Loading...
HomeMy WebLinkAboutBuilding Permit #128-11 - 799 TURNPIKE STREET 8/13/2010 BUILDINGPERMIT O S�LlD /6�+ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:L44 / ( *"D Date Received 4q E S $ Date Issued: I. l ACHu IMPORTANT Applicant must complete all items on this page '. r~�3"--trv .aA^-t 4J � �. "moi h .r# 1'•. u {�k.�.c'�'.f• }b 'u^ Lt �'j3..'P`,w A -rF t , 1'sl Sa 3+ r �. `., �i T'x �, L.br�,� •�. '� ,q '-i,2�yY' 1Z-i 't .`�a.y 4' 7`'� '& .f' +. r•"t.,p a ,qr„ r r r. -?' •rt.^�+C .�ka ' 0 =A& -�' y z � M.:. OR law. ............... t af���.i��Ty. `5" `-r.., �..��✓ �.��T.},5.;. s '€'� a J. 'v.L1"`}x'','�.yA'F�aF°3a�mr-+�'• Y'..� .u.'�aw.t� �s xL y �-i- H ''�.r�`�'S 4c?ti1� '�e -?r.�n..t c�....,3 d ��.� ��*,-i?-�..s� Asa _-._ 7.-t-�5�fr i^.• t - 3 s L� ��vJ�Y�t�r���N�� �. �kf7 t,rr���;r�`zt4 a � TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building -- One family- Addition Two or more family Industrial Alteration Noof units: ommercial - Repair, replacement Assessory Bldg Others: emo ition ' Other P.> e;6✓� - a rp.,>,,,�kt� - � ��`ti � �E,�' -��'z5```�,`. ���� �, �t��as"�' t`"�5�'�`.�;''��. .m��' �LL Mr�"w � ��P'ES�� ''.'�ss -T.r �� ���1I�TaT y��"� x`� y r Y ..a-,t' 7 �ss�'�;o�tq tr '�s• -�-�+r� usit gr' _ DESCRIPTION OF WORK TO BE PREFORMED: B���P. � h��s-,�G� ��G�S (��r��. 6���: � C�.r/<:�c L�• � Gil � ""`S �-- C/��� , ���c��u°coy"�� �(/✓�C�, �� --< - Identification Please Type or Print Clearly) OWNE •-Name,--_ _ R. Name: Phone: Address: '�. o- '�"'t` �3 `'4-1Ty,�,a65 � .. ,... c� T� t ,R.4.`' c .- ��,ct(a .•�z'S�t�"c�-h.ti�y� � /l��+h•7 a�JIN' "r � "'1 ��, �.`y�'.�.a �. c_ 1 ' ,%' �' "�i-i d '-'+ �r �'Sj,' ap �".��� � ac. tp'l°xsl 3'L, ARCH ITECT/ENGINEER_ & �,o!r GP1 Phone: /� �� 3/4t-�(,z �,Z,' Address: l No. J �l FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ '3, cod FEE: $_ Check No.: D Receipt No.:_213 / NOTE: Persons contracting with unregistered contractors do not have access to the ` ranty fund g J. .-t/OuuneT natuTev� m 61 C071 astir f_ kill 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENT S `HEALTH - Reviewed on Si nat ure 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: '��'� i� y� T,�►T� q, Located 384 Osgood Street e1RLJG %`1 �IelY1�J�Jls7 �. '� p Dr �pserr� �tee# L no21 Lrocatetlt iJlllainf:ee# ev I nalumda�e 4a Dimension 4 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 No MGL Chapter 166 Section-21 A—F and G min.$10041000 fine NOTES and DATA— For department use) I _ C i ❑ Notified for pickup - Date i . Doc.Building Permit Revised 2010 i Building Department The following is a fist 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 o 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 j ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 Location ! / c S'/ . No. Rf Date -l d �ORTh TOWN OF NORTH ANDOVER F w n + ' Certificate of Occupancy $ CMUs<�' Building/Frame Permit Fee $ ..7� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� { 233 ,1 Building Inspector NORTH Town of6Andover . 0 No. o , dover, Mass., AKIF Ap COCHIC EwICK A0RATE O P'P C7 7 S V BOARD OF HEALTH Food/Kitchen Septic System .- BUIL.......... DING INSPECTOR THIS CERTIFIES THAT...... .... ............ ....... ....... . .......: ��....... Foundation "MaGi has permission to ere ........... buil gs on .... !. ....�...... Rough to be occupied as...... . .. . . ...................................................... Chimney provided that the person accepting this permits all in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS NSTRU TARTS ELECTRICAL INSPECTOR UNLESS CO Rough Service ............ ............................................................... .............. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the ?remises,_ — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected' and Approved by the Building Inspector. Burner, Street No. SEE REVERSE SIDE Smoke Det. NORTH TONM of b Andover O q._. w.4'. No. O L A K o dover, Mass. T mss- COCMICHEWICK �11 7�A°RATED P'P�,��C� S t J BOARD OF HEALTH Food/Kitchen PERMI T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... ��........................ :.............. Foundation has permission to ere ........... ........................ buil gs on . . ........ ... :........ :::... :..:. ... .... ...... Rough to be occupied as ..... ...... ......... ........ ........................................ Chimney provided that the person accepting this permit s all in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC TARTS Rough ............ .............................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the .Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected' and Approved by the Building Inspector. Burner, Street No. Smoke Det. SEE REVERSE SIDE I CORMIER CONSTRUCTION ANDOVER, MA 978-815-4468 CONTRACT FOR DEMOLITION ADDRESS: 799 TURNPIKE ST,UNIT 101/103,NORTH ANDOVER OWNER-JEFF LEONARD SCOPE OF WORK *ENTIRE UNIT IS TO BE GUTTED TO SHELL/STUDS -ceilings/light fixtures removed/ insulation in ceiling and walls removed -interior partitions removed -electrical ' made safe'; old wires removed in walls and ceilings -plumbing cut and capped -HVAC system removed/ including* , registers, condenser, electrical controls etc 9 9 g � -carpet and floor adhesive removed -window trim and dry wall *All debris/materials to be disposed. Unit to be left broom clean $3000 X �� X 08/11/2010 15:10 FAX 978 750 8808 W J LYNCH INS AGENCY [ 001 DATE(MMIDUIYYYY) �-a (CERTIFICATE OF LIABILITY INSURANCE OP ID JF 08/11/10 .�THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE:CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFI(:ATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMP(IRTANT: IV the carHicata holder is an AE)FATIONAL INSURED,the policy(Ias)must be endorsed. If SUBROGATION IS WAIVED,subject to the tarms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such andorsemant(s). PRODUCER y NAME: AIC,Ne Ext): LAIC,No): William J Lyn::h Insurance AJey .MAIC_ 92 High Street ADDRESS: Danvers MA 01)23 CUSTOMERIDM CO:RMY-1 FhOne:978-750-0044 Fax:978-750-8808 INSURER($)AFFORDINO00VERA09 MAIC# INSURED INSURER A: Evanston Insurance Com an Cormier Jmdover Constructi0a r INSURER 13: Commerce Insurance Ra Von healtv Truat, Catamount Con'tacting .Corp INSURERc: AIG Insurance 3 Crensh:;:lw Ln INSURER D: Harle svill.e Worcester Andover Il 01810 INSURER E: wINBURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 13 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 166UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIC.%THD. 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 ArVORDED BY THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO A1,4 THE TERMS, EXCLUSIONS AND CONPIYION:•OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — VS:R` $ua Q EXP — __ LIMITS L7'R TYPE OF INSUI:ANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYVY) GENERAL uAa1LITY EACH OCCURRENCE $ 1 OOO 000 .?L X COMMERCIAL GENERr•LLIABILITY 08rTLP1007734 0l/27/10 01/27/11 PREMISES,Enactu,rente s50,000 CLAIMS-MADE OCCUR MED EXP(Any ono parson) S 5,000 — PERSONAL 8.ADV INJURY_ S ,OOO,000 GENERAL_AGGREGATE $2,000 000 GE NT AGGREGATE LIMIT A'hLIES PER: PRODUCTS:COMP/OP AGG $ 1,000,OOO PRO- S X POLICY JE CT LOG ALITORMOe1LF-LIABILITY COMBINED SINGLE LIMIT $ i (Eo eccidenl) ANY AUTO BODILY INJURY(Per person) $250000 _ ALL OWNED AUTOS BODILY INJURY(Per ecddenl) S 500000 El X SCHEDULEDAUT06 T07838 08/29/09 08/29/10 PROPHRTYDAMAGE $100000 (Peraeddenl) HIRED AUTOS — _ F NON-OWNED AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCHSS LIAR CLAIMS-MADE AGGREGATE S a DEDUCTIBLE S S RETENTION $ - �! W(IRKERSCOMPENUATIOh WC 3100840 01/21/10 01/27/11 TORY LIMITS ER AND EMPLOYERS'LIABILIT! Y 1 N E.L,EACH ACCIDENT $ ANY PROPRitTDR/PARTNE:9IEXECUTI L�Ij A --' OFFICER/MEMBER EXCLUD_0. E.L.DISEASE-EA EMPLOYEE $ (Mandatory In NH) If jea,describe under E.L.DISEASE-POLICY LIMIT S DSCRIPYION OF OPERATIONS below E, Builders Risk CI 239053 09/13/09 09/13/10 Buildings $1,000,000 ]ESCRWTION OF OPERA'nONS I LOCATIONS I VEHICLES (Attach ACORD 109,Additional Rom%rks SGhedull,If Moro spode is requirod) Construction ope._ations at in North AndOver, MA, Add'] Iri$ured:Town of North Andover. CIERTII-ICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRI6EP POUGILS BE CANCELLED SEPORE TOWN THE SXFIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NCE WITH THE POLICY PROVISIONS, AUTHORIZED RE NTATI Town of North Andover 1600 Osgc,od Street (North Aneover MA 01845 ORISORATION. All rights reserved, kCORD 25(2009109) The ACORD name and to 0 Bred marks of ACORD 1 The Commonwealth of Massachusetts Department of Industrial Accidents IL Office of Investigations f • 1. _ [i i ' 600 Washington Street Boston,MA 02111 cwww.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Corm l e-r PhJoytr /���n S fr. K ' Address: Cren S h aw La Ctzttzra�l�unt Cvn P City/State/Zip: rl nj DVQr M R- 01 910 Phone #: Are�u an employer?Check the appropriate box: Type of project(required): LE I,am a employer with 1j +: 4. ❑ I atn a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.C] I am a sole proprietor or partner- listed on the attached sheet. t ❑ Remodeling ship and have no employees These sub-contractors have 8. [Demolition workingfor me in an capacity. workers' comp. insurance. � Y P �'• 9. ❑ Building addition in . insurance 5. ❑ We are a corporation and its [No workers' comp. 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp. insurance required.] *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. Insurance Company Name: Che r-1 s �-QSUra n�e Policy#or Self-ins. Lic.#: �J C a 3 S a Y0 3 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 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 th DIA for insurancecov age verification. I do hereby cell y under the pains 0' penalties of peijury that the information provided above is true and correct. Si nature: Date: 1Z IID U Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pen-nit/license applications in any given year,need only submit one affidavit indicating current policy infonnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov(dia I DEMOL / TI ON PERM/ T PL AN 7'?9 TURNPIKE S T. UNIT /O/ NOR TH AND VER, MA DR. JEFFREY LEONARD NOTES : REMOVE ALL INTERIOR WALL, CEILING, LIGHTING, FLOORING ( INCL. ADHESIVE TRIMS AND DOORS. REMOVE ALL ELECTRICAL ( LEAVE NO " LIVE " WIRES. HVAC TO BE REMOVED ENTIRELY ( CONDENSER, DUCTS, REGISTER AND WIRING ) : ALL PLUMBING SHOULD BE REMOVED AND ALL FEED/WASTE OUTLETS TO BE CAPPED REMOVE EXTERIOR DRYWALL, INSULATION, WIRING AND WINDOW TRIM l WITH CARE I. " DO NOT " REMOVE THE DRYWALL ADJACENT TO THE STAIRWELLS AS THIS WILL BREACH THE REOUIRED FIRE RATING. ALL INTERIOR WALLS ARE " NON BEARING " _ • o A I L eaas_ 1, j FIRST -FLOOD EXISTING. CONDITIONS DEMOL I TION PERM/ T PL A'N ✓ 779 TURNPIKE S T. UNIT 10 NOR TH ANDD VER. MA NOTES DR. JEFFREY LEONARD REMOVE ALL INTERIOR WALL, CEILING, LIGHTING, FLOORING ( INCL. ADHESIVE I TRIMS AND DOORS. REMOVE ALL ELECTRICAL ( LEAVE NO " LIVE " WIRES. HVAC TO BE REMOVED ENTIRELY ( CONDENSER, DUCTS, REGISTER AND WIRING ) : ALL PLUMBING SHOULD BE REMOVED AND ALL FEED/WASTE OUTLETS TO BE CAPPED REMOVE EXTERIOR DRYWALL, INSULATION, WIRING AND WINDOW TRIM l WITH CARE I. " DO NOT " REMOVE THE DRYWALL ADJACENT TO THE STAIRWELLS AS THIS WILL BREACH THE REQUIRED FIRE RATING. ALL INTERIOR WALLS ARE " NON BEARING " ROE3'_R Y MIC G` 4 r / j f' i` 1 /f /f � I 7E It i FIRST FLOOR EXISTING CONDITOONS I *- Massachusetts- Department of Public Safeh Board of Building Regulations and Standards Construction Supervisor License License: CS 14717 Restricted to:..00 JAMES J NEWCOMB 151 SHAWSHEEN RD ANDOVER, MA 01810 cam_�yi' Expiration: 82612011 Tr#: 4018 (bmmi.siuner I ✓tie�om�rnoouvea�i o�.,2cfiueeCta Office of Consumer Affairs&Business Regulation JARHOME IMPROVEMENT CONTRACTOR. Registration: j>-�01311 Type:, Expiration: _612512012 Individual SNEWCOMB James Newcomb 151 SHAWSHEEN RfJ Andover,MA 01810 Undersecretary _. , 4094 0 21 Date ....... ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS CHUS This certifies that ......................................................... has permission to perform ....... ....... wiring in the building .................. I..... . at...2 .......... ..... North Andover,Mass. .......................................................... Fee ... ......... LPic.N& ELEMICAL INSPECTOR Check # /C� Official Use Only THE COMMONWEALTH OF MA55ACHUSETTS Permit No.-tAo .9 __ Deportment of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy&Fee Checkedd-?� 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--911—Tu-, ,> ®_j 1c� s,:+- upit to I Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes ?2 No • (Check Appropriate Box) Purpose of Building f�r1-t GG Utility Authorization No. _ Existing Service__ Amps Voits Overhead • Undgmd No.of Meters New Service Amps __Voits Overhead • Undgmd No.of Meters Number of Feeders and Ampacity (� �g Location and Nature of Proposed Electrical Work 6\BIonO,)P� t-� 9,ec .�Y0Lcjc /��. Aeaewe—r Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above In No.of Lighting Fixtures Swimming Pool qmd qrnd Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Bumers FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total t No.of Di osal No. Pum s Tons KW No.of Sounding Devices _ Nod of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices • Municipal • Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW I Signs Bailases Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If y u have checkeg YES please indicate the type of coverage by checking the appropriate box. INSUB0N6E = BOND = OTHER = (Please Specify) �J lns� Estimated Value 6f Electrical Work$ t7 (Expiration Date)_' Work to Start Inspection Date Resquested _ Rough Final Signed under thePenalties of pedury: / / fL i — FIRM NAME z LIC.NO. Licensees t1 o LQ S �l,��- �r Signature LIC.NO..G��d�__ ress C6; " Bus.Tel No. .7'p- Add y�6 �`' Alt Tel.No. SS(a 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) Telephone No. PERMIT FEE $ (Signature of Owner orAgent) — — Location No. a Date - D NORTH TOWN OF NORTH ANDOVER 3? i. . 0 ~ _ g + Certificate of Occupancy $ CMusEt�'' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ —3 Check #--- � N% 16539 til All( (60- building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER DATE ISSUED: 3 M SIGNATURE: C Building Commissioner/lmimtor of Buildings Date SECTION 1-SITE INFORMATION I 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 279 919 P -6 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area s Fron e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqfired Provided Required Provided 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes—No M 2.1 Owner of Record Name(Print) Address for Service: nature Telephone 1 2.2 Owner of Record: ;Name Print Address for Service: O z M Signature Telephone SECTION 3--CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ ��ose�y A? Licensed Construction Supervisor: License Number W r lleloZyz yr/ 15 IT �19G//��r/�je 01/9 Mn Address j �j 9/a>Zo.3 > Expiration Date ic nature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Comlany Name 3�yD //`� T ` py.— ,n/A/ Nn Registration Number Addr `'s Expira on Date ^ t nat Tele hone !� SECTION 4-WORKERS COMPENSATION(M.G.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. —Signed affidavit Attached Yes.......0 No....... SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ;t Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: sec?x©h/ 'Ila SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL-USE ONLY Completed by permit applicant x Z� 1. Building (a) Building Permit Fee 69001 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 . Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total- 1'+2+3+4+5 . -- . R, QQ; % Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLUTS FOR BUILDING PERMIT I, ,as Owne Authorized Age f subject property ereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 Sip-nature of Owner/Agent Date iN NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS 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 _ The Commonwealth of Massachusetts .4 . d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 S�1b. Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City 1-1712AW(1Z1(°`i0— Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for rry employees working on this job. Company name: zf/? Addresscity. Phone Insurance:Co. Poliot# Company name: Address City': Phone#- Insurance Co. Policv# �C d Failure to secure coverage as required.under Section 25A or MGL 152 can lead to the imposition of oirninai penalties of.a fine up to$1,500.00 and/or one years'imprisonment_ welLas_chMpmaitiesinlholmn�da-STOPMRKDRDER.and_afire-c(O]D M)-aiLwagaiwn)p understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i I do hereby certify under the pains and penalties of perjury that the information provided above is brie and correct Signator-e pat-- /41-zcr,� Print name IC Phone# Official use only do not write in this area to be completed by city or town official' City or Town PermitAicensing []Check ifimmediate response is required Building Depf p Licensing Board p Selectman's Office Contact person: Phone# Health Department E:i Other tAORTH Town o Andover 011 No. 0,3 0 It- L A E 0 dover, Mass., 7* COCHICH WICK O'4ATED BOARD OF HEALTH Food/Kitchen -PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.... 7*,VW.4 14 LO 0 -4 POP Foundation has permission to erect... .... buildings on .... ....TWO .,S.f..kq*........S.t�i......... Rough to be.occupied as.......P sp 4 4s.11�........ eA oaouChimney ........ ... ........................................................................................................ 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 rel ting to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. I TA?b/3_4 0 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ........................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street N0. FSEE REVERSE SIDE Smoke Det. I L� FILES BUSINESS OFFICE I FAX alo I r -1 I�I L J GLASS ABOVE COUNTER l.� CONSULTATION 1 - JL B'' DE PROPOSED.- PLAN SCALE: 1/4"=1'=0" THON 7�9 T� �r/r'iile sT J EFFF 799 T! NO. A WALL LEGEND sICALE: 1 EXISTING PARTITIONS TO REMAIN DATE 4/ DRAWN BY ---------- --- L-uicTikif` DAD-nTinkl TO RF nF-Mt)IISHED