above referenced building to assess damages resulting from a recent fire. This report is written to outline our findings with regard to the fire damage to the building, provide an opinion as to the extent of the damage, and make recommendations about the repairs required to the property. The building is comprised of a cast -in-place concrete foundation, 2x nominal wood wall and floor stick framing, brick masonry, and wood framed roof trusses with plywood sheathing and asphalt shingles. The buildings in the development are approximately 40 years old. An investigation of the affected building areas was conducted in order to determine structural damages resulting from the fire. Attic areas were toured to determine the conditions of roof framing members. Observations made during our inspection are as follows: • Roof trusses are installed at 24" on center. Three damaged bottom chords were noted at the center of the roof trusses. The damaged chords span from the exterior wall approximately I V inboard. Two diagonal members are connected at the third point of the chord. Splice plates exist at the inboard end of this member and plywood gussets exist at the exterior wall joint. It is recommended that the damaged bottom chords be removed and replaced in kind. All connections with existing truss member shall be made as follows: o Diagonal Member Connections: %" plywood gussets ora either side of joint. Gussets shall extend a minimum of 18" past joint onto adjacent members. Gussets shall be secured with construction adhesive and No. 10 screws at 3" on center, staggered, both sides. 125 <iK1:1:NV,1;;A1 i'I. • 0(l I.%CY; \(A U?11.9 • X1,17) -17-2-.:{100 - FAX ( 6 1 7 ) 472-IJ50 03/19/2004 15:43 6033296234 ENVIROMENTAL RESTORA PAGE 04 n Mr. Brad Charters Environmental Restorations, Inc. January 2, 2004 Page 2 of 2 o Splice Connections: 3/4" plywood gussets on either side of joints. Gussets shall extend a minimum of 18" past joint onto adjacent members. Gussets shall be secured with construction adhesive and No. 10 screws at 3" on center, staggered, both sides. • Damage was noted to the double top plate of the wall adjacent to the hallway. It is recommended that the two damaged top plates be removed and replaced in kind. Joints in the top plate shall be offset a minimum of 16" and shall be secured with 16D ring nails. No grade stamps were visible on the truss members during our evaluation. If the grade of lumber cannot be determined prior to the start of construction, the contractor shall utilize No. 1, Henn -Fir or equal for truss repairs. Plywood for gusset repairs shall be 1/4" CDX or equal. Subsurface conditions of some areas of the structure could not be reviewed during our evaluation because wall sheathing was in place. If further damaged areas, not similar to the deficiencies noted in this report, are revealed during the repair work additional review may be required. We trust that this report provides you with the information you require at this -time. If you have any questions or require additional information, please don't hesitate to call. Very truly yours, Christian M. McCullough Peterson Associates Consulting Engineers, Inc. W04104010 N Andover HA - Fire Review\Report.doc 03/19/2004 15:43 6033296234 ENVIROMENTAL RESTORA PAGE 05 tV lu ,ujco i i• I I • U to U '� I i ami • OO a I • I m m LU I I Co a Win O �• � I r('1 �_v z ( v 75 C Y •y O O Qj Ln 0 Z° I •I Lu C7 � oz a / • W3 O / • / 4.1 M fu 4.3L ~ Z (D Z UJ • / I 4)V l' H �1LJOw I sl dv: � fit] I I EZ O t � U � O I• ( N H U pLLI O +v v c ,.- Ja N 03/19/2004 15:43 6033296234 v . , A. z g ENVIROMENTAL RESTORA am V PAGE 06 Ly Kroi OR O O rL m b i W W tv \\ t U o a != A • :off : U, n a C :t O �uC/) ® L 1CON W Mo zQ �_2 .r UC/-) m CO U MA 09-61 co 0 CD cc 0 s CD CL Cl y ® C co Cm coO CD y c '9 m m co Q co CL4-0 ro CD CS LCLo Q CL CL Ca mQ. C ca C Z CL C.� CO) c C C C _cc . CL H LLI LLI W W 19 ui ui U) C O != A • :off : U, n a C :t O ® L 1CON �_2 .r m L W. CD C E 1' � i ' ®� y �� s :LL e h :yCc C o WO nV y m � o� L ct'L.+ O OD C O � N 0 0 A V ` nO 0) C Q O f! m C •O = as 'Co.. Lzim N CDs L .y ®_ •dL IN O _ f' .� C C= o .y O U m OmC CO2 g ®�O* A O O L CD n :a MA 09-61 co 0 CD cc 0 s CD CL Cl y ® C co Cm coO CD y c '9 m m co Q co CL4-0 ro CD CS LCLo Q CL CL Ca mQ. C ca C Z CL C.� CO) c C C C _cc . CL H LLI LLI W W 19 ui ui U) Datez— TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .::.........: ....... .................................. has permission to perform .................................................. .-K. -rjj-j, F wiring in the building of .....1::.: ... .... .... . W�1./ ................... I ........ .... at.................................. ',1- ...................... .............. ,North Andover, Mass. Fee,. �� ......... Lic. NA a;.�j . ...... ............... ....................... Check # ELECTRICAL INSPECTOR 5!31 mac`' eM&WA07M5XZ7W 057 DO -6-4 4 POO& S441t BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMITJO P All work to be performed in accordance with the M (Please Print in ink or type all information) Town of North Andover ``' The undersigned applies for a permit to perform the electrical work described below. Official Use Only Permit No. 5751 / c7c7 5 .� CMR 12:00 Occupancy & Fee Checked [/ A ELECTRICAL WORK Electrical Code 527 CMR 12:00 Date RIM U.494 23t?A0¢ To the Inspector of 6'tres: Location (Street & Number � 12 $11 6 NA H W A y Owner or Tenant n[oxIff .4N rPO V t,Kr /�t0 USWG +.frjflo o t y Owner's Address l Z '31A.1614,4H WAY Is this permit in conjunction with a building permit Yes No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Voits Overhead 0 Undgmd 9 No. of Meters New Service Amps Voits Overhead 0 Undgmd 0 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: 16Eko u l; ANO 62EwjNE gu itNT to t w a 7'0 2 UGlsemc(cs f L (,IGFf7 A,- 0 i INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I1have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = Aave submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE - BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perry: FIRM NAME G601Z�/G J`.I KA-*LIGPn SPP GE0ee(D JJ f4ASSE LIC. NO. A j3 263 LIC. NO. G 7,8 932 Address ?0 fox 4G9 5,4AlPow+J P4 o3&� Bait Tel. No. / 603-881-45 71 OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ D Total No. of Lighting Outlets No. of Hot fuse No. of Transformers INA Above 9 In II No. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators INA $ No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices U Municipal 0 Other No. of Dryers rYe Heating Devices 9 KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydra, Massage Tuds No. of Motors Total HP OTHER: 16Eko u l; ANO 62EwjNE gu itNT to t w a 7'0 2 UGlsemc(cs f L (,IGFf7 A,- 0 i INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I1have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = Aave submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE - BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perry: FIRM NAME G601Z�/G J`.I KA-*LIGPn SPP GE0ee(D JJ f4ASSE LIC. NO. A j3 263 LIC. NO. G 7,8 932 Address ?0 fox 4G9 5,4AlPow+J P4 o3&� Bait Tel. No. / 603-881-45 71 OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ D The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone F1am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity I am an employer providing. workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance Co. Policy # Company name: t� Address City: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION w Location ,J19 Z?110�?/AGW w A L No. �r Date O: M1.x ORTM TOWN OF NORTH ANDOVER - _ L Certificate of Occupancy $ cNE<� Building/Frame Permit Fee $ swus Foundation Permit Fee $ Other Permit Fee TOTAL 4 4{Check #�%®�i� 17L66 /0��, Building Inspector 1.1 Property Address: 12 Bingham Way 1.2 Assessors Map and Parcel Map Number Number: Parcel Number North Andover Housing Authority 310 Greene St Suite 1 1.3 Zoning Information: Zoning District Proposed Use Address for Service: 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft 2.2 Owner of Record: Front Yard Side Yard Rear Yard Required Provide Reqttired Provided ReqWred Provided SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record North Andover Housing Authority 310 Greene St Suite 1 Name (Print) Address for Service: 978-682-3932 Signature Telephone 2.2 Owner of Record: Nzme Print Address for Service: R Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Charles J. Minasalli Licensed Construction Supervisor: C S 0 71 0 7 7 License Number 10 Hazel Dr. Hampstead, NH Address 7/25/05 603-329-6101 Expiration Date Signatu Telephone Z, Af...t,* 3.2 Regi ed Itorc Improvement Contractor Not Applicable ❑ Company 1 fame Registration Number Address Expiration Date Signature Telephone r: �i SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506), Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......Ck No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building IS Repair(s) N Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Repair bottom chords of (3) burnt trusses. Repair top plate of (1) interior wall. SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit a licant _iiMCiAL':USE-,QNLY . 1. Building 1,000.00 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 3 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 1 0 00.00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �%U�i e P l . as Owner/Authorized Agent of subject property Hereby authorize Environmental Restorations, Inc. to act on My beh ; n all matters r,40ve to work autho d by this building permit application. �/�� Signao& of Owner Date SECTION 7b OWNER/AUXH0MZED AGENT DECLARATION 1,D/Q %� o/I'JP 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 Nam Signa e of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TlNMERS 1 2 ND 3 RD SPAN DEVIENSIONS OF SILLS DIMENSIONS OF POSTS DM ENSIGNS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS 1 SIZE OF FOOTING X MATERIAL OF CH ANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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: LL & S Recycling Salem, NH (Location of Facility) Signature of P rmit Applicant 2/17/04 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing. workers' compensation for my employees working on this job. Company name: Environmental Restorations, Inc. 10 Hazel Drive City: Hampstead, NH 03841 Phone#: 603-329-6101 Insurance Co. AIG policy# WC4814160 Company name: Address City: Phone #: Insurance Co. Policy Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do herby certify under the pins and penp/frlps of perjury that the information provided above is true and correct Print name Charles J. Minasalli President Phone# 603-329-6101 Official use only do not write in this area to be completed by city or town official ❑ Building Dept FlCheck if immediate response is required Building Dept D Licensing Board p Selectman's Office Contact person: Phone #: I] Health Department ❑ Other FORM WORKMAN'S COMPENSATION ®' CERTIFICATE OF LI BILITY INSURANC E__OP ID L PRGDucER; .' _ � ,.,.; IR -2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INF DeSanet s Insurance Agcy,NLY AND CONFERS,,NO RIGHTS UPON THE CERTII Inc Inc. HOLDER. THIS CERTIFICATE DOES NOT'AMENO,.E) 36 CuAmi:ngs Park ALTER THE COVERAGE. AFFORDED BY THE POLICI Woburn MA 01801 Phone:781-935-8480 Fax:781-933-5645 INSURERS AFFORDING COVERAGE INSURED DATE{MM!DD/YY} 09/0./,0,.. )RMATION ICAtE , SEND OR S BELOW. INSURER A: AIG Environmental INSURER B: CNA Insurance Companies Environmental Restorations Inc INSURER C: 16 Hazel Drive Hampstead NH 03841 INSURER D: INSURER E: COVERAGES HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING NY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR LMAYPERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH OLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER - O C E O CY X 1 DATE(MMIDD/YY) DATE MM/DD/YY GENERAL LIABILITY LIMITS A X COMMERCIAL GENERAL LIABILITY PROP1123222 EACH OCCURRENCE $ 1,000,000 06/10/03 06/10/04 FIRE DAMAGE CLAIMS MADE [j�] OCCUR (Any one fire) $ 50,000 X Inc.Asbestos/Lead MED EXP (Any one person) $ 5,000 Abatement Liab. PERSONAL S ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG $1,000,000 AUTOMOBILE LIABILITY B ANY AUTO 00002513348 COMBINED SINGLE LIMIT $ 1,000,000 04/12/03 04/12`'/04 (Ea accident) ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $ X HIRED AUTOS (Per person) X NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ EXCESS LIABILITY AUTO ONLY: AGG $ X OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND A EMPLOYERS' LIABILITY WC4814160 XTORY LIMITS ER 08/01/03 08/01/04 El. EAC,' -I MA,NH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 OTHER E.L. DISEASE- POLICY LIMIT $1,0001000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Illustration of Coverage CERTIFICATE HOLDER N ADDITIONAL INSURED; INSURER LETTER: CANCELLATION TOWHO_ 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ; 30 DAYS WRITTEN To Whom It May Concern NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE,NA BLIGATION OR LIABILITY OF ANY KINOUr6N THE SURER, ITS AGENTS OR REPRESENT ES. - tlTHORIZ EPRESENTATIVE , ACORD 26-S (7/97) 0CORPORATION 1988 ✓lie �avrv;�zazruPsz���ip�_.`�uuazlu6eG7it BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 071077 Birthdate: 07/25/1960 Expires: 07/25/2005 Tr. no: 13745 Restricted: 00 CHARLES J MINASALLI 20 CRANE RD E HAMPSTEAD, MA 03826 Administrator 02110!2004 14:38 7819227873MC�i ARENS VCLING YNTL p4rE 02 North Andover Housing Authority Joanne Me Comerford, Executive Director One Morkeski Meadows (978) 682-3932 North Andover, MA 41845 (978) 794-1142 FAX (800) 545.1833 Exct. 378 TDO j ccynterf card (an7arthet nd��_crh;ti,com February 5, 2004 Paul F. Dowling, CPCU McLarens Young Intemational Global Claims Services 76..R Winn Street, Suite 3B Wobum, MA 01801 RE: I2A Bingham Way, North Andover., NIA 01845 NOTICE TO PROCEED Paul F. Dowling is hereby authorized to have a contractor connnlence work at the start of business day on M.onda.y, Fcbruarw 16, 2004,,' You are informed that Joanne Comerford is the contact person for the North Andover Housing Authority and Bill Miller is the DHCD Construction Advisor, Please ackii.owledge receipt of this Notice to Proceed by signing and dating the original and 3 copies. One to be retained for ,your files. Please fonuard one original back to the housing authority and one to the coritractor. The Housing Authority's Tax Exempt Nutriber is 042427248. Sincerely, JoaComerford, Executive Director ACCEPTED PY, Name of Atli stet BY: Equal Hamming Oppor?.upiry Date: e? 6 - I Z ,31 1V 6 WA en vi RI 6 F100,z -N-)►..(A N a January 7, 2004 McLarens Young International Attn: Paul Dowling_ 12 Bingham Way North Andover, MA 01845 RE_ NORTH ANDOVER HOUSING AUTHORITY FIRE AT 12 BINGHAM WAY Dear Paul, As per your request and our site visit, Environmental Restorations, Inc. is pleased to provide you with a quote to perform fire restoration work at the above - referenced address. SCOPE OF WORK: ROOF Remove and replace (3) three burnt truss bottom chords approximately to the center of the truss, and install new plywood gussets. LIVING ROOM Demo all fire -damaged 5/8" sheetrock and replace. Remove and replace fire -damaged insulation. Remove apartment entry door and replace door header and approximately 20' of burnt top plates. Reinstall apartment entry door. Tape, mud and prime replaced sheetrock. Paint walls and ceilings. Re -finish approximately 150 sq. ft. of damaged wood flooring. Install new vinyl cove base. BEDROOM Demo all fire -damaged 5/8" sheetrock and replace. Tape, mud and prime replaced sheetrock. Paint walls and ceilings. Re -finish approximately 150 sq. ft. of wood flooring. Install new vinyl cove base. FRONT STAIRWELL Demo all damaged 5/8" sheetrock and replace. Remove and replace fire -damaged insulation. Tape, mud and prime replaced sheetrock. Paint walls, ceilings, and stair kicks. Refinish (3) three handrails in front stairwell. hope this is helpful to you. If you have any additional questions, please feel free to contact me at (603) 329-6101. Sincerely, Bradford W. Charters Project Manager P E 7 E R 5 0 N A S E® C o A T E 5 C O N 5 U L T I N G E N G I N E E R 5, I N C. January 2, 2004 Mr. Brian Charters Environmental Restorations, Inc. 10 Hazel Drive Hampstead, NH 03841 RE: Structural Review — Fire Damage 12 Bingham Way North- Andover Horsing Authority Project No. 04010 Dear Brian: As requested, Peterson Associates has visited the above referenced building to assess damages resulting from a recent fire. This report is written to outline our findings with regard to the fire damage to the building, provide an opinion as to the extent of the damage, and make recommendations about the repairs required to the property. The building is comprised of a cast -in-place concrete foundation, 2x nominal wood wall and floor stick framing, brick masonry, and wood framed roof trusses with plywood sheathing and asphalt shingles. The buildings in the development are approximately 40 years old. An investigation of the affected building areas was conducted in order to determine structural damages resulting from the fire. Attic areas were toured to determine the conditions of roof framing members. Observations made during our inspection are as follows: • Roof trusses are installed at 24" on center. Three damaged bottom chords were noted at the center of the roof trusses. The damaged chords span from the exterior wall approximately 11' inboard. Two diagonal members are connected at the third point of the chord. Splice plates exist at the inboard end of this member and plywood gussets exist at the exterior wall joint. It is recommended that the damaged bottom chords be removed and replaced in kind. All connections with existing truss member shall be made as follows: o Diagonal Member Connections: 3/4" plywood gussets on either side of joint. Gussets shall extend a minimum of 18" past joint onto adjacent members. Gussets shall be secured with construction adhesive and No. 10 screws at 3" on center, staggered, both sides. 125 GREENLE,AF ST. A QU I NCY, MA 02169 - (61 7) 472-3100 a FAX (.617) 4 72-1 350 Mr. Brad Charters Environmental Restorations, Inc. January 2, 2004 Page 2 of 2 o Splice Connections: 3/4" plywood gussets on either side of joints. Gussets shall extend a minimum of 18" past joint onto adjacent members. Gussets shall be secured with construction adhesive and No. 10 screws at 3" on center, staggered, both sides. ! Damage was noted to the double top plate of the wall adjacent to the hallway. It is recommended that the two damaged top plates be removed and replaced in kind. Joints in the top plate shall be offset a minimum of 16" and shall be secured with 16D ring nails. No grade stamps were visible on the truss members during our evaluation. If the grade of lumber cannot be deterr��ined prior to the start of construction, the contractor shall utilize No. 1, Hem -Fir or equal for truss repairs. Plywood for gusset repairs shall be 3/4" CDX or equal. Subsurface conditions of some areas of the structure could not be reviewed during our evaluation because wall sheathing was in place. If further damaged areas, not similar to the deficiencies noted in this report, are revealed during the repair work additional review may be required. We trust that this report provides you with the information you require at this time. If you have any questions or require additional information, please don't hesitate to call. Very truly yours, Christian M. McCullough ,0' Peterson Associates Consulting Engineers, Inc. G:\04\04010 N. Andover HA - Fire Review\Report.doc N v- 0 \ oo I I N ®I ® m O v Q N ~ m \ V W c 3 i W O Z o p 0 N-_0) Cl) O N Z O a W < Z °Z o' Cl) O �J N W Oy � �- Z W0� a U a p i c m p i C9 N N w ® ooW I U ®I =moo i I 07 Z o ~U I® w Ln N v- 0 _a M I N O Wzp O v Q N ~ m Z V W c 3 W O Z o p 0 N-_0) Cl) O N Z O a W < Z °Z o' Cl) O �J N W Oy � �- Z W0� a U a p c m p i C9 N N r LU z Q v a� U N L U N 41 a� N t V) N 4 Q `-- W Q W (� (J J N M I N N ti a W .. Q N V W W 0 z C/) 01 m C 0 L. O O O 0 O z C) Cl) UI ,� z o Z W Zoe N Q � 0 z o ,L, N O ~ to O S�+- r (U (n � LU O. O V °j v l O >, O m U N U Q N 4-3 o �z O �i o � z z � o U U) oa a� ° o w )v Uco v v) o u. o a U c w o w u. w w o w r9'i u', o w c i% w w rn z cn O o U) O z W Pl 0 CO) .y O L f+ c O CD _v CO) O O h C O cc C cc CO2 rel CD CM C CD m m CDi Boof+ CD CLO CL C �p� O J R CD CD CL CO2 C M c c ;a, o CD • :off := o C3 C..) 3 :a0 Nt m c :=o CD N m C r V ID s c r 40i O r , O C CL E C', o a 1; � i ; ®� N • C r: C � m s m a E _N : N W C O cc E _v I o N C m CD cm fir: om cc C C O CL m =v0imc c coo w t •a r W C.s c Z C.3 CD ci cm 1 E COD _ CL A m� OC .0 ` N 9 J O ca CL*- W Pl 0 CO) .y O L f+ c O CD _v CO) O O h C O cc C cc CO2 rel CD CM C CD m m CDi Boof+ CD CLO CL C �p� O J R CD CD CL CO2 C M IM °f NORTH ,4, ° O 'SSACHUSi Date//"/ -7 6 Y. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that t` ...C. "5. .................. has permission to perform .. .17 ............................. plumbing in the buildings of . 14 at ... 1�r.a fLv. >..1•v/ . ............. �North Andover, Mass. Fee. Lic. No.. 70 .7 . ......y.'`�- ....... . PLUMBING INSPECTOR Check # 6222 MASSACHUSETTS or print) H ANDOVER, MASSACHUSETTS Building LLodation .fJl i k7fl9f (�plG/�/Ud1 /S�GJ �l16, New 1:1 Renovation APPLICATION FOR PERMIT TO DO PLUMBIP )wners Name /Y /14�fAZ7/4/y4ih of Occupancy 40r,1;6?417 WIL FIXTURES ' Date Permit # "L Amount Plans Submitted Yes 11 GGEN-i (Print or type) Check one: / Certificate Installing Company Name �1�� �� Corp. Address S� 141 / ST Partner. A If Ka Business Telephone 7-., 4.2i ;Z,. ---Z4 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the'type of insurance coverae by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 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 erf ,tom sued for this application will be in compliance with all pertinent provisions of the Massachusetts State bin Code an the General Laws. By: igna ure or Mcgliseaum T pe of Plumbing License Title �6 City/Town Eicense TluynDer Master Journeyman ❑ APPROVED (OFFICE USE ONLY A Date. ........ r�' >- \-%N, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that 'm/ .................. has permission for gas installation .................... in the buildings of ....P IJ : *� /.I*,. I X ................. at ....4-9-1 4s- I/ / North Andover, Mass. Fee.4... Lic. No..C/0.-( --- ------------ PPI?CTOR Check # 4902 P4 MASSACHUSEIIS UNIFORM (Type or print) NO�2TH ANDOVER, MASSA Building Locations r "Owner's Name New❑ Renovation 1:1ReplacementEf I FOR PERNIff TO DO GAS FUnWG' Date ��- / e P � Permit # Lt L r Amount $ Plans Submitted ❑ (Print or Name _ Address C hcocone: Certificate ���ng Company jorp. i r� ❑ Partner. usiness Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy ET -Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all or the aetans anu mivrrnauvu I „avc auviimwu k.,, ---j ........ .YY., .-..• .• •• •� •.. best of my knowledge and that all plumbing work and installationsperformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S e Ga e�h�pter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber %� %y f ❑ Gas Fitter Liceiise u er 0 Master ❑ Journeyman -IST. FLOOR 1 • FLOOR (Print or Name _ Address C hcocone: Certificate ���ng Company jorp. i r� ❑ Partner. usiness Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy ET -Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all or the aetans anu mivrrnauvu I „avc auviimwu k.,, ---j ........ .YY., .-..• .• •• •� •.. best of my knowledge and that all plumbing work and installationsperformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S e Ga e�h�pter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber %� %y f ❑ Gas Fitter Liceiise u er 0 Master ❑ Journeyman Date ...... �. �• N° 46°9 ".° R7 :1tio TOWN OF NORTH ANDOVER • s PERMIT FOR PLUMBING �SSAcNU _ This hi certifies that .. /-V ..... l`-' `'r✓Y �" ' �'""" has permission to perform... ``�. — �' • • ...... • • • • • • plumbing in the buildings of?:�`!-�-' -P^� at . -L-� / <f''�� - *�. �..• • .- • , No4h Andover, Mass. Fee d !!. Lic. Nor `�� r! �. :? �.• ......... r ` PLUMBING INSPECTOR Check #1,2/j Z WHITE: Applicant CANARY: Building Dept. PINK: Treasurer masa MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) _ 1 I . & I 1V&t7 4 *vQa Vc&., Mass. City, Town Building AT: Location f3/n!/� G W4M A14Y_ _ Date_ _�a • 41 - ae DD Permit # Lf�o4% Owner's Name_ /�QlL ,/�j✓b ✓dl�+ v Si"+ G 4V -*^s / rr Type of Occupancy: Came a lTY New ❑ Renovation ® Replacement ❑ Cff7%-Tar". Plans n FIXTURES Submitted: Yes ❑ No l (Print or Type) Check One: Installing Company Name _ROBERT jel SRV 1 NIL riS, `I'►.0 , [� Corp. 20S (n C Address A-? ALLEY S -r. ❑ Partnership 1_16atz MA. 01c10?_- 444 I ❑ Firm/Company Business Telephone -7`5 S - 55 f - 04(a 4 Name of Licensed Plumber or Gasfitter -TEP.RANC.S M -bESM0Nb Certificate 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 Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that 1 do not have liability insurance including completed operations coverage. Signatureof polic�ncrjy to i / I have a current liability insurance policy to include completed operations coverage. �, W �D.0,�D By Signature of Licensed Plumber Title City/Town Type of Plumbing License N0(Ag2 [Z Master ❑ Journeyman APPROVED (OFFICE USE ONLY) License Number I 1 i • ...■■■■■■■■■■■■■■■■■■■■■�■■■■■M (Print or Type) Check One: Installing Company Name _ROBERT jel SRV 1 NIL riS, `I'►.0 , [� Corp. 20S (n C Address A-? ALLEY S -r. ❑ Partnership 1_16atz MA. 01c10?_- 444 I ❑ Firm/Company Business Telephone -7`5 S - 55 f - 04(a 4 Name of Licensed Plumber or Gasfitter -TEP.RANC.S M -bESM0Nb Certificate 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 Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that 1 do not have liability insurance including completed operations coverage. Signatureof polic�ncrjy to i / I have a current liability insurance policy to include completed operations coverage. �, W �D.0,�D By Signature of Licensed Plumber Title City/Town Type of Plumbing License N0(Ag2 [Z Master ❑ Journeyman APPROVED (OFFICE USE ONLY) License Number M© v m A v c � A D m $ A m m o � r � c n m -+ ml v � Z p N O v m � m z � 00 O m O I � M© u w m r O m O m O m m A m c N m O z F tl f, A v c A m $ A m r n p � O m m z 00 O m � m � v c v z v O 3 -a 0 O r c 3 z 0 u w m r O m O m O m m A m c N m O z F tl f, Date. .K :.?.l."C-.?....... 4, TOWN OF NORTH ANDOVER o PERMIT FOR GAS INSTALLATION This certifies that .. l/!40 5.<.� . 7 -Cr ................... has permission for gas installation ... eR. /'). /-: 5 -< ............. in the buildings of ........ at .?..� ..I'! �:.1.,.:,!........ ,North Andover, Mass. Fee :� .)— .... Lic. No.,). ?.s. 5.... ....�. . !.......- . �- ........ ,GAS INSPECTOR Check # ) i '7 43u3 j 4 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FIT TING (Type or print)Date •�b 3 NORTH ANDOVER, MASSACHUSETTS j Building Locations �T� ��Permit # _ F � N Amount $ 1,�" Owner's Name New ❑ Renovation ❑ Replacement [Er Plans Submitted ❑ N A, Business Name of Licensed Plumber or Gas Fitter k one: Certificate Installing Company Check Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ Noly Ifyou have checked yes, please indicate the type coverage by checking the appropriate box- liability oxLiability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and 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 and it Issued for this application will be in compliance with all pertinent provisions of the Massack"us tts Mate Gas Cpdp an apt 42 ofthe General Laws. ICityaown VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber -:�-O -7?q Gas Fitter License Num er ❑ Master ❑ Journeyman • 1. FLOOR :4TH. FLOOR :8-TH. FLOOR N A, Business Name of Licensed Plumber or Gas Fitter k one: Certificate Installing Company Check Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ Noly Ifyou have checked yes, please indicate the type coverage by checking the appropriate box- liability oxLiability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and 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 and it Issued for this application will be in compliance with all pertinent provisions of the Massack"us tts Mate Gas Cpdp an apt 42 ofthe General Laws. ICityaown VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber -:�-O -7?q Gas Fitter License Num er ❑ Master ❑ Journeyman