Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #743 - 27 ABBY LANE 5/21/2010
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: `y IMPORTANT: Applicant must complete all items on this page LOCATION - r ," L Print r PROPERTY OWNER!?V- Print MAP 210_.PARCEL: ZONING DISTRICT: Historic District Machine Shop Village yes n ves n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential w Buildin One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other SeWell floodplain Wetlands Watershed District ater/Sewer DESCRIPTION OF WORK TO BE PREFORMED: CA�aaNa I U k ( 2 OWNER: Name: Address: CONTRACTOR 'Name: Address: e Type oar Print Clearly) K \r) fir- Phone: Arlo J J4(- vvv\ U 1 S e ma - Supervisor's Construction License: Exp. Date: Home Improvement License: _ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ it FEE: $_ / 6D Check No.: 30 Receipt No.: L 31 1 NOTE: Persons contracting w' 1 unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of .contractor Location No. Date Z� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Q Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1�) "34D 231 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM /�' Jl� C.� S/��C✓� s���/. DATE REJECTED DATE APP .OVED PLANNING &DEVELOPMENT 7 COMMENTS ><ONSERVATION COMMENTS r HEALTH Reviewed on Signature Reviewed on � I I I I J-0 Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 O FIRE DEPARTMENT - Temp Dumpster on site yes -no— Located at 124 Main Street Fire Department signature/date Comm Street 0 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ( W S �— ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA – (For department use) ❑ Notified for pickup - Date .......... . ............... .... _... ..... _...... _.... _............ ..... ................ _................ .................................. _......................... ........ ....... _....... ................ ................ ........ ...................... ....... ........ ........ ......_._................... _......................... ............................ ...... ........... _................. _.._._......... ................. ................ ........ ....... Doc.Building Permit Revised 2010 I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy. Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 dlI S h W Cd A W aG 0 W° C/) o U) U z z Cd a w° a U �' w w a _ a w rZ w' O_ N p U w ' `° w . z 8 + LLJ z CL J O 9 i U 0 O 4-1 co CD co L O Z COD. O H o c co cm Ca Q OMA co �MM EMM W W CD CD L O� C O O � O M o a C Ca h CD cc ev = -5.0 c. o co C z a 9-0 ca C.3 c c — ' c COD U) LLI U) W W 19 W N w c o m c o � O_ N C V V O. C O O C O m ECDa C oo. N O 4! cO c C o.:r N W ' O m N V : m o `� �c a m = C ' N R N m y mo N m m Z_„ O C h Q ams CDom CC. z C C O H CD = N O C = m m 3 CL � W G y z t� o �- c eo 5 uj .E � v o, V m O �.`� C N 2 W CD = H Z w arm J O 9 i U 0 O 4-1 co CD co L O Z COD. O H o c co cm Ca Q OMA co �MM EMM W W CD CD L O� C O O � O M o a C Ca h CD cc ev = -5.0 c. o co C z a 9-0 ca C.3 c c — ' c COD U) LLI U) W W 19 W N w NORTH TOWN OF NORTH ANDOVER OFFICE OF - BUILDING DEPARTMENT L �+ 1600 Osgood Street Building 20, Suite 2-36 n North Andover, Massachusetts 01845 Gerald A. Brown Inspector of Buildings HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number c�� II 1Strreet Address G� C� HOMEOWNER C h n J-F�G9P� I r l nr Cs I S D 363 Name Home Phone Work Phone PRESENT MAILING ADDRESS (/ Telephone (978) 688-9545 Fax (978)688-9542 Map/Lot City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirement that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 689-9540 PLANNING 689-9535 9 F s k 9 F i i r R 1 9 .s� o _. T J Q The Commonwealth of Massachusetts Department o f £radustz ial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Workers' Compensation Insurance Affidavit: Buiide s/Contracto 3pLcant Information rs/Electric' sans/Plumbers Name (Business/Organization/Individual): Address: M City/State/Zip: �. A VYjl Phone#: (�� Are you an employer? Check the appropriate box: L ❑ I am a employer with�_ 4. El am a general contractor 2. ❑employees (full and/or part-time).* I am a sole and I have hired the sub -contractors proprietor or partner_ ship and have no employees listed on the attached sheet t worlang for me in any capacity.workers These sub -contractors have cam insurance. urance. [No workers' Comp, incranCe 5. ❑ We are a corporation ] and its officers have exercised their <!ed 3 a homeowner doing all work right of exemption per MGL Myself [No workers' comp. c. 152, § 1(4), and we have insurance required_] t no e„S, em to P Y " [No workers' comp. ins>sran Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs ce regwred ] I 13•7 Other -y ^VFic n: Lhsi ��^? box.�l mus! ,so uu oet tee section ee _ ' Fwners wno submit this affidavit indicating the; are dog dl •.;+irk and �..•wetyws' comr,...s�cc •,,.�.,,.....r 'ContractIomeoors that cbwk �' then hire outside coattacto s f tim submit a new affidavit inti; sting such. �„ts box mtut attached an additioaal sheet showing the name of the sub -contractors and their wnrk,..c,......_ __�__ ` cmpeoyer tnat is providing workers' compensation insurance or m e ,,.TUU. information, f y mployees Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation policy declaration pave (showing num Failure to secure coverage as required under Section 2 p ne showing ger and expiration date). fine up to $1,500.00 and/or one-year imprisonment, ass well asMGvd penalties the ad tform e of a STOP WORK ORDER and imposition of cruninal penalties of a a fine of up to $250.00 a day against the violator. Be advised that a copy of this stattment may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify n th pains and penalties of perjury thczt the information provided above is true and correct WAN Official use only. Do not write in this area, to be completed by citj, 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 6. Other b Inspector Contact Person: Phone r: Information an- d 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 Iegal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association Ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartr,,Lents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintcmance, construction or repair work on such dwelling house or on the grounds or bufiding 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 withbold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work um-t:il 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' comp enation 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 stare to sign and date the affidavit. The affidavit should be returned to the city or town that the anpilicauou for the permit o7 12Ce^ce :4 being r=ested, not the Department. of Industrial Accidents. Should you have any questions regarding the taw or Lf you a e required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitilicense 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 afndamt 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 bum leaves etc.) said person is NOT required to complete this affidavit_ The Office of Investigations would hke to than 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.andfax..number.._ Tice Commonwealth of Massachusetts Dgmrtment of Industrial Accidents Office of Investigations 600 W ashingtan Street Boston, MA 02111 Tel. 4 617-727-4900 e3, -t 4016 or 1-9 7 7-MASSAFE Revised 5-26-05 Fat. # 617-727-7749 umru7.mass.-gov/dia. O3.52 Dated. . . .. .. /. I ........ NORTp 6�4 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING US This certifies that .....Ln 41,�-d S-vdvo� ................................................................................ has permission to performel." ... wiring in the building of ll*�4 ...... ............................................. ............ No Andover Andover FeeNo. . ..... Lic. ..... ...... Z E�ICAL INSPE R .. ... Check # fpr?7 - — Commonwealth of Massachusetts Official Use Only •1Permit No. / 32 2, Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod (MEC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE MA ALL INFORTION) Date: 1: / N / i 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) 0 _-711%� e c.l LA -(— Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Xr (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service'TW Amps 1 ?,rl �Z`fy Volts Overhead ❑ Undgrd New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Lh S7q I G`*/F-� c �.�-Ur►S %rr ScvdzGll Completion of the ollowing table may be waived by the In ector o 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 Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ........................................................... Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Municipal Ll [I 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: Estimated Value of lectrical Work: Sidc), Attach additional detail if desired, or as required by the Inspector of Wires. v (When required by municipal policy.) Work to Start: j Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERA E: 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 Pf BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of erjury, that the information on this application is true and complete. FIRM NAME:®n�eG� /G' v 1 I1�'�N1 � LIC. NO.: Licensee: Ieyno,-u( 19 5d116L v^ Signature LIC. NO.: (If applicable, enter "exempt" in the license nurriber line.) Bus. Tel. No.iq'r'if g!5=' Address: /Yla',ria' Ta D/ lt%Gb��'�i t l , ^/-' OJ4 3d Alt. Tel. No. *Per M.G.L c. 147, s. 5"-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 Owner/Agent Signature Telephone No. PERMIT FEE. $ T 5 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): L"gona'-d le SC/( 1("Ct", Address: 2 /1'1&9 hR L 65 34' City/State/Zip: tot vt' 4;df� 3Q Phone #: g7e6 — °fi i S —6`7/ 6 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. U21 am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition IO.KI—Electrical repairs or additions I LEI 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 171161+1 _ Insurance Company Name: -�y Policy # or Self -ins. Lic. #: Wo Lljj 2-7 Expiration Date: Job Site Address: ':2:z .Ab�fT 4 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert un er the pains a�n penalties ofperjury that the information provided above is true and correct. SilZnature: //A����G/ 9./,l�/ _ Date: 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 #: BUILDING PERMIT FrEvn l ry O�t.�D TOWN OF NORTH ANDOVER 0 A APPLICATION FOR PLAN EXAMINATION Permit NO: (000 Date Received ATED PP``gy �SSACH�15�� Date Issued: i �P l IMPORTANT: Applicant must complete all items on this Daae LOCATION G- ice't5` j 1, A-IA9 J. 14 &Amex— 0 [64-_S _ PrintPROPERTY OWNER__ G � S ! tq{ fO Print MAP 210 4J 4 PARCEL � � ZONING DISTRICT: Historic District yes no b Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer utbUKIF I IUN OF WUKK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: (f -`4(Z tS k1) 114 Phone: gnril-1s1�)Go-Q Address: 2� A L'e`i L&k4 E CONTRACTOR Name:--'-'-` 0aiLA Address: -' Supervisor's Construction License: Exp. Date: Home Improvement License:10 . <�I-Z,4-- Exp. Date: -7 J l"7 r/ t 0 ARCH ITECT/ENGINEER'1 � i^'td ' /JA Kew Phone: 1,0-S - Address Nho Reg. No* 3 3 FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $_ 673 ----- FEE: $ Check No.: �✓r� Receipt No.: �2 2 5'/a NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of -co-- Location i No. Date ` NaRT� TOWN OF NORTH ANDOVER � OL 9 Certificate of Occupancy $ Building/Frame Permit Fee $— ACMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 229'10 • Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales t - Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS�6�/ CONSERVATION Reviewed on Signature COMMENTS l o c) HEALTH Reviewed on Signature COMMENTS . Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: t_ocateo 664 Us ooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 MainStreet Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) r lle�g�l �r ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 No Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 L_1 00,00 PROPOSED POOL LOCATION CLIENT: CHRISTOPHER KING THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: 27 ABBY LANE, NORTH ANDOVER SCALE: I" = 60' DA TE: 4/6/10 ZONING DISTRICT R -Z MIN. AREA = 21,780 S.F. MIN. LOT WIDTH = 100' MIN. FRONTAGE = 100' MIN. FRONT SETBACK = 20' MIN. SIDE SETBACK* = 20' MIN. REAR SETBACK = 20' (* - THE STRUCTURE MAY BE PLACED UPON A SIDE LOT LINE WITHOUT A SIDE SETBACK, PROVIDED THAT THE ADJACENT LOT TO WHICH THE ZERO SETBACK IS LOCATED HAS THE REQUIRED SIDE YARD SETBACK.) CHRISTIANSEN;;, SERGI PROFESSIO AL EYORS NGINEERS LAND160 SUMMER ST. HAV£RHILL,MA. 01830 TEL. 978-373-0310 @2010 BY CHRISTIANSEN & SERGI INC. 2vlHOFN SS MICHAEL OR J. m SERGI m \0 No.33191 ESSP:O� E suRNPE:-� DRAWING N0. 97066010 0 F=4 E !�l h as it �¢ x w 0 A O m u wo N n U) z 0 C o m w w 'C U cd a w 0 w —co w x w M W o C2 cii w' o U a a: cts w a W m o cn o v/i o c w : o c i ccO ti O cj C.3 CL c cc ev m c :off CD E a Vo ts CD O C, �+ �0 h Eso 3 o m - Ocw rya Cm c 3 N m �� 4Q H O E o t nL � y m � c y Q mC tome mZ = m m3 F- ca Oma~ W c O+=�+�t LL B g -M .. N! C.= cc. c O w W E ca 'D v cm C) m m ._ CO3 C. m? o:o = A C',N •� s C.� m N Z r.+ N O i H c cm 0 CD m OI C m `o cm c N m t 0 Z co CD :T co 0 CD O Z CD O y G C O cm I 0 coca H m m •co O O d. -v � � L tC O d 0. a c c �� v J .� CA C.3 CD V y O C a C c Cos II�w Y/ LLI N W W 19 W U) Lit - 22.4' zomw lalS icr R--2 MA AWA - 2t, M S.F. AK LOT WlDTM = JW" AAK FAiG A4W r 1010' AW AWW SfMCK = 20' AM SW SErM4CX+ ic 20' R ASM. !NEAR SrFS" = 2Q' FM STRl1iC1[ W W r BE MACED LMM A SLOE LOr LIM *7PAWr A SIDE 3ETRIMM MVM THAT TME ADJOCIW LOr TO fl?KW "K MO SEIRWIr /3 LW -470 NAS YW REO Rll M SM rARD SURAM) fOUNDATIDN LOCATION PLAN CLAW: MOM AN OM R<r r w5 cEwnFVA MN R4 MW AND LJ%#= W ?W AWME LxIE;VT, LOCd7AXW 27 AMY MINE, &=M ANDOVER SCALL-• t' = OD' DAM 418106 APPMUM ��" �OW ns (TAW calprAmm ago mw comma aw olma a OWL eq► s yam n nrf 0AW fW Arr !�f�asr OMW MW VMr ernNs APOW.MM WM nff �r� raruaaw of a,esTarsrr aaw , CM air& --M" as quo AW UNUffolMarlrroU & sof TAW M A OROMME rr fiaav cmw+o� � a m maw a my�- CHRISRANSM & SERGI VIM VA� Sr. MSYIES AAL #I= M Ars-in-fat a •r ammmuffm t Am ae ORAWNG N0. 47066010 22.41 _ peey �,NE T.O.F. a-223.5' FOUNDA TION LOCATION PLAN CLIEAIT: MOM AND0M 14<Y TM CUT7f7l^A MN Lt A" AND L!/M LOCAllom 27 AAr LAIN ApMM ApioOVER SCALL- !- = M' VA1L 4119106 zoivAw D►S )cr R--1 ;Way ARBA - 21.7M &A. WL Lot OWN = 100' AOL FRWA" is FDO' UK FlMr StMCK = 20' MA SIDE S! rAWCA** x 20' • UK REAR SITAWrK - 30' (* - rw ,1RlenARE W r K PLACED WIM A SIDE LCT LM M7MUr A SIDE M WNCH "ff 2EMr SEM CX 5 LOCATED HAS 111E REMOM SLOE rARD SMOCK) aawr nwr "w P wr smxaw scow cow=w v of lammoI1m smear or w Ld" APPKCM f � Ar -UM w AMM 0p4 eOMtlwMM An mff� $mow me In nM 8MMM dMWA Off Ms vm AT nE 0" nar my olMV= 0"M MWM VW AVMMM AMpW.MM MM AE MMlf�1 rina kw dr 7 t sm #a ar nem mmI a Ai aarfMNpIn p wmn Cfw or & MW Mc AIS AW M UNNOMM UW R MM TAW M ACA4 wMer FW 4TAWRMW aW an nM AMM df AW MW- CHRIVIA1VSEN &SERGI Wow w omwn mm t no me DRAWING NO 970660 i o Zai North Andover MIMAP 27 Abby Lane March 29, 2010 38.0-0040 / 065.0- 89 / Horizontal Dalum: MA Stateplane Coordinate System, Datum NAD33, / 065.0-0290,; / 065.0-022 1 065.0.0291 I Valley Planning Commission (MVPC) using data provided by the Town of Roads Roads / North Andover. Additional data provided by the Executive Office of ! /rya• /�ytS,, /// 06 5.0-0292 ,r �u I 3 L for planning purposes only. It may not be adequate for legal boundary - Trails 0 MVPC Boundary O -• -' to 9 deOnlUon or regulatory Interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING c / 2l. 065.0-0293 •, 065.0-0293 THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY 0 Paroas • i i • o ,� 4 OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Hydrographic Features .y;^oe+�eD ��S�g THIS INFORMATION 065.0-0024 SSACMUSF ! 065.0-0294 `y °tt "jV / t' r• 06.5.0-0288 065.0-0295 956,• 100• � 100' 0650-0287 065.0-0284 065.0-0285 !� "� 065.0-009;2: '_"•.._:. _... � ..: - . 065.0.0286 • -- _ 'r .:.:4. 1q� ,. aUt..':::::' •�llt . ' : •.. alt..:'.'::: R .I, � 038.0-0042 ., ..,;p ♦ b= / , �• ...:• •`.q:;.. ..: ...:• .. zj /// ♦ o � / -- =• - . :-- :. - ( 10?.A-0234 d, I, 038.0-0334 038.0-0170 107.A-0232 — Reil Line Interstates Horizontal Dalum: MA Stateplane Coordinate System, Datum NAD33, — Interstate — MajorRoads Meters Data Sources: The data forthls map was produced by Merrimack NORTH Valley Planning Commission (MVPC) using data provided by the Town of Roads Roads Ot q r North Andover. Additional data provided by the Executive Office of L7, Easementsr s`eO ee< awe 00 Environmental Affainal assGIS, The Information depleted on this map Is 3 L for planning purposes only. It may not be adequate for legal boundary - Trails 0 MVPC Boundary O -• -' to 9 deOnlUon or regulatory Interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING 0 Municipal Boundary ♦< • THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY 0 Paroas • i i • o ,� 4 OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Hydrographic Features .y;^oe+�eD ��S�g THIS INFORMATION Streams - v Wetlands . Exempt Lands 1" = 107 ft ^�° SSACMUSF A— Y �Lory r North Andover MIMAP 27 Abby Lane March 29, 2010 ' -028 �,1 41b SE 04 41 Interstates Interstate — Ma)or Roads Roads Ci Easements 0 MVPC Boundary I7 Parcels 1" = 107 ft .{�. <.� e: C: 065.0-0286 Av '+ 06.5.0-0293" ✓/ , �5.0-0291 u y1r 'A' �1 - ` 295 ` a Horizontal Datum: MA Stateplane Coordlnats System, Datum NAD83, Maters Data Sources: The data for this map was produced by Merrimack Valley Planning Commisslon (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MaseGIS. The Information depicted on this map Is for planning purposes only. It may not be adequate for legal boundary definition or regulatory Interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION _ tr 41 Interstates Interstate — Ma)or Roads Roads Ci Easements 0 MVPC Boundary I7 Parcels 1" = 107 ft .{�. <.� e: C: 065.0-0286 Av '+ 06.5.0-0293" ✓/ , �5.0-0291 u y1r 'A' �1 - ` 295 ` a Horizontal Datum: MA Stateplane Coordlnats System, Datum NAD83, Maters Data Sources: The data for this map was produced by Merrimack Valley Planning Commisslon (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MaseGIS. The Information depicted on this map Is for planning purposes only. It may not be adequate for legal boundary definition or regulatory Interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION The Commonwealth of Massachusetts Department of Industrial Accidents Office of £nvestigations 600 Washington Street Boston, MA 02111 N79%, mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Dplicant Informatinn Name (Business/Organization/Indi,)idual): Address:—:t '� �,d„m.6 _,e� City/State/Zip: 0 V� Phone #: <i>'M -G4-q Jao �-o Are you an employer? Check the appropriate box: 1 WL I am a employer with 150 4. ❑ I am a general contractor employees (full and/or part-time).* 2. ❑ I am a sole proprietor or and I have hired the sub -contractors listed partner- on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ lam a homeowner doing officers have exercised their all work myself. [No workers' comp. right of exemption per MGL C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' Pomp, insurance required_] `° "}' applicant that chi's _1. must also iiL out t e se, -to, helov: hoe, 1 Id �.eir 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 I3.gOther?qa orneowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Iam an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:�16AW_q lc� Policy # or Self -ins. Lic. #: � � q -C' p. t .Z© ( t Ex iration Date: Sob Site Address: �(g'2¢- City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby c9*7 underai d penalties of perjury that the information provided �above isitrue and co»ect - .. 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): L Board of Health 2. Building Department 3. CitY/Town 6. Other Contact Person: M Clerk 4. Electrical Inspector 5. Plumbing Inspector ft Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the. performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with, no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be. returned to the city or town that the application 61- the permait or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials , Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a homeowner 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 Department's address, telephone and fax number. The Commonwealth. of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-72.7-4900 east 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5 -26 -OS unAm1,mass__gov/dia ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE 03/24/2010) PRODUCER (603)432-3666 FAX (603)432-6076 Lakeside Insurance Agency, Inc. Three Wall Street Windham, NH 03087 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED South Shore Gunite Pool & Spa, Inc. 7 Progress Avenue Chelmsford, MA 01824-3606 INSURERA: National Fire 20478 INSURERB: Valley Forge 20508 INSURERC: Everest National Insurance Co INSURER D: INSURER E: ' COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD*L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE (MMIDDNYI POLICY EXPIRATIONDATE LIMITS GENERAL LIABILITY INS4013391907 04/01/2010 04/01/2011 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,00 CLAIMS MADE rX ] OCCUR MED EXP (Any one person) S 5,00 A PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,001 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2,000,000 POLICY PROECT LOC J AUTOMOBILE LIABILITY SAP4013391888 04/01/2010 04/01/2011 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) B BODILY INJURY $ HIRED AUTOS NON-OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY 7101000110091 04/01/2010 04/01/2011 EACH OCCURRENCE $ 5,000,000 X OCCUR FiCLAIMS MADE AGGREGATE $ 5,000,000 C $ $ DEDUCTIBLE X RETENTION $ $ WORKERS COMPENSATION AND WC4013391891 04/01/2010 04/01/2011 X We STATU. I JOTH. EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 1,000,00( B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 1,000,00( OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 OTHER INS4013391907 04/01/2010 04/01/2011 Work Sites Limited Pollution Cov A Ea Pollution - $1,000,000 1 11Pollution Agg - $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Covering swimming pool construction/related operations of the named insured during policy term. C Statutory coverage is provided for NH and MA. No executive officers are excluded from coverage. Chris King 27 Abby Lane North Andover, MA 01824 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) o ACHUS Date.....?':.-1'�9 ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... V ..................rAo.. .................................. ............................................. has permission to perform .......... I ...... Z ........... wiring in the building of .................. K(."-,Iq .... ............................................... 7 ........................... 1 .147. North Andovei, Mass. Fee ... �0 ........ Lic. No. Wr/,,.3 .............. 4" EaCTRICAL INSPECTOfi Check # 0071� 9361 Department of Fere Services _. BOARD OF Fl�'E F'E?EVENITfC fd REOULA701` , S5 6 Official Use Only Pennit No. q 53/ Occupancy and Fee Checked _ [Rev. 9/051 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cole (MEC), 527 CMR 12.00 (PLEAS E PRINT IN INK OR TYPE ALL INFORMATION) Date: y j u', d City or Town of: ocr 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) a Owner or Tenant y IS Ovvuer's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Telephone No. W 360 OPY79 Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity . 1 Location and Nature of Proposed Electrical Work: ��Q ( • ' Connietion n0he tnlMw;,. , -1,1, . , 1.,, , a z... No. of Recessed Luminaires ---r----.. -�.._�...... .....6 No. of Ceil.-Susp. (Paddle) Fans ... — ,....y ✓c 1`-1— 11111 Iiul/culul V.l rrfreJ. No. of _. _._ Total Transformers KVA No.'df Luminaire Outlets No. of Hot Tubs Generators KVA No. of Lununaires Swimming Pool Above ❑ In- ❑ o. ol Emergency Lighting rnd, grild, Battery Units , ' No. of Receptacle Outlets No. of Oil Burners- C t FIRE ALARMS No. of Zones _ No. of Switches No, of Gas Burners No. of Detection and,, Initiatin Devices No, of Ranges No. of Air Conti. TotaTonsl No. of Alerting Devices No. of Waste Disposers Heat Pump Number. Tons KW No. of elf -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local Municipal F1 Other Connection No. of Dryers Heating Appliances Security Systems:* No. of Water No.KW N0' of No. of No. of Devices or Equivalent Signs Ballasts Si Data Wiring: , No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors , 'Total HP Telecommumcations Wiring: _ No. of Devicmor E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 liabili insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coN rage is in force, and 1�as exhibited proof of same to the permit. issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under th ains and penaltieNbn that the information on this application is true and complete. FIRM NAI\ �i LIC. NO.: Licensee: ignature h LIC. NO.: (Ifapplic int "ex [" 'n t e ' rrs.) Bus: Tel. No.. Attires . Alt. *Security tYstem Contractor License required for this work; if applicable, enter the license number here: OWhTL'R'S INSURANCE NVAJVER: I am aware that. the Licensee does no(have the. liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner' Owuex/Agent ❑ owner s agent. Signature Telephone No. EER1fl1T FEE: S r 6-7-14 - Of ,►ORTp �ti f p SACNu ../ �. Date .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING a This certifies that ............... has permission to perform .....'`.! .:... - !-' .......................................... wiring in the building of.. . ........................................................... at c,-),7 `� . - , North Andover, Mass. Fee�.'...... Lic. leo. )a..... II.! ............ . ELECTRICAL INSPV Check # Z- 8442 -C-\ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �� z( v / BOARD OF FIRE PREVENTION REGULATIONS [Rev. Occupancy and Fee Checked 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 C /R 12.00 (PLEASE PRINT IN INK OR TYPE ALL PVFORMATION) Date:— 2 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notiXb his or her intention to perform the electrical work described below. Location (Street & Number) -7,1_1 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes 7 Purpose of Building 77j L 20 o "1--N Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service t"-, Amps I-uG Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Undgrd Q" No. of Meters Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: (� j' , .��i,�,, I'1° 1.1 �'�✓ c'� 7r7/ ` �`��� Com letion - the o17--i—t bl b No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans a e may a waived b the Ins ector o Wires. o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets f �� No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o o. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total . Tons 2— No. of Alerting Devices No. No. of Waste Disposers Heat Pump Totals: Number ............................................._... Tons KW o. of elf -Contained Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of No. of Signs Ballasts . Sectio Systems:* or Equivalent Data Wiring': No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: -4dacn aaaitional detail y desired, or as required by the Inspector of Wires. Estimated Value of El � trial Work: o e � , of CJ (When required by municipal policy.) Work to Start: i07-7 (11 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 EJ BOND ❑ OTHER ❑ (Specify:) I certify, under the pairs and pen¢lties f erjury, that the information on this application is true and complete. FIRM NAME: l.t'� iU✓c dy. lI'�'+✓1 LIC. NO.:5��3 Licensee: ��r��°�ct �c ll ►-=%>'L Signature IC. NO.: (If applicable, enter "exempt" in the license numb r line.) Bus. Tel. No.: f Y�; ) 1/1' - Address: �rC Address: e-;, :?1 u y h r_. t� `ti Ta 1' i� %:s ✓t �' rj�l , %l, cli g,Q Alt. Tel. No.: *Per M.G.L c-147, s.5'7-61, 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 Signature Telephone No. PERMIT FEE: $ 6U,I,f,� ek. The Commonwealth of Altrssachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 f"; www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address:_ City/State/Zip: 16119 C/Tf 7 0 Phone #:�s' Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. �'I am a sole proprietor or partner- listed on the attached sheet. # 7• ❑ Remodeling ship and have no employees These sub -contractors have S. [J Demolition working for me in any capacity, workers' comp. insurance. q. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its / required.] officers have exercised their 10.Z]Electrical repairs or additions 3. ❑ i am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself, [No workers' comp. c. 1.52, § 1(4), and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' comp. insurance requirecL] 131:1 Other •Any applicant that checks bort#1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheetshowing the name orthe sub -contractors and their workers' comp. policy information. I am an. employer that is.providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: 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 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby ceWfy underthlepaim anApi ennaaJjlties ofperjury that the information provided above is tr ee and correct Signature: - �e'��/< r v%2 e� Date: Phone #: 6' Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions -' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal ofa license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance 'coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should, be returned to the city or town that the application for the permit or license is being requested, nofthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self. -insured companies should enter their self-insurance license number on the'appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant that must submit multiple permit/iicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA €-2111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.govrdia