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HomeMy WebLinkAboutMiscellaneous - 1280 Turnpike Street i 0 2371 Date....,, . .... goo ; N �+ f pORTM 1 3r�.t�``.°.;°•°"oar TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING 7SSACMUS P This certifies that .........5 s.,..�. . ?.::.�1�..C.CJ .4, :.............................. 4 has permission to perform ...... ...... .�n$2... �.4�.: !.�............... wiring in the building of..... ..:...................................... at.... .. :U.... c'` ,c ..1. .'.. �..........5.T ...... . ,North An o ,Mass. /C)v......... Lic.No.7,,7Z�Y1............. ....... ...........��... . Fee....... . , ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer THE COMMONWE<4LTHOFA M MUSE77S Office Use only j z DEA9RTMFNI0FPIIB0CS4FElY Permit No. � 3 7/ a BOAROOFFMPREVEM[70NREG(IL 4H0NS527CtV1P12- Occupancy&Fees Checked APPLICA TTONFOR PERMIT TO PERFORMELEC7'RICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 S Z �/ •— d 0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date T Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. PARCEL Location(Street&Number) AJ r-14 /i// A �le< •.r/l7 Owner or Tenant /i/ex,-7,* --e d `tl e Owner's Address Is this permit in conjunction with a building pernut: Yes Q`No [D (Check Appropriate Box) Purpose of Building E�� �2 ,�Jt.,u� �S'%�-jiv-%J Utility Authorization No. Existing Service tip Amps 4Mel o Volts Overhead M Underground ® No.of Meters New Service Amps / Volts Overhead r--J Underground No.of Meters Number of Feeders and Ampacity ,.,cation and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs �_ No.of Transformers Total KVA 1o.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground and No.of Receptacle Outlets / No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals �- No.of Heat Total Total No.of Detection and Pum Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices o No.of Self Contained x{✓ Detection/Sounding Devices 0 No.of Dryers _ Heating Devices KW Local Municipal © Other Connections No.'of;Water Heaters No.of No.of Signs Bailasis Nooydro Massage Tubs ._ No.of Motors Total HP OTHER- -- h>st==cov=W.Pmattotbrm4mmxrtsdNbsmdxmtGalaaliam IbaNea=ulLmbtldyhnam=Pbl Dyna dngCMTI&- CawrdWcr tssubslarifialegivaia t YES NO Ilea%eabTnWdvabdproofofsatrletotheOffim YES M NOWgqiiMa If}wllavva�ad®dYEs pleaseit thetype�oa tryd�ad�gthe cboxE � BcND Q rnHFx Q (Pi�espe�y) Estm*dValueof0oohcalWoiic$ WaktoStmt ftWadialLutvRegtrstad Rough Final SigiedundaTTiePt r allksofpetjury: FIRMNAME s�o r�or' GJhL1�s ,�► Lioa�eNo Lioa>sae 1,/r ll•arm 'S�t Sig>ahae ��•/y� Lioa>seNo 2 Z-7 amissTelm &00 - ,/3 L/Jai K- NLIC 0,q2 1-7 AltTdNa OWNER'SINSURANCEWArvU;l maw&ethattheLicrosedmnothaNet rmsLaatneeaaaWcr saisbrt legxvalatasmqunodbyMaoxadmg&C)a=lL3ws andirirTsigxAw ndmpariIIt waiv`st m eq'mTo . (Please check one) Owner M Agent a Telephone No. PERMIT FEE$ Signature ot Uwner or Agent *7 q � N2 21 / 1 Date....... ...U ...(�. a HORTF� TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING °•,T- �sS�cMusE� This certifies that ..... n�..................e ...r�� t h� ..-.... has permission to perform .. . u '.f...................................................... wiring in the building of.... v!�'S.f....(1..:C...W....... . .... ..... .......... at...........U/..... .c t....c�..... ..................... ... .North Andover,Mass. Fee..fD4 .... Lic.No.Z72� ............ .. .�� .., `.:....................... ELECTRICAL INSPECTOR u WHITE: Applicant CANARY: Building Dept. PINK:Treasurer THE QDMMOrWE1LTHOFMAI SSA0K7SE7TS Office Use m DEPARTAIDVIOFPUBLICSAFM Permit No. / / BOARD 0FFMPREYEAW0NRWUT4TI0A S5r0V IZ.* Occupancy&Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date a'JS—®Ca Town of.North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. I Location(Street&Number) AaM 1U?IyD)JIe S%R? E7_ SGT✓ /ILC— Owner or Tenant /'d es/Tl 1�>eVa a�e7vT- Owner's Address 9?1 41/T/AJ 5712 '7 _'�!/Te_ ,-2F Al A1/berz_ M, Cl/$y S Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) fp&•i/r-"' Purpose of Building AI M n :TJg—ri&1 Utility Authorization No. 60 5 Existing Service Amps Volts Overhead Underground No.of Meters New Service Ampsa?7)1` W Volts3,0 wOverhead Underground �— No.of Meters y- �2L Number of Feeders and Ampacity A: Location and Nature of Proposed Electrical Work 5-7 Uy"'o S7 AT./Q J No cif Lighting Outlets No.of Hot Tubs No.of Transformers Total t1 • KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground zround No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices jNo.of Dryers Heating Devices KW Local Municipala Other Connections No.of Water Heaters KW No.of No.of p Signs Bailasis "No.Hydro Massage Tubs No.of Motors Total HP OTHER- 1rs xwxCaxrage Rnu&rttotk'Ieta*wmvzdW1wmdwemC=aW Laws 1hawaomatLiatkln%==PbhycdudigCarzpkte oritssttsta>tralgivdlat YES NO lhaw bmftdvalidpoofofsa e1otheOf i=YES NO Ifj mhawde3WYES,pk%endicaletherAxofwmagebyd�adngthe NK ArC BOND � OT R ftm ) Fxpcdtlrnl]atie Es&mwdvakrdEklrWWak$ ISw.04 Walkliostart AM//Y_._._.... hspaciwD*Rage*d Ragit Final Signed utdeMRmkks ofpapty FIRMNAMEJ /I ' LneNa 7o2>a92 Lica�J4/ue:' 1�ire C/yu SigIMNe Lioa=1,b 7mot�v► �J d r�/ BusimssTd.Na Adan /,Oj' d �l/7J� ..7 y"L .��G7� At Tel Na OWNER'SWSURANCEWAIVER;Iamawdtethatt xLi wdumW heirs r&=o ►W"stbtatialecpnwbtasmg=edbyMnm ta%CardLaws anddvtmysigtl&munt mpan*appficadmwanesthistaW*mnem (Please check one) Owner a Agent ll Telephone No. PERMIT FEE$ �ad'yy Location .' �} L�-�• u� No. �. ` Date MaRTh TOWN OF NORTH ANDOVER f 1 i ; ; Certificate of Occupancy $ • __. .' Eta Building/Frame Permit Fee $ sACMus Foundation Permit Fee $ C Other Permit Fee $ TOTAL Check # 3668 i r Building Inspec�to( COW ROL F ' PERMIT NO. D 31RUCTION APPLICATION FOR PERMIT TO BUILD********NORTII ANDOVER, MA n1APNO. 1074 LOT NO. /¢ ¢, 2. RECORD OFOWNERSHIP DATE BOOK PAGE ZONE, y� / SUB DIV. 1,01 NO. � c� / erSi%� t✓c` .sr..� Co2 '��1 SS G 3 s LOCATION �� e ,s7. RTlT 114 PURPOSE OF BUILDING 011'NF,R'SNAntE 6i'T /)G✓ E/O .✓7— �o�[ NO.OF STORIES . SIZE OWNER'S ADDRESS Z31 ff�TO.v S� BASEMENT ORSLAIi itJo . /�.✓�a✓<< .✓!/f. /,��f e��✓T—�✓ z s✓rs.t ARCHITECT'S NAME eXe'r. ✓r ` SIZE OF FLOOR TIMBERS ] 2ND RD :T 1„Jc. /�Q,',✓Fe2c�G� �-ir eT ST2ve-T�• L BUILDFR'S NAME S✓ Q,(/��f �0 CRQ/� �Ji¢ST1idSGLJ �./T� SPAN DIS FANCE TO NEAREST BIIILDING DIMENSIONS OF SILLS UIST'ANCE,EFROMS"IREF,'r �� Z DIMENSIONS OF POSTS e PEP-MIT !SSUED DISTANCE FltOnl LOT LINES-SIDES z 9 REAR DIMENSIONS OF GIRDERS AREA OF IAT y� .j SF FRONTAGE 3 S p ' IIEIGIII"OF FOUNDATION PE"Wiffitl SS IS BUILDING NEW J 5 SIZE OF FOOTING x IS BUILDING ADDITION nlD MATERIAL OF CHIMNEY IS BUILDING ALTERAT ION IS BUILDING ON SOLID OR FILLED LAND sv�i WILL BUILDING CONFORnI TO REQUIREMENTS Of CODE c—S IS BUILDING CONNECTEh TO TOWN NATER BOARD OF APPEALS ACTION, IF ANY Np,J e- / � IS BUILDING CONNECTED 10 1ONN SEWER IS BUILDING CONNECTED TO NAI URAL GAS LINE �� �/Ii0 /9�J INSTUCTIONS 3. PROYER'I'V INEORAIATION LAND COST /Bv DD o EST.BLDG.COST PAGE 1 FILL our SECTIONS 1-3 ES U.BLDG.COST PER SQ. FT. • EST.BLDG.COST PER ROOM ELECTRIC METERS mus r BE ON OUTSIDE OF BUILDING SEPTIC PERAirr NO. ATrACIIED GARAGES ntUSTCONFORnI"TU STATE FIRE REGULATIONS 4. APPROVED BY: Conn PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR^ BUILDING INSPECTOR D,1-IE FILED OWNERS TELA c26 D Z arsoCP'� CONTR.TELH F7 e 771' -e7&Z ' coN'IR.LIcN S�8 S- ;"9 Tr Fr iyjsT�-tsc-tJ SIGNATURE OF--OjWNNER Olt AU'IIIORIIZED AGENT FEE ��pc ZJ^ i ag lI.LC. PERnlrr GRANTED Revised 5/5/99 JNI r � � 1 NORTH Town o Andover No. os2 CONTROL _ ,� CA�NSTRUCTIt)N D - �, o_ dower Mass., COCHICHEWICK ' ORATED P? C5 S BOARD OF HEALTH Food/Kitchen PERMIT T D V� Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.M.GS.l'T'!...UkY...rf;,P!�P...,�Scr �Q Q, /7;,f1lrZytSoN .e ... Foundation has permission to erect..... ? ZL7........ buildings on ..l.ZSo2Pv�c6r�. ,.. Rough to be occupied as.................$os-;z��u t-4�.C..l-... p 1�4. ...�.. .. . ....................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS CONI'ftOt. CONSTRUCTION Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Cog. e.� OSS G7 7 Street No. SEE REVERSE SIDE Smoke Det. �� ��wo2ski Tv st�/3.vt A r e /a Nex L�cely- Mesiti Dev Group Fax•978-5578160 Dec 14-4999 X11-2:37 P.02 OFFICE OF BUILDING INSPECTOR"- TOWN OF NORTH ANDQ%ER CONSTRUCTION CONTROL r PROJECT NUMBER: PROJECTTITLE:RO%JTE 114 FORGE N%Altd ANO PUMt-141" S A' '10 5 PROJECT LOCATION: P60. AN D OV E R M A FOMEST Vtrs-W &STATCS puMP146 tiTATj9 NAME OF BUILDING:IkO fsjQ PA 1}11.1. PtJM�ING STI®►T�on1 , NATURE OF PROJECT: W ASTIswATER PAGILITY ••x r� as >r� �� raw �, IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE !166ING'.GO0E,-r I, ROGER O RTO N REGISTRATION Nt 'A720;L BEING A REGISTERED PROFESSIONAL ENGINE ER!#RGI ii;E6II1HEREBY.CERTIFYYTHAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: r 1411r ENTIRE PROJECT ARCHITECTURAL ❑ STRUCTU=RAL ❑iMECiANICAL ❑ �W* FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER(SP-ECIFY), FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY MdWLEG ,'SUCH BANS:? Ni COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS W0d►STATE BUILDING CODE. ALLAC£EPTABLE ENGINEERING PRATICC-S. SAND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY { '�' TA wokSKI CVEOT&&a We. 41WI FURTHER CERTIFY THATHALL PERFORM THE NECESSARY PROFESSiONAL';SERVIOES AND :BE ta-PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS" O D€TERMIIVE'THAT `)O1f�THE WORK IS PROCEEEDING IN ACdORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING'' O J PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED 1N ISEGTIO- 1 1.• Review, for conformance to the design concept, shop drawings sa# ples othef ubr is ' which are submitted by the contractor in accordance with the regWremer-ft' Curl titictldn .. I documents. ("1w+loa�K.l (6E6TIE6114' 1tdG. S%004. 8 RESP8t4SISL 'f6K1 A 2.+ Review and approvat of the quality control procedures for all code=requrn l�cantrviled\materials. $At4ORS1.I 0oESOTS&YA 1w. SKA.LL. _ 3.6 Be present at intervals appropriate to the stage of construction to become,:generally familiar with, the progress and quality of the work and to determine, in genwal ifi,ttte vmrli; s;being ., performed in a manner consistent with the construction documents: ` `` i'AW 00.SIzl Cs�sOT'�il� I IJ�# }_ PURSUANT TO SECTION 116.2 .2 HALL SUBMIT WEEKLY , A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER_ VILD.INC INSPECTOR SAN906LS".1 COESTSOK IMM -" UPON COMPLETION OF THE WORK,JSHALL SUBMIT A FINAL REPORT AS TO THEM SATISF=ACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY., SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY,OFA �9 NO l rc) N FRY PUBLIC MY COMMISsiibN E)C tF#ES JVAV `' OA k- a r' FCor,SewahOvL Q.NI .-QJ1pSf QVC CtN��.�l/ r ' , FORM U - LOT RELEASE FORM &572w t��%� �°��% S✓�T�''� INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from. Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *'"******�******"*"*APPLICA,NT FILLS OUT THIS SFC T lON** ********* ** **** APPLICANT /+'/e1�1, /Jer/C/.osrl,C.�/�x°0/1 4. PHONE 97 .f–d LOCATION: Assessors Map Number /0 7,4 Xor- /98 PARCEL SUBDIVISION ,//�, LOT (S) —ig-LE. STREET 5A7,e,-f 7✓R��� --� /�PT�' 1/4 ST. NUMSER 7g� ,*-**O F r 1C 1A L US 1= REqf MMEND TIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED 2 dp DATE REJECTED COMMENTS VV W �AZ�, a TOWN P -ANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEYVER/WATER CONNECTIONS - =(: _ ;ii-teN� t7 i ®N DRIVEWAY PERMITc� FIRE DEPART b1 ENT RECEIVED BY E1J1LDiNG iNSPECTCR DATE Revised 9\97 m jr FORM U -° RELEASE FORM CONDITIONS DIVISION OF PUBLIC WORKS N®Ia°I'HC ANDOVERg MASSACHUSETTS APPLICANT: Mesiti Development Corp. Tel 978-687-5300 LOCATION: Map107A,Lot 148 STREET: Salem'Turnpike Rte 114 .....®.....:. Station(Boston Ski Dill)..................®...,...................®®.... This sip off is conditional subject to the following conditions: 7J` / - 1. A detail of the 2-'/3 inch and YXch water services, with shutoff locations is added to the plan. 2. That the drive extends around the proposed pump station completely and that all of the interio ,�X area is paved. Pavement must extend to gate in front of propane tanks. 3. Final grading must be inspected in the field and approved prior to pavement. 4, Street drainage cannot enter the site over the driveway. The driveway profile must meet the driveway requirement of the Town, details attached. 5. At the second 45-degree bend, on the force main, out from the station the maximum cover over the force main cannot be over 5 feet. V--� " orce6. 'The westerly easement line must be a minimum 10 feet horizontallpomainasnowshown. �1 �i?�s i�/� -�-� ,�G� 7g � �/ 3���� 7. The present road specifications of the Town of North Andover shall apply for all paved areas. This includes the gravel,these are minimum requirements. ,,;V '' «✓�/ r° 'S,.�`'' 8. The turns around the building must meet NbssHighway standards for a single unit vehicle (SU-30). 9. The fence opening to the propane tanks must include two 4-foot gate that both swing out to leave an 8-foot opening. 10. The electric and telephone lines must be underground. 11. All changes roust be shown on the plot plan within 30 days of our date of signoff..on the Form U. The plot must be resubmitted to the DPW for final approval and then copies distributed to all appropriate Town Departments. If this is not done the DPW will rescind its signoff and inform the Building Department of said rescission. Agent for APPLICANT: _Date. __--- Print Nance: /4X' v°t c F0'%AVN' 0F NORTWANMVER DIVISION OF I"UBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 J. WILLIAM HI'VIURCIAK, DIRECTOR 1coves Rond Jr. Telephone (9785 0 ) 68950 Director of Zn ta 7 F (98 1 .) 688-957� .00 Acm%js December 9, 1999 Mesiti Development Corp. I I Old Boston Road Tewksbury,MA 01876 RE Boston Hill Pump Station This department has reviewed the"Pump Station Plan" Salem Turnpike—Route 114,North Andover Massachusetts prepared for Mesiti Development Corporation, 11 Old Boston Road,Tewksbury,Massachusetts. We find that this plan satisfies all of the conditions required in the Form U—* Release Form dated 11-30-99 with the exception of number 3 which is a field inspection to be made at a future date,when appropriate. Sincerely, James Rand,Jr., Director of Engineering CC: Bob Nicetta MW Design Consultants Richard Pelletier TOWN OF NORT11 ANDOVER DIVISION OF PUBLIC WORKS I .384 OSGOOD STREET NORTH ANDOVER, MASSACHL-ISETTS 01845 J. WJLLIAM KMURCUK. DIRECTOR, Jaives Rond .Jr, flF T14 -7 e -'Phone (9/8) 68 09 50 1)irector 0 7, !fkg71?eerM.;,, 688-957 2December 9, 1999 Mesiti Development Corp. 11Old Boston Road Tewksbury,MA 01876 RE Boston Hill Pump Station This department has reviewed the"Pump Station Plan"Salem Turnpike—Route 114,North Andover Massachusetts prepared for Mesiti Development Corporation, 11 Old Boston Road,Tewksbury Massachusetts. We find that this Plan satisfies all Of the conditions required in the Form U—Release Form dated 11-30-99 with the exception of number 3 which is a field inspection to be made at a future date,when appropriate. Sincerely, 9. James Rand,Jr., Director of Engineering CC: Bob Nicetta ME Design Consultants Richard Pelletier RE'CEilVED DEC 0 9 1999 13UILDING DEP -r i 1 U610 VN 'S83ANVO 95i ,1(08 Od ov"Aok NOS8315tlM'`.£ ��33f s�r;is�;sa aaailstlEe s«e�e��.;2 sa . , a32n,, ;8 :saildx3 r np j 3SN3311 80S:A63HS Nil fZhSN03 A13iVS 3?1906 A 1N3N18tld30 h- y., 163379 • R�sir�c�:r :. �� r @0 a.000 c er.i;es.0 :+,ace „m _v domes The Commonwealth of Massachusetts Department of IndustriaUccidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: v S A /2 All —/0� �rJ�//�-� Location: z/ G Cit/ /�/0 r fi-N oo L),� Phone # 76- aI am a homeowner perTcrming all work myse!f. aI am a sole proprietor and have no one working in any capad-by E211_/1 am an employer providing workers' compensation for my employees working on this job. Comoanv name: P S -/-I e-/0 P Address � J S Cihr &o{ 1 I`� N a�1-2.1, Phone'Tg7Cf-(�c t Insurance Co �n/ � / LFG� �i�G �'U�'Q✓/C Policv T NIDA a l 3 y y7` "od I , Comcanv name Address Phone m Insurance Co. Policv T Failure to secure coverage as requirm under Section 25A or iVIGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years imprisonment as well as avis penalties in the fcrm of a STC'P WORK ORDER and a tine of(5100.00) a day against me. I understand that a copy of.his statement may be forwarded to the Office of Investigations of the GIA for coverage verification. I do hereby certify under the pains and penalties or perfury that the information provided above is,'rue and correct. / Signature Date Print name '�� Phone m 7e' —� Official use only do notwrite in this area to be completed by city or town cfriciai' City or Town Permit/Licensing Building Dept ❑Check d immediate response is required ❑ Licensing Board Selectman's Office Contact rerscn: Phone rc ❑ Health Department F-i Other The Commonwealth of Massachusetts m a Department of Industrial Accidents Office of Investigations ora Boston, Mass. 02111 , Workers'Compensation Insurance Affidavit Please Print Name: /'�e�.` T. A) e — Location: /do 67 Ivo.• 4,vd'a ✓e..e_ � /��• Phone 978— 687- 5 3�0 am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity f�1 I am an employer providing workers' compensation for my employees working on this job. Comoanv name: J. Masterson Construction Corporation • Address PO Box 165 City: Hathorne Phone#: 978 77Jm82_a2, Insurance Co. Acadia Insurance Policy# WCF1300518 ComDanv name: Address City Y. Phone#: Insurance Co. Policv# Failure to secure cov 9 as requ�� nder ection 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,51'0.00 and/or one years''s priso nt as W®il s civ penalties in the form of a STOP WORK ORDER and a fine at($140.00)a day against me. i and and that a y t s even may •e formrded to the Office of Investigations of the DIA for coverage verification. I do Herby ca% th ai ar�d pe to of perjury that the information provided above is true and correct. Signature / ®ate 11-08-99 Print name J//h) J. asterson Phone#978 774-8782 Official use o6ly donot wMe in this area to be completed by city or town official' Ij Building Dept (:]Check ff immediate response is required Building Dept Uncensing Board ® Selectman's Office Contact person: _ _ _ Phone#:_ _• Health Department Other 1 I+-'0 3 f 193= 11. C12 9 _5'8 E.1 9 P.W.• E Cl: T,he Commonwealth of Massachusetts 7 Department of Industrial Accidents Office of Invastioadons ` l Boston, Mass, 02111 Workws'Corrvensation basurerwe atfffdav;l Please Print Nam&: 4606 ,J , City �� '9.� o v e..0 �1•!t PhQ a S�7S�- ggf 7 (`I am a homeowner performing all work myself. - 1 am a stile proprietor and have no one working in any capacky I, I mile �1 1 Sett ar employer providing workers' mpensation for my employees working on this joo, c2mrany name: city. v�ni Y-Y)E a Phone : I `i ►�G ! S�omaanv natrrie� Addre City' — +hone . r` Policy0 ritilve to Secure cmerafe ex required under Section 2SA or MGL 152 can lead to the iIlion olcrlminai�>ertaldee or s tree up to$1,W000and/or one yeere'Impr"riment an"I as olvo penaitiee in the form of a STOP LNORK ORDER and a fine of($1013,M)a day Wsfr4 t me. I underMand theft a cagy of this statement rosy be forwarded to the Office of Inveatlgatwo or the VIA for Coverage vennoalion. I"herby;#my 40ft FWM and s of penury the Ms lrvbrmavan,orvvtdea above is We ane Mrvwt ) signature— \\ _. Date Print"t-ne CIG ` ��V�J � Phone 080-7 Omeiel wee a" do nod wrWn this area to be comp4ted by city or town aRielal' © r9tAWing (dept ❑Check if mmadte(a rtaponse is required Bu'ikft DeO 0 Llr'xensing Board L) strmClman's of co CantactPvwn,_..._._--- -------�_ Pnvne c _._— Lry Health Npartrm& Other 01/31/2000 11:49 9786876279 J MASTERSON CONST PAGE 05 OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER ' QONSTRUCTION CONTROL PROjwT Nwast~ 3 J✓Z PROJECT TifL& /lr4a //I' PROJECT LOCATIGR:_ . �ld� �*'�K A�O, WOlff "me OF BU LDI> . MATURE OF PROJECT: -f ✓F�C .tc �,:� �,., . ,� ���..��;� IN ACCORDANCE WITH ARTICLE 1t8 OF THE mASSACHUSE 7S STATE BUILDING COPE, I-474f—_y ��4Gfi 0 2S�C/ _� REGISTRATION NO.3 G 13 BEING A REGISTERED PROFESSIONAL ENGtNEMARCHITECH HEREBY COR j FY3# , • w 1 Ram THAT I SHALL PERFORM THE NECESSARY PRCFESSIONAL SERVICES MIO Be PRESENT ON THE CONSTRUCTION SITE N TE O A REGULAR ANt7 PERIODIC sAsIS To DRMIME THAT THE WORK IS PROCEEEDING INACdOADANCF WITH THE DOCUMENTS APPROVED FO THE BUILDING PERMIT MIO SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 110-0 s 2. Review and apprwW of tht gaality cauroi procedures for all code-required contrailed materials. 3. Be present at Intervals appropriate to ft stage of constructim to became, generally familiar m& the Progmss and Quality Of Me work and to determine, in general, if the work Is being performed in a manner cOnsistant with to Consbuction documem, PURSUANT TO SE"ON 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS R TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUIL INSP CTOR. UPON CCMPLETION OF THE WORK I SHALL SUBMIT A FINAL REPORT AS TO E SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUP e SUBSCRIBED AND SWORN TO BEFCRE ME THIS 7 DAY OF F �® a000 C. C� � SUSAN C.ELMORE,Notary Public NOTARY PUBLIC r MY COMMISSION EXPIRES MY Commission Expires March 25,2002