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Miscellaneous - 1459 Salem Street (2)
�� I � `� I Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Department Building 20, Suite 2035 1600 Osgood Street North Andover, MA 01845 RE: Insured: Steven & Naomi Najarian Property Address: 1468 Salem Street Company: Commerce Insurance Company Policy/Claim Number: BBCDCP, PAVX46 Date/Cause of Loss:' 1/4/2018, Pipe(s) Froze & Burst Our File Number: 35276-M Claim has been made involving loss, damage or destruction of the above captioned.p property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mike Peterson, Ext. 115 On this date, I caused copies of this Notice to-be--sent-to the persons named above at the addresses indicated above by First Cla Mail. r to J �� Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Cc: North Andover Health Department North Andover Fire Department Building,20, Suite 2035 795 Chickering Road 1600 Osgood Street North Andover, MA 01845 i North Andover, MA 01845 The Commerce Insurance CompanySA° MAPFRE Citation Insurance Com an SM P Y 11 Gore Road;Webster,Massachusetts 01570 INSURANCE 508.949.1500 1www.mapfreinsurance.com January 05, 2018 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 - �?.F.:- =O° r Ansi 1: c�r�M—N IATA.jARIANI/,NAC?MI-j- ATApIA?4T Property Address.: 1468 SALEM ST Policy#: BBCDCP Date of Loss: 01/04/2018 File#: PAVX46-MWXVP5 Claim has been made involvingloss damage,ge, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. ESTHER O'NEILL Telephone: (508)949-1500 Ext: 15388 Sr Claim Representative,Property Toll Free: 1-800-221-1605, Ext: 15388 On,this date, I cause copies of this notice to be sent to the persons indicated above, at the address above,by first class mail. January 05, 2018 J. 3 CIC 254 (Rev.4/95) MAIL M80 Date. ,!. " ... .6. ... .. '�i N°RTM pft .ao ,tip . !TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION as SACHUSES This certifies that . - . . . . . . . . . . . . A has permission for gas installation in the buildings of :' z . . . . . . . . . . . . . . . . . . . . at . `���! ��-- x -.��- ". , North Andover, Mass. Feer.. . . . Lic. No `1''. . . . . . . . . . . `~GAS_I NSP Check# / - r �$ux�:.a.., •,�..-�,.�-�.,k.:a..ar�v%�: .,a.......- ,..zw�r.;,..�,,,. �. -�,.,._..-.,.,,�.�.�.....:•. .*�-. A� _,.......mss._ .'2�t_r.�e1 -._•�:a,..� vc.;. MASSACHUSEM UNIFORMAPPUCATONFORPERWrTODO GASFIIT NG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations ���0 C.71e C—�/ • Permit# Amount$ Owner's Name ?/1/ vy zlk 7,41,f/ New Renovation Replacement Plans Submitted a m y C U E+ x z o x � H a o L o z H �a ar1l c a � z z ` w w w N z w F O z O z 3 a � .tea � a SUB-BASEM ENT BASEMENT 1ST. FL'O O R 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH. FLOOR 6TH . FLOOR 7TH. FLOOR ! 8TH. FLOOR (Print or type) Ch one:e: Certificate Installing Company , Name /y d/ /� fuoip. 69 — Address w/ � /T d Partner. usin Telephone Rrm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check on ji have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes,pleaa:ipdicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond w,. 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 1 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 perf9fted under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S to 9f Code and Ch 14 Pegol Laws. By: Signature of L tensed Plumber Or Gas Fitter Title lumber �� Cityfrown ® Gas Fitter License Number ffy M- er APPROVED(OFFICE USE ONLY) ® journeyman Date. .R - .. .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING A Io �,S$ACMUS� r'S This certifies that .,/ .... ............................. has permission to perform .e- - .. ,! <!� a ..................... wiring in the building of...... . . - ....(�.~ f; at... � :...., .......... :.^... ........................... ,North Andover,Mass. Fee .;J!..v .. Lic.No. �{: r` ........... .......... ......... .. — r y LECTRICALINSPECTOR k Check !t ___ 8 $ 61 i ` Commonwealth Of Massachusetts official Use Only Department of Fire ServicesPermit No. �'G�j Occupancy and Fee Checked - ` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL-WORK All work to be performed in accordance with the Massachusetts Electrical CodeO (PLEASE PRFNT EV INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the of Wires: By this application the undersigned g'ves notice of 's or her in to perform the ele pecttricOrwork des n ed below. Location(Street&Number) Owner or Tenant (9 ° Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes El No Purpose of Building / ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / volts Overhead l ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: 011 Completion o the ollowin table may be waived b the Inspect o Wires. No.of Recessed Luminaires No.of Ceil:Sus No.of Total p.(Paddle)Fans Transformers TVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above ln- o.o mergency ig g d. ❑ rnd. ❑ Batte Units — No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Tones 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 Waste Disposers Heat Pump Number ons KW No.of Self-Contained Totals: ..._.....___. ._..._....._.._.....__._._. No.of No.of M Detection/Alertin Devices Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security %stems: No.of Water No.of N No.of Devices or Equivalent Heat K W o.of Heaters Data W' Q:__ Ballasts . mmg' No.Hydromassage Bathtubs No.of Motors No.of Devices or E uivalent Total HP Telecommunications Wiring: OTHER: No.of Devices or E vivalent Estimated Value of E ectrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start Zf D Inspections to be requested in accordance with INSURANCE MEC Rule 10,and upon completion. om leti RAGE• P p on. . Unless waived by the owner,noermit the licensee Provides proof of liabili P for the performance of electrical work may issue unless ty insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ .(Spec' . I certify,under t pains and penalties of perju ) ry, that the in or anon on f this a Lica ' FIRM N PP tion is true and complete. f /1 r p Licensee: s ' s LIC.NO.: 2 p j® v� p i Signature applica ( °< LIC.NO.: i If ble, enter"exempt n the license number line.) Address: '✓ /s+c7 �!� Q- GLg S Bus.Tel.No.: {. *Per M.G.L c 147 s 57 6 ,security work requires Department of Public Safety"S"License: Alt.L cl.No.. OWNER'S,INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage required by,law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. i The Commonwealth of Massachusetts ki Department of Industrial Accidents Office of Investigations 'rt~ 600 Nlashington Street Boston, MA 02111 j www nzassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plambers A>Vl cant Information Please Print Legibly Name,(Business/Organization/Individual); p�fd7114 Address: i y eol,v 4kn� f !� City/State/Zip: 1, 6 r �} dam!S Phone#: . 5 -4'6 67 Ili S Are you an employer?Cheek.the appropriate box: I! Type of project(required): I.[] I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 F1 New construction I am a:sole proprietor or partner_ listed on the attached sheet.t 7. []Remodeling Ship and have no employees These sub-contractors have 8. []Demolition working for mei' any capacity, workers' comp.insurance. [No workers'comp.insurance 5. El We are a corporation and its g ❑Building addition �!aired I0. Electrical ] officers have exercised their ❑ repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs q ] .employees. [No workers' !i comp. insurance required_] I3.[].0ther Any applicant that checks bo)'#I must also fill out the section below showing them worketr'compensation policy information. t Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new affidavit indicating such. tCor►tractors'thatchack this box mustattached an additional sheer showing the name of the sub-contractors and their workers'camp"policy,information. 1 ant arra employer that is.providing workers'compensation insurance for my employees; Below is the policy and job site . nformatihn. ' Insuranee,Company Name: Policy 4 or Self-ins. Lie.#: Expiration Date: ; 4 Job Site Address: city/state/zip— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1, 500.00 and/or one-year imprisonment.,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her ' certify under the pains an penalties of perjury that the Oformadon provided above is true and coaxed Si tore:F Date. / d Phone k s'Q,�G/2 Y —A Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 6.Other 5. Plumbing Inspector ' 4 ; Contact:Person: Phone#: Information o and Instructions ons ` Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." Y An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more bf the'foregoing engaged in a joint enterprise,and includirng the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner.of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house .or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings`io the commonwealth for any .'applicant who has not produced acceptable evidence of compliance with the insurance'coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. IfanLLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also'be sure to sign and-date the affidavit. The affidavit should he returned to the city or town that the application for the permit or license is being requested,notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate dine. City or Town Officiais A Please be sure that the affidavit is coinplete 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 applicar►t 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'l:e. a dog license or permit to bum leaves etc.)said person is NOT.required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts li Department of Industrial: Accidents Office of Investigations 600 Washington Street Boston, MA 02111. Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7745 Revised 5-26-05 VAMmass.gov/dia Date .f &ORTIy - - - 0'<«•° .1tio TOWN OF NORTH ANDOVER osi PERMIT FOR PLUMBING 41 CHUS 1 This certifies that . . . . !. . `. . .13.1. .. . . . . . . . . . . . . . . . has permission to perform . . . f• • • . • • . • • • • • . . . . . . . . . plumbing in the buildings ok?H . . . . . . . . . . . . . at . . . . .S L.. .. . North Andover, Mass. Fee ?P�v . .Lic. No. )r0 . . . . . . . . PLUMBING IN PECTOR Check !/ 8120 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) ' NORTH ANDOVER,MASSACHUSETTS ©Gj / Date rn?k • Date Building Location Owners Name Permit#.. zo Amount Type of Occupancy New Renovation Replacement ® Plans Submitted Yes ❑ No n FIXTURES FCc � �l WW �" U P6 ►Z•r Z A, 0-4 Ci z a a O 3 A W A w E~ H x F x a d x o ° a a s o° x A a a 3 H a 3 x SLRBM BASE air 1E HJOCR M YLOCR 3MFLOCIR 41HHjOOR sfflH-OCIR 6M HfM - (Print or type) Check one: Certificate Installing Company Name U Lkl Corp Address Y%1 Ct lN LAA CC i D3 Partner. Business Telephone 6 4 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,'the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett e Plumbing Xle and Chapter 142 of the General Laws. By: 1gna ure o icense um er Type of Plumbing License Title CityfI own icense um er.?.00 �4 Master Journeyman ❑ APPROVED(oFFTcE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 KashingtO Street Boston, MA 02111 www-mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers A °Iicant Information Please Print Le-aibl Name (Business/OrgmiratioMndividual):—z—)�f VI G�--' i( Address: City/State/Zip: tool t /� !J•.y /1/l,� 03 U 3p_� Are you an employer?Check-the appropriate box: I �-I am a em Type of ro'edE r to P n' 1 t employer with 4 (required):'Iama ❑ general contractor and I employees(fWl and/or part-time).* have hi 6. []Naw construction hired 2.0 I am.a.sole proprietor.or partner. listed on the attached sheet.$ 7• ❑ Remodeiin ship and have no employees These sti&contractors . have 8. working for me in an capacity, 0 Demolition y capaci workers' comp.insurance. [No work=,comp. insurance 5. 0 We are a corporation and its g, ❑ Building addition req1 Am aed.] officers have exercised their i0.0 Electrical repairs or additions ;.. 3.❑ I am.a homeowner doing all work right of exemption per MGL I I.Q Plumbing myseIf.[No•workers'comp. c .IS repairs or additions P 2, §t(4),and we have no insurance.required]t employees. [No workers' 12❑ Roof repairs 1. comp. insurance required] 13-7 Other *Any appiicartf that checks bot:#l must also fill out the section below showing their workers''compensation policy information t Homeowners:who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit _ !Contractors that check this box Must amahed an - additiara.,heelmdi such. �''� thecatras cit. name of Yre sub and their workers'came.poli— ' I am an employer that is: ro ' g: p tnfomuion. p ,tndut workers con: ensmtion insurance for may.employee: Below is the policy and job site information, ll Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: ------------ Job Site Address: l wt d"'<(�✓� Of . —r City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL 6. 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 faun of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cerfd nd the pains and ofP e dory that the Provided armW in JF P �ded above is tru e and owed St tore: CZ%%6�•�.i-- ficial use only. Do not write in this area,to be comlpleted by city or town official City or Town;,, Permit/License# Issuing Authority(circle one): L Board of Health Z Building Department 3.City/Town Cierk 4. Electrical Inspector S.Plumbing Inspector 6.Other --------------- Contact Person- Phone 4: Information a nd Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, - express or implied,oral or written.„ An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trmstee of an individual,partnership,association or other legal entity,employing employees.*However the owner.of a dwelling house having not moreethan,thme aptastmentg slid who resides therein,or the occupant of the dwelling house of another who employs persons•to?do maiiten>nicc;construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because,of such.empioymeint be deemed to be an employer." MGI,chapter IS2,§25C(6.)alsa states that"eveiy,stete or-,local licensing agency shall withhold the issuance or renewal of a license or permit to,operate a business or to'construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required" Additionally, MGL chapter 152,§25C(7)states"Neither t3he commonwealth nor any of its political subdivisions shall enter;into any contract for the performaruee of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation.affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the N members or partners,are not required to carry workers'co-rnpensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also'be sure to sign and-date the affidavit The affidavit should be returned to the city or town that the.application for-the permit or license is being requested,not"the Department of Industrial Accidents. Should you have any.questions regau-ding the law or if you are required to obtain a workers' compensation policy,please call the Department at the naber listed below. Self_ing Wired c*rnnsen � ies ahnil id e.,r� self-insurane'e'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 rmit/lice!rtsg number which will be us .as a;b .ti Pe ,,- , e•, ference number.�In addition,an a iicant z b ,. PP that must submit multiple permit/license applications in any given year,rived anly submit dne 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'ttie affidavit that has been officially stamped or marked b the or town may be provided to the YY Y applicant as proof that valid affidavit is on file for futureermits or licenses. A new affidavit p 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. ;`� The Dep 's address,telephone and fax number: The Commonwemlth of Auf ache i6tts''�4 Department of Industrial Accidents Office of lnWestib$tions 600 Washington Street Boston, MA 0:2111 TeL#617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www-mass.gov/dia Dater/?./�.! ..... .. NORTH Of 3? '` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �9SSACHUSt r` This certifies that . .D.4f! . . �. Lr1.� . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . n. T-3 . . . . . . . . . . . . . . . . . . . . in the buildings of . . . 1 . moi+/�/��. . . . . . . . . . . . . . . . . . . . . . . at . . .����.�. .„S05'l. �v . .?;. . . . . North Andover Mass. Fee.o.2JJ.. Lic. No.1. a ° . . . GASINSPECTOR Check# `3 6840 2 MASSACHUSETTS UNIFORM APPLICATON FOR P ERMIIT TO DO GAS ffrn VG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building LegationsZ 5`� / Permit# Owner's Name ` Amount New ��G Cts Renovation � Replacement Plans Submitted ❑ " zzw . � C rn . .� F r- F a z r cC 0 w w a o � z H� w [- a t- rn z rz w w z d w z F w w x m W > a d m z p w z -� w SUB -BASEM ENT + o f U a aco 0 _ BASEM ENT aa 1ST. FLOOR 2ND , FLOOR 3RD , FLOOR 4TH . FL00'R 5TH . FLOOR 6TH . FLOOR 7TH , FLOOR. 8TH . FLOOIR (Print or type) Q ,/ ,/ Name vhn �/�-� f �/7' Check one: Certificate InstallingCom Address l �Ci� s T /iii pay Corp- Partner. Business j;,Pj1U11r d Name of.Licensed Plumber'or Gas Fitter Firm/Co. FINRANCE COVERAGE urrent liability Insurancr.poIicy or it's substantial equivalent Check one- If e checked yes, please indicate the type coverage by checking the appropriate box. No� nsurance policyOthere of ind tyP emni tyBond13 nsurance Waiver I. aware that the licensee does n_ ot_ hese the insuranceral Lawsand that my signature on this permit application waives this n uiree coverage required by Chapter 142 of the q menL of Owner or Owner's Agent Check one: t hereby certify that all of the wner details and information I have submitted(or entered)in a glint best of my knowledge and that all plumbing work and installations perford 13 med under Permit Issued for this lic comati pliance with all pertinent provisions of the Massachusetts State pp n are true and accurate to the Code and Ch r 142 of the Gender-dPLa Son will be in Title Signature of Licensed Plumber Or Gas Fitter 1:3 Plumber p lcity/Tci D Gas Fitter Icense umber Master _ APPROVED(OFFICE USE ONLY) Journeyman 4. I fie e.ommnsiweQlth of Miusachusettc Department e artrnent o a )lid P .f Industrial Accidents Office o Ircv .1` estce ations "'U", 600 600 Wash�o�on Street Soso c; M,4 02111 s.gov/dia Workers' Compensation Insurance Affidav'it' gwilders/Co AD Ilcaant Information ntmctors /Elect ' rac zanslP'Iwnbers Name.(Business/or _ p Q Please Print LeaibIV ganization/Inaividua(): /C. P7.'Y Address: f Aq4 CIty/State/Zip: e, jct/ /✓lf Q, Phone Are you an employer?Check the appropriate box: all a employer with _ 4. _ T ❑ I am ad ofProject em }o ees(fill] and/or art-ti )em .* have h-mesal contractor and I Type (required): P Y ( p .-d the sub-contractors .6• ❑ New construction 2.0 I am a sole proprietor a partner- listede to P ship and have no employees attached sheetern capacity. i 2• ❑ Rode}ing working forme in any e Sub-contractors have Thesworkers' 8. Demolition workers, [No workers' comp. insurance 5..❑ We are a comp. insurance.. required.] _ corporation and its 9. ❑ Building addifion of5c3.❑ I am'a homeowner doing all work ri ht of ext ve exercised.their }0:❑Electrical repay or additions • myself. [No.workers, comp. ptlon P,'MGL 11. P c. 152, § 1(4),and we have no ❑ plctmbmg repairs or additions rf, insurance required_] t em l0 124 P Y�-•s. [No workers' ❑ Roof repairs *Any applicant that checks box#1 mnstaiso fill out the section below P1--o ou2sttraI�Ce required] 13. ]Oth.r f r'IUnteOWller£WiIU Stli)tnli:t'ilis siildavil ifldicarill, L'iei'fire Wli'lg titzir workers,,compensa#jon policy Iniom7gt10Il. iContracrora that ch _ `oirg�'t='r� ecf:this oox musi ac=hed an additional sheet show] "1u hi-outSiae cUntraeiors roust su'omii a ntw rtr the name.of,the sub-cam„Mors and theft Ivor amda°ii inaimring I am mr.employer tha<is providirao workers'cory,er�:a> /cera`comp.policy information. information. oa i, nsurance for ng'employees. Below Insurance Company Name: is the pofiey and job site �/'� �CZ policy#or Self=.ins. Lir,. #: Expiration Date: Sob Site Address: Co�s�Z /��'! 6 / �d'�/�O�4 Attach a copy”of the workers, City/sute/zi • compensation policy declaration Q P .Failure to secure coverage as required under Section 25A of pabe(showictg the policy number and expiration date). fine up to S1;SOQ-00 and/or one-year imprisonment,as well MGL c. I52 can lead timposition of crm.o as civil penalties in the forme of a STOP WOR}�ID�jERal l es a fine � of up to.5250.00 a day against the violator. Be advised that a co of a Investigations Of the DIA for insurance coverage verification. of this statement may be foru'arded to the 'Office of t do hereby certifj, er thesins , P enaliies of perjurf1 zhaz the in or f mafion Si--nature: Pro' above is.True and correct Phone#: Qate: �C G p� Official use only. Do not write in this area, to be complexed by city or town o c ' ff ciaL City or Town: Issuin-Authority(circle one): Permit/License# I. Board of Health 2. Building Department 3. City/To�,s,n Clerk 4 Electrical I ii: Other aspector S. PiumbinQ b inspector Contract Person: Phone;`r: iniormanon and instructions Massachusetts General Laws chapter 152 requires all employers torovide workers' co e P compensation for thea employ..-es. Pursuant to this statute,an employee is defined.as"..'ver-y person in the service of another under any contract ofhire , express or implied oral or written." An employer is defined as`pan individual,partnership;as 5ocia6on, corporation or other legal entity,or any two ar more of the foregoing engaged in a joint enterprise,and inclurliri.g the legal representatives of a deceased employer,or the receiver!or trustee of an individual,partnership, associati on or other legal entity,employing employees. However the owner of a dwelling house having not more than.three ap 5,",- ents and who resides therein or the occupant of the ` dwelling house of another who employs pc_?son`s`t©r'"dnina int_nance,construction or repatr�work on such dwelling house or on the grounds or building`appurtenant thereto shall not because of such einipioyment\be\deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state a r local,iicenRag agency•shall withhold the issuance or w renewal af.a'iiceaseoT;permit to operate a business or to construct builaiitgs`in'the commonwealth for any t applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of-this chapter have been presented to the contractingauthorify.". Applicants Please fila out the workers'compensation affidavit compZ•etely,by checking the boxes that apply to your situation arid,if necessary,supply sub-contractor(s)name(s),address(es) and phone number(s)along with their c„-rtificate(s)of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members Por partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have_ employees, a policy is required_ Be advised that this affidavit maybe 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 reg,Tdirg the.lava, or if you are required to obtain a workers' comaensat}on policy,please call the Department at the n$znbor.listed below. Self insured companies should enter their self-insurance license:cumber on the appropriate line. . City or Town Oficial, Please be sure that the afndavif.is complete andprinted ieQrb}v The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appiicanL. Please be sure to fill in the permitlI}cense number�which.uvill le.used<as.a reference numb x, M m A. number In addition, an that must submit multiple petmit/liceri�e a plicatior►s in arty =ven year,necd only submit ant affidavit indicating n �current policy inforinati�on`(if necessary)and under"Job Site Add -ess"the applicant should write"all locations in (city or town)." A,copy of the affidavit that has been officially starnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit isl on file for future permits or Iicenses. A new affidavit must be filled out each year. Vrhere a home owner or citizen is obtaining a or permit not related to any business or commercial venture (i.e. a.dog license or permit to burnleaves etc.)said person is NOT required to complete this affidavit. The Officeof investigations would like to-thank you in advance for your.cooperation and should you have any questions, . please do not hesitate to give us a can. The D partinent'fs address,te}ephone and fay,number The CarnmonweaLith of Mas`cachus� Dcpartrnent of Llidushial Accidents. Office of LIIvestigatiord 600 Wash�ington Sheet Boston; MA X12111 Tel. 4 617-727-4900=-t 406 or 1-877 Mfi.SS.kFE Revised 5-26=05 Fay,4 617-7-7-7749 NN'u'u'.mass.gov/dia i jj N° 2604 Date.... ......................... TOWN OF NORTH ANDOVER e p PERMIT FOR WIRING .o fes' �I ,l ,SgACMUSEt This certifies that .... <... (. � u' -� ,r .............................. has permission to perform ..—,.<,U u '�? b'ryt. ... .� ....... ..... wiring in the building,of � at..... .. .......................................�..........,North Andover,Mass. Fee.�.I/) ...... Lic.No :%... . ` . ,; - �� ........................... ELECTRICAL INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Official Use Only Permit No. r S Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 'APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number_ 5e4,e;,Z1 5-7— Owner or TenantJ-#W I e-� /14- K 4A/ Owner's Address ° /�6 Sq'�r� cS 7 Is this permit in conjunction with a building permit Yes l No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps_ Voits Overhead �J" Undgrnd ❑ No,Of Meters New Service a Oct Amps / - *oa*o Voits Overhead Undgrnd ❑ No.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work coo 6G No.of Lighting Outlets No.of Hot fuse No.of Transformers Total KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators I(Vq No.of Receptacles OutletsNo.of Emergency Lighting No.of Oil Burners Bette Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone and No.of Ranges No of Air Cond Total No.of Detection Tons Initiating Devices Heat Total Total No.of Di osat No. Pumps .Tons KW No.of Sounding Devices No..of Dishwashers No./of Self Contained S ace/Area Heatin KW Detection/Sounding Devices No.of Dryers ❑ Municipal ❑ Other Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters,. KW Si ns Bailases g Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE, Pursuant to the requiremen6ts of Massachusetts General Laws I haA a current Liability Insurance Policy includina Completed Operations Coverage or its substantial equivalent(&-- NO = valid proof of same to the Offic = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box. ZIS RANCE = OND _ OTHER = (Please Specify) Estimated Value of Electrical Work$ /c��D (Expiration Date) Work to Start--7-=--,%-,7—00 Inspection Date Resquested Wt`// 4,/6,4. Rough Signed under the Penalties of perjury: Final FIRM NAME f//�vcs�Y �= nL�1��� LIC.NO. Lkensee Y K Signature LIC.NO. I Address Fb9,>X f,967 ,��`L�FJI=r�OLO r ✓'7�s Bus.Tel No. Alt Tel.No. 6——? 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. PERMITTEE $ I Location No.' Date NORTh TONIN OF NORTH ANDOVER O:,«Io : ,MO f s Certificate of Occupancy $ b''•°''<�' Building/Frame Permit Fee $ CHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � i 13690 .� Building Inspector (o .j TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ��,_.,",,,,.�K.,m�r`r£; :#y;a kk�.��� �'„ t,�3t- � "�,.��'.. ^w'� �' � �.��y `w -u �'� Y �" ''r' •�,.�,c^w9a p� BUILDING PERMIT NUMBER. / DATE ISSUED: O SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION i-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: I L-1 sA/ 10 } A/,/ Do vim.<- i /,y1 Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided d Z Flood 000ne normaton: 1.8 Sew 1 1.7 Water SopptyM.G.L.C.40. 34) Ifie� Disposal System: Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I 2.I Owner of Record W(C C �,L-I I C-� 4,e- ( . /.�tcl i S � ��� � SFi lE� �'� '"�� Az Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: :.x Name Print Address for Service: i Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number Address Signature Telephone Expiration Date ra 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Sr nature Tele hone SECTION 4-WORKERS COMPENSATION(NLG.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Si ned affidavit Attached Yes.......❑ No.......0 SECTION 5 Descri tion of Proposed Work check.alI applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify. Brief Description of Proposed Work: z . �X /,S— SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be s OI?FIC USE$ONLY � Completed b permit applicant u 1. Building (a) Building Permit Fee r D 6 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(8)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PEPMT as Owner/Authorized Agent of subject property 4011 Hereby authorize to act on My behal --all matters relative to work authorized by this building permit application. Si nature caner Dat SECTIO 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS 1 2ND 3 SPAN : DIMENSIONS OF SILLS DIWNSIONS OF POSTS DRvIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t 1 FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANTA hJ i C SICA y PHONE ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER STREET S le/YJ STREET NUMBER / OFFICIAL USE ONLY j` 1s��z ........:........................... . .. ................. RECONIMENDATIONS OF TOWN AGENTS �ai-2- 4.I_wo�NET NOME malmossamummonamommsoommummommensommossomenmEamonsomensonsommmmse e�/ ^ t DATE APPROVED Ok CONS RVATION ADMINISTRATOR DATE REJECTED COMMENTS . C> W P_ ) DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD��INSPECTOR HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS Ke eV lea 5 Ct 60 a 76'-6M t J' rl c✓ ��' �i0 e� � �%/ PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT' DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE R•,� MORTGAGE INSPECTION PLAN NORTHERN ASSOCIATES, INC. 342 v.muly smscr ANDOVER MA 01810 rEL_ (97B) 474-4410 FAX (976) 474-5067 MOR MIX)R!JANICE L MCKM AND MICHAEL S LEWIS DEM-.1136/124 I=ION:1468 SALEM STREET PLM:5059 CWY STATE:N'ANDOVER,MA SC!►IE:1=50' .DATE-5/4/95 J014:99/3721 ...-. 191.70' 30.01 I.OT 3 44,190 sf± r a N r♦ 2 STY i WOOD 0 d FQR] #1468 rl • ;n o o � �.a 31.4:?' 144.57' SALEM STREET - CERTIFIED TO:FIRST FSS &W FSB norCt riiim nert9a94 Inapeeclon was prepared this sort e e Ina actio.vas sjaei tieeliy [or worcgege parposm only tnd g 9 D pa IWIthled Lr eecorAmree I with the 7tehnieel Sterxleror- Im•lwlretrye baso 1e not [e ba relied upon oda feesnor property �y114 OF Ins( bens ac adopted by toe natcechutetts oaere of lint euroey, used for recording, preparing dead v oeglntretlon Of 1?oteavlonn) Wsalnecre and Land 'a.**ipeivoC, or construction, poicaroorC ware e]' •-urveyera 25V Gnn iei• ec. tulfdinv loeacian and off...a ere y turthor•tote mot In my p.nlweelonnl apinlnn that pproxinately loosed en ant ground end A• the strictures Chelan eentol•e vlth the lesel renin Iror ltonln art dlreua creel flcelly for tening eecrrelnetion TESTA dtnantienel setback rogolrenontc at the tlno of conctractlan wa only anO erC not to be Irsld to*ateblirh property ere cxenpt under prowls lone o[11.t.L_ U1. sO-!�Seo. 7. lkrte. Tho ntttera than bar— sit anted on o. 19667 ollanc-[wtnlsnee in/oreaclan.ens nay be tubieoc 4e 60 ,Qt Wt rraparty/Ilouze is not ]ll a Flood Hazard. to former out-oelel, tot)nge, eeaesent.e end rlghcc 1 TRP �1" of lad snd otber setters of record and D 2.rropsrty/Ilauoo is in b flood hazard liras. y, ". A1lrt).e Cyd $I � er otMr rl7qnm. Ilarehern ACaodetea. ]ne. ualdas ne 'CitLog D].]ntorwsion Ss insuffielebs to deeerwine respwltlblll ty herein to the land Owner or aceapent. Q Flood (lltard. etepto ne reebwlNlbility ter eanrget reeulCl nq troo Bald rlood hazard detetwincd tr sareledX rabienea by anyone other than the oaid tortgevee sea Ice achene •I.SursTloe Rate Map Pone!e. Mtec L Ia connection with its proposed aartgage cinenclntto Goad Wrtgetar• veto 6/'JJt��! Zane I NORTH a Andover 0 O LA dover, Mass., o Z- COCMICMEw ICK 7� ADRATE D P'1' y S BOARD OF HEALTH Food/Kitchen Septic System , PERMIT T . .C=02=b BUILDING INSPECTOR THIS CERTIFIES THAT...4..a �.A�.... ........... ....�' .�'............A...... ...... ........ � � Foundation - 68 has permission to erect....z4 ®® ... buildings on .. S.A.11 ....... ...................... Rough to be occupied as...AA.#-w4! �v vm ® 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. In ® ®6 P i PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. QM, 9:1W � Rough o T&e Final PERMIT EXPIRES IN 6 MONTHS Re 0vks:*4 S � ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST� � �+ � � Rough r� Gy► ............... ........ .... .................................................................... ......R.. Service TO BUILDING INSPEC. Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on , T the Premises — Do Not Remove Final No Lathing or Dry Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Street No. SEE REVERSE SIDE smoke Det. NORT1y ]. "own 4 ;G ndover . p 1.<.. a M ® ® a h rm over, ass., 16 T O �- l A COCMICMEWICK V A�RATEO P. ,�5 11 S BOARD OF HEALTH ER Food/Kitchen Septic System �s W*+Y BUILDING INSPECTOR THIS CERTIFIES THAT... .. 0. .... ..�@. ...........e...... ...... ®.. ..... ................ Foundation has permission to erect....I.4` .... .i........... buildings on .. . ........ .A.A.............. ...................... Rough to be occupied as... ......... 6 .�o vm 4 70 o/ im poop yah 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. M ® ® if PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ,e�" ® Rough M�1 0 76°" PFinal PERMIT EXPIRES IN 6 MONTHS 0 ® ��® � UNLESS CONSTRUCTION T S ELECTRICAL INSPECTOR ro Pe ��v � Rough �� •ts ............... ........ .... .............................................................................. 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 ,4 Street No. SEE REVERSE SIDE smoke Det. 241 0 Date..... #• HOR711 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SAC14U This certifies that ..........Q .....ffc,—u. .. .......................... ......... has permission to perform ... 4 ............................................................. wiring in the building of........ .......... ........................... atlY.C.r......� ......5.t .... . ..............., North Andov r/ ass. M Fee...b .... Lic.No. ........... ................. ........ ELECTRICAL INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer .;ate\• , 77IBC0A&10AWE4LTH0FAi4ma1U,SEM Office Use only I DEPART g W 0FPUBUCSAF-7Y PC7rnit No. / _ = BOAROOFFMPREVF1r770NREGM770NN5270MIZ-,,1 Occupancy&Fees Checked APPIICATTONFORMUPT TOPERFORMELE=CAL 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 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. AP PARCEL Location(Street&Number) /r/O/ R -S 2-4 ,q Owner or Tenant lj�A//.S /�'G Owner's Address Is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box) Purpose of Building S i���l -'!ew /)-,/ Utility Authorization No. Existing Service o Amps./ / c7 Volts Overhead O Underground No. of Meters New Sc4vice � Amps/,;26 l,?YJ Volts Overhead � Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 7n.C-rP-dam'- PA/& Si`ZC J �40 G� No,of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above IM Below Generators KVA ground L,,Qhj ground No.of Receptacle Outlets No.of Oil Burets No.of Emergency Lighting Battery Units No.of Switch Outicts No.of Gas Burn 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 Deteciion/Sounding Devices A No.of Dryers Heating Devices KW Local Municipal Other Connections ®. No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER' �K S�c // 02 �/j.t//L G-I ✓' J3�0 7�00/%lS hlst=xeCo Ptaa tothetac}mattads�C�alaalIaws IhawaalQ=lmbtldyhma=Pobyi<dxh%Carvice ' CowrdWcritsst>=ale4uvalent YES ® NO Ibaheader aodvaiidprofofsmmtotheCffim YES M NO a Ifyauhavednd®dYES,pledsemdatdre peofamrwbyd=kngthe INSURANCE BOND CJII-IIR � tease SPAY) ExoirdtiafIDme EstirnatadValueofE1ccbcal Weds$ WakfDSW J.S- h=xfimDateRetjc*d Rough Fmd Signe m±rtTrPtmi&sofpetjt><y: FIRMNAME I�oa>seNo L�l- ao9og Lioa>see 1'AJGL�/,/J~ A, 2&tJSignahue ,.Ib BtwmTeLNa 978 -776—,.r 7-,1"9 Addess- POSex S�6 7 OQ 60 D" j id s AILTUNa 9,>L? OWNER'SR4SUTANCEWAIVFR,Iamaw&ediattbel=wdmmthsiNedrmmz=oAaaWcr&sksontole4makriasregmedbyMasadmsett cvrnalLaws aadtha2rrrysigrfatuaernthispan�rtapp)xa0rnwaiwsihistacVmartart (Please check one) Owner Agent `l Telephone No. PERMIT FEE$ Signature ot Owner or Agent '� . '� 1; � '� .�` •.. ,� L ,� �f �. � �. /fix � � � � � 1 ,, � �� � 4� v Y ,, .; �� . �' I� 1 - - 3 21 Date.. .:.�.S. .. NORTH TOWN OF NORTH ANDOVER a pf Sao ,e AtiO c� _ p� PERMIT FOR GAS INSTALLATION 4 i F 9 i SSACHUSEtAh _—mss certifies that . ./. :1y.s 11rfi`a. . . ! �!"�.�,�?� .�'! �. . . has permission for gas installation .P-1,3.i' .5. . . . .?. -�':�v /7 �� c> in the buildings of . .�`. . . .�`. . . . . . . . /. . . . . . . . . . . . . . . . . . . at . .P` .'f t' .,F . . . �. -. . .� F , North Andover, Mass. . . . �: Fee. r!�?.,.:�. . Lic. No.. .�''/.��.�. . . . . (GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer a i s MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Awd oy&r-- ,MA Date to 419 Receipt# Permit# 3 ( Y Building Location OwneesNameZ Map: Lot: Zone: Typeof Occupancy New O Renovation ❑ Replacement❑ Plans Submitted: Yes❑ No ❑ Fee: H 0 Y W ¢ y 2 A N N N U f,. Q v W Lt N O K 0 t1 O w ¢ O V S N Z -' ¢ W > m z 2 , ¢ p a 0 W a ¢ c n 0 W C x m W Q = Z o N 0 > W N ¢ C7 V W N W Q K - F W 1- 2 W W N J z Q = ¢ � L7 ¢ W W U y � Z J h- Z F- W W O > LL F- W J H W Q W > S W M Z Q ¢ Q Q O O W _ O W - CC I 2 O 0 = LL 3 C 0 -1 U Q > O O. N O s { SUB-BSMT. BASEMENT e\ 1ST FLOOR 2ND FLOOR Q 3RD FLOOR 4TH FLOOR Q 5TH FLOOR i 61. ' 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name )�AS�y:rn ?rrj2c,-nr- -�rrii� , iy7iC Checkone: Certificate Address i,31• U30 1-C-t- !3�- -D cs n v t=r-3 Y11 rA Corporation EstimateValueof Work. ❑ Partnership Business Telephone li 11- '100 - 3 ;L a -6 (� ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter WI!tlt n 'fir-V% CLC-05Y1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 12111' ii No ❑ If you have checked,ygs, please indicate the type coverage by checking the appropriate box. II A liability insurance policy Nr 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. Checkone: Owner Agent❑ Signature of Owner or Owners 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 underthe permitissued for this application w compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of they I aws. By Type of License: r�® L Plumber Signature of Licensed Plumber or Gas Fitter Title Gasfitter Master License Number cf' City/Town Journeyman APPROVED (OFFICE USE ONLY) i i i , - BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE , NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME S TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. a 9 PERMIT GRANTED . ti DATE 19 GAS INSPECTOR