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HomeMy WebLinkAboutMiscellaneous - 1 VILLAGE WAY 4/30/2018 (2)I AL -ft, Date... .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that f� b �<rj t , ................. . ..... ........................................... I .... :: ........ , 4,J V,� - " U has permission to perfornmn ..... �i ......................... A wirinVnhp uildingof ......... .. . ....................................................................... at li I 114"a W4 ............. ........ -6 .................. N n ver, Mass. . .......... Lic. No . ............... Fee . ................ .... ........................... Check# ELE RICAL INSPECTOR 2 ir 61 ff 4- �G 2 G I d" 0 -zci I t 9 Commonwealth of Massachusetts Jt Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS ' M T(6 al Use Only Permit No. Occupancy and Fee Checked Lev.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 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the InspectJ of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) / 1/1 I -A b -t5 ti✓ /Q�jl Owner or Tenant 5(0 o Y7 -Q,_ a -C-) 14 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Nj No ❑ (Check Appropriate Box) Purpose of Building 1�71 �_ ,�L( I '� Utility Authorization No. Existing Service 11.V0 Amps k / t Volts Overhead ❑ Undgrd � No. of Meters _T_ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (,,etre rT. ,,,Tot;,," nftho fn17nwt;10 tnhlo mn„ he waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets 3 No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o Emergency ig tmg o.01 Batter Units Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No, of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis osers P Totals: .. .............................................. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local F]CMunicipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems-* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail V desirea, or as reguirea oy me tmpeccv. Ui rr &r Estimated Value 'Ele 'cal Work: '0 (When required by municipal policy.) Work to Start: Inspec ions to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE VE 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penaltiesperjury, that the information on this application is true and complete. FIRMTe' t 1�� LIC. NO. Licensr Signature LIC. NO.: 01,Gj (If app liter " xe pt" in a licens ber line.) 61-15 Bus. Tel. No.: " i' Addres�� Alt. Tel. No.: % *Per M.G.L c. 147, s. 57-61, security work requir Depa ent of Public Safety "S" License: Lie. 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 Owner/Agent Signature _ Telephone No. I am the (check one) ❑ owner ❑ owner' agent. PERMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed f on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an }— electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the " notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH IN5F CTION: Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: - S" FINAL INSP TION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ,S� DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com 4 r .. The Commonwealth of Massachusetts F Department of Industrrial Accidents 1 Congress Street, Suite 100 y Boston, MA 02114--2017 .�` www mass.gov/dia O,M Sv Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITf)NG AUTHORITY. Name Address: City/State/Zip: Ase you an employer? Check the appropriate box: Phone 4: &7 1-6 31 LF] I am a employer with employees (fL'U and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] In I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no emplbyees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have einployees and have workers' comp. insurance.T 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and We have no employdes. [No workers' comp. insurance required.] Type of project (required): 7. 0 Naw'oonstruction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12T[]Plumbing repairs or additions 13. [] Roof repairs 14.[] Other *Any applicant that check's box #1 must also fill. out the section below showing their workers' compensation policy information: Homeowners who Sul Al., affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit in such tContractors that checkthis box must attaclied'an additional sheet showing the name of the sub -contractors and state whether or not those entities, have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensati n insurance for my employees. Below is the policy and job site information. y Insurance Company Name: Policy # or Self -ins. Lic. Expiration Job Site Address: l i/t (/� City/State/Zip: 1/6Ir`f Attach a copy of the workers' compe. sation policy declar 'on page (showing the policy number and expiration date). Failure to secure coverage as requited under MGL e. 152, §25A is a criminal violation punishable by a fuie 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vert. o X do her y rerfi under tliep�nd lties of perjury that the information provided above is'tt�ue and correct. Official use only. Do not write in this area, to City or Town: completed by city or town official Permit./License ## Issuing Authority (circle one): i 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 them 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 whohas not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C('1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for theperformance 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 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 permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "rob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia COMMONWEALTH OF MASSACHUSETTS , } BOARD OF fLECTRICIANS — ISSUES THE,FOLLOWING LICENSE AS -A t REGISTERED MASTE:R,ELECTR"It—AN OGRA:DY ELECTRIC RANDA'LL S :OGRRDY �'�a' ,fir „:= 245 FORGE `VILLAGE RQA.D GROTON MA 01450-2043 1.2493 A 07/3.1/1: :67093 ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... has permission to perform ... wiring in the building of .... ......................... at ... I,-Vl ....... ...... !��Zl ..... Jl—'. �,4orth Andov r er Mass. IV 6:2 OOL 6? Fee ... �R� ....... Lic. No . ............. ........ E**,KR;I'�Zi Check # 8677 , S 2 7_o - o/t l ��©(k " IN uommonweann or massacnusetts %JL,.,U1a,/'"y Department of Fire Services Permit No. U T? BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 4/1/2009 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) Village Green @ Route 125 Owner or Tenant Mass Highway Telephone No. (781) 641-8485 Owner's Address 519 Appleton St, Arlington, MA 02476 Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Ap ro riate Box) Purpose of Building Existing Service 60 Amps 120/240 Volts Utility Authorization No ' ey Overhead Undgrd ❑ No. of Meters 1 New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Single Phase — 3 wire — 120/240V Location and Nature of Proposed Electrical Work: Replace underground electrical wire 60 Amps _Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑In- El rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pumpumber Tons No. oSelf-Contained Totals: Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local E]unicipa ® Other Connection No. of Dryers Heating Appliances I{�, Security Systems: No. of Devices or Equivalent No. of Water Kms, No. o No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP o Wiring: Telecommunications Devices No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 ® BOND ❑ OTHER ❑ (Specify: Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: ASAP Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the inform aton this applica ' n is true and complete. FIRM NAME: Republic ITS /7', LIC. NO.: 20282A Licensee: Shawn Berry Signature _ h LIC. NO.: 32640E (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 800-544-4876 Address: 8 PROGRSS ROAD BILLERICA MA 01821V Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Liceifsee 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: $ 50.00 JA, IA 4. Ipo 3WIl 111VA ;v ON, �'A'9'�, f � r.»X a � �,r,�,+eF' - � . � , �i �f '^r :�.• — x n.;a µ 'c ' : + •..Ib ,Ifiy • A ,<' 9+n °d rng, '';b M' AvT `i�,A •,# "^LL �Pr°� •� � n,�. 3 Y h y 4 t#� x' �k �......JH�i.w: gyp* e jYp. � ' xgYy{k M H a+xr •-v�P.�� -k�3i %*ll In All 01, $_,�"' diek 74, Air RT �� e ip.: TAT � w •.��� n�R�a^r� � r,� ' ��� � �� b �r 31 '14 Date. ....... '40RT#j TOWN OF NORTH ANDOVER "0. ". "Oo ". PERMIT FOR GAS INSTALLATION This certifies that .... �-x' .- Z-.,- . .'� �!� (. .'� ... z �/ h as permission for gas installation .... ��( - - in the buildings of .................. at ... .,North Andover, Mass. Lic. bi/09/99 12-08 25.00 pAID GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS F TING e or print) 1NUKIM ANDOVER, MASSACHUSETTS Building Locations LUu Date 3-2- 19 9 Permit # 3/// I Amount S 2j ^ N • A nd ©(/'er i 1kr-I Q . Owner's Name 4 U 2 0/7 eh rcO — New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or type) 69—Check one: Certificate Installing Company Name Alkle I&C761C P coc2 Corp. /6dy C Address & o e� 72 6 ❑ Partner. Ald r, 1>1 Business Tele 9 Firm/Co. Telephone 4 � � 9 �s �Z�� 0 Name of Licensed Plumber or Gas Fitter 2j ��!^� 3 /4n e!7 to II— INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of t44General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber. ❑ Gas Fitter (cense 7umber Master Journeyman z � _ w In U C w w In z C % C _ 1= z SUB-BASENI ENT BASEM ENT 1ST. FLOG R 2ND. FLOOR 3RD. FLOOR 4T H. F L O O R 5-T H. F L O O R 6T If FLOG R 7T 11. FLOG R 8T H. F L O O R (Print or type) 69—Check one: Certificate Installing Company Name Alkle I&C761C P coc2 Corp. /6dy C Address & o e� 72 6 ❑ Partner. Ald r, 1>1 Business Tele 9 Firm/Co. Telephone 4 � � 9 �s �Z�� 0 Name of Licensed Plumber or Gas Fitter 2j ��!^� 3 /4n e!7 to II— INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of t44General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber. ❑ Gas Fitter (cense 7umber Master Journeyman Ipcation No. V40RTN 'AND'' TOWN OF NORTH'.- OVE 0 $0 jaiddfiAdillk S Certificate of Occupancy-, 4L s" Building/Frame Permit Foundation Pe mit F 14U "01--', d, -ee Other Permit F 'S,6wer Connection Fee $: 'G' Water Connection FeC,-:..I'.,__ TOTAL AIAY X`11 6@idin-'g- i n -s ­Pe -'6t_ 6W.-�'Y-.' 60,411. Lo !on No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ 4- 11" Building/Frame Permit Fee $ 2 0 0 Foundation Permit Fee $ CH Other Permit Fee $ P4 Sewer Connection Fee $ SEP 'n��-*r Connection Fee $ 199., TOTAL $ Ir" �O- An�t,, A -k 9 4, A; Buildind Inspector Div. Public Works C Locatioln Z No. 7 Date TOWN OF NORTH ANDOVER Certificate'of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ /0 0, CC) Other Permit Fee $ 1 046111 46. Sewer Connection Fee $ fter Connection Fee $ 4)y r ),. -0,00 ) $ 1,5 4� <9,9 To A Building Inspector i - Div. Public Works Locati on No. LO r)ate t TOWN OF NORTH ANDOVER Certificate of Occupancy $_ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee 142wer Connection Fee XVC onnection Fee Ab 1��)TOTAL $ 16-00's-0 1$ 1 op -o, 0--b $ C�000, 00 '717010 A Iler col, Building Inspector .ct or 3/3/ Div. PubliF Works PERIIIT NO. 107 7 4 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 4 fj/ 2 & /PAGE, 1 MAP ' 0: ZONE I I LOT NO. SUB DIV. LOT NO.�— 2 RECORD OF OWNERSHIP IDATE C, �j- BOOK PAGE 1Z�3 13S 1 LOCATION p 1t�IlM-E ` PURPOSE OF BUILDING 4 f-(:t(oc-'N�.1,. !I �'C OWNER'S NAME NO. OF STORIES I SIZE OWNER'S ADDRESS 1.6 aS C Cj_j n� 04 BASEMENT OR SLAB ��F ARCHITECT'S NAME 4-`,S��i9k- �S�'fJPA+"Ti�(Cs►� .I_ SIZE OF FLOOR TIMBERS IST �X �(✓ 2ND Zxlo 3RD /1 C BUILDER'S NAME tl �� u�`i SPAN DISTANCE TO NEAREST BUILDrNG �� (+� • DIMENSIONS OF SILLS .- b DISTANCE FROM STREET f C� a POSTS 311-L DISTANCE FROM LOT LINES-MSIDES REAR Li 'C' " GIRDERS AREA OF LOT �, fi FRONTAGE `�� -� L' HEIGHT OF FOUNDATION THICKNESS I o I I 6�g. IS BUILDING NEWS "'.4�5 SIZE OF FOOTING q I[t �I ( X V IStBUILDING ADDITION �A MATERIAL OF CHIMNEY M C r -r IS BUILDING ALTERATION N� IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER "I C S BOARD OF APPEALS ACTION. IF ANY \` A v IS BUILDING CONNECTED TO TOWN SEWER \jFS IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST `���I Lyp 6 SEE BOTH SIDES A M EST. BLDG. COST \�, 16 PAGE 1 FILL OUT SECTIONS 1 - 3 ?•Tw + `Vi�X39 I EBT. BLDG. COST PER 8Q. FT. u Q S' PAGE 2 FILL OUT SECTIONS 1 - 12 L- ` a I ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING PERMIT FOR FOUNDATION ONLY lt9�V ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIR1 LATE BY PARA: � 112.7 S. pp. C. ` PLANS MUST BE FILED AND APPROVED BY BUILDING INS PE CTMT�E7I:�FEEIPAID: I DATE FI ED — -4"z ZZ14111t PERMIT FOR FRAMEZRI-111-DING. SI A E R OR AUTHORIZED A ENT F E E Z2,5 , e'C---, < PERMIT GRANTED d 19 12- � IT Fff. Z ` `!`! Fbu� tRAME PERMIT ► o t EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. N y:v 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF BELECTMEN NV'Id 101d S30b-ld3M SIH1 'a3SOdWiM3df1S '013 'S30VM -VE) 'S3HOM0d H11M 'SONIa11f18 d0 SNOISN3WIa 10VX3 aNV S3N11 10'1 WOMB 30NV1Sla aNV 10"1 JOSNOISN3Wla 10VX3 MOHSiSf1W N01103S SIHl n i -4 Z AON Vd f1000 l abOD3V ONlallns -" ` 0NIiV3H ON I P E I , 4'I PSL —IW 9 D180313 110 SWOOM dO 'ON L SV0 S831V3H 11Nn E).i,H 1NVIOVa ONINO1110NOJ WV aOdVA a0 S,1.M lOH SS31dVa OoOM S10:) '8 'Sw9 1331S WV31S _ 'S10D -9 'SW9 839W11 Nand SIV lOH 03JSOd 3JVNand SS313did lsior OooM ONIMH ll I ONIWVld 9 00VO 3111 _ Goold 3111 S3aniXld Na300W t IdON Oa llob _ 63MOHS 11VIS 13AVa0 B aVl ONI9Wnld ON 31V1S NNIS N3HX1X S34NIHS 000M AaO1VAV1 S319iIHS 11VHdSV 13SOID 431VM 03HS I V lbld 1�9WV�J ('Xid L) Wa 131101 OaVSNVW _ 'Xld EI H1V9 d1H 319VO O awnld OL looll 5 �I 3aOIM 1 good dns DNIIIIM 3WVad NO 3NO1S ASNOSVW NO 3NO1S X19 b30N1:) 80 ':)NO:) _I 80011 8 'Sdis DI11V 3WVad NO X0Ia9 ASNOSVW NO )IDla9 E S71001d 9 3111 'HdSV N0NlWO� 3WVad NO oxmis ASNOSVW NO O:)Jn1S ONIOIS '183A `JNIOIS SOIS31SV O.n�OSVH ONIOIS 11VHdSV HidV3 S310NIHS DOOM 313aON0� I NICIIS SO8VO9d080 511VM .v 6 N3H011X NS300W WOOS 0V3H S3DVld 3ald 1.W.91 ON VRV DI11V 'Nld VRV .1.W.9 'Nld '/c % , 'L ' ilnd V3SV _ E L HSINId )( I 1N3W3SV9 E NIdNn iIVM Aa0 8313V1d Sa3id 3NO1S a0 XDla9 3NId 'X.19 343SJN00 E 313SDNOD lOIN31N1 8 NOI1VONnoj Z N0110f1M1SN00 SiN3W1aVdV TT s3Jlddo S4'dO'S AIIWVA '111nW tt AIIWVd 310NIS Z AON Vd f1000 l abOD3V ONlallns -" ` FORM U TOWN OF NORTH ANDOVER LOT RELEASE FO1k1 SUBDIVISION 5, ASSESSORS MAP SUBDIVISION LOT(S) �"u N-- PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET �� ``� v'.v� -� APPLICANT PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE CONSERVATION COMMISSION CONSERVATION AD1•1IN. OQRD OF HEALTH SAN DEPARTMENT OF PUBLIC WORKS DRIVEWAY P SEWER/WATE DATE APPROVED �j•?j •� DATE REJECTED PATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED 3�< /GC, FIRE DEPT. 1A*d672-121J 4 sir.-c� (-�V- is /H 9'0017,,)� -; e P� �l ���1 iL,LA,)c ;hs,—��� , �/ �4i1 014,,-,(f-Add,ce nee, k( Ld,7-t f ,e�lP�t%.e7 �� %0��l�ry ;s4 RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. i 05 z CC LIJ uj cim z O z Q D z O LL OC O LL W a h U/ > u.J o= �>< 7W C� mLIJ O 00 C 'C 0 N s w 0 O L CL .0 V m NO .� qw tv mi Z cc cc 0 O 0 CC Q V W W O z W z z W W O (' V H ? 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L►J UJ Ljt V W Q 0 An J �M1 ow ,c I 12 �-,.'o 2 t j Q6 yvj c- le This certifies tha ............................. has permission to perform.� Q -6A -fl -or-, ......... buildings of. plumbin 5..t.�,,� C) .. ........................................................................ at ....... I ...... ............. North Andover, Mass. Fee4A............... Lic. No . ..................... ................................................................................. Date ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Check # L� al PLUMBING INSPECTOR 4- 2-0 1 �0 (e I �?-911,— V'Y\ P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE / ( PERMIT # JOBSITE ADDRESS _ OWNER'S NAME L►P _T'� �'� �'C....� OWNER ADDRESS S TEL FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL 9— NEW: D RENOVATION: ® REPLACEMENT: K#} — PLANS SUBMITTED: YES � NOMI FIXTURES'l FLOOR- BSM t BATHTUB ( _ CROSS CONNECTION DEVICE L=J DEDICATED SPECIAL WASTE SYSTEM = DEDICATED GAS/OIL/SAND SYSTEM ! `_,_ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ! _ DEDICATED WATER RECYCLE SYSTEM ( __ DISHWASHER= DISHWASHER! _j DRINKING FOUNTAIN ._ FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN ! _ SHOWER STALL _( W SERVICE / MOP SINK TOILET URINAL t WASHING MACHINE CONNECTION { WATER HEATER ALL TYPES _I WATER PIP 'OTHER C WWWMWWWMWWWWW WFWF W M_ W F�r�rl����F�F� INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES P 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Eq OTHER TYPE OF INDEMNITY Q BOND D! OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this ap and that all plumbing work and installations performed under the permit issued for this application Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I�Jo�, C�—` .�s/..._.._ I LICENSE # IVIP2--'1 P �% CORPORATION �1 #�]PARTNE! CHECK ONE ONLY: OWNER 0 AGENT 10 n are true and accurate to the best of my knowl in gompliarde' with all Pertinent provision of the SIGNATURE P01# LLC 0� COMPANY NAME �__ �� g,�, ADDRESS CITY p /% STATE v ZIP (, /`� TEL FAX CELL 2���>>f���� EMAIL al �I o z wEl w M iii w LL :,A Date .... ��W.1.5... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION C AJ This certifies that .................................................. ..................... has pertmission for gas innsIllation ..04.L-.5L.-je . . ....................................... .. ........ ...... .. in the build' ,g . ......... ................ f, 1 ................................................................. at ........... k .......... North Andover, Mass. ............................. .............. Lic. No . .......................... ..................................................................... Fee ��. N" GAS INSPECMR Check # LQ�, 2 G+ TYPE OR PRINT CLEARLY MASSACHUSET+.S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATEZ#41 / PERMIT# �66riz v CITY l ® 41 -- --- -- JOBSITE ADDRESS OWNER'S NAME I�T/�►9�P �S ©''I C OWNER ADDRESS TE FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL NEW: [] RENOVATION: Cl REPLACEMENT: APPLIANCES 1 FLOORS -4 BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE -HEATER ROOF TOP UNIT TEST UNIT HEATER• = UNVENTED ROOM HEATER WATER HEATER RESIDENTIAL Q PLANS SUBMITTED: YES � NO 10 1 11 -- --- - ' T-- L V— INSURANCE COVERAGE have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 12 1 •13 1 14 YES NO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND 01 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this applic and that all plumbing work and installations performed under the permit issued for this application will Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEi2 t� �[:=LICENSE MP MGF JP 0 JGF LPGI CORPORATION ©# [—E � PA CHECK ONE ONLY: OWNER EI AGENT 0 ati re true and accurate to the best of my knowledc b i co liance wit ertinent provision of the �8IGNATURE p ®#I LLC ®# COMPANY NAME:���`� -_ — ____,_., II ADDRESS CITY e _ _� STATE Zip TEL FAXCELL glEMAIL �� rA W H z 0 U a � '4 O rl 0 °❑ W >- O CL Z U w 4* cn a a w w a 0 (�+ w U) g w w ►- V J ..tet d H IL CL a � w = w F LL 0 z 0 H U w L7 , C�7 - r l Clx The Commonwealth of as e' is Department of Indu alras z r 1 Congress Street, Suite 100 Boston, MA 02114-2017 t www mass.gov/dia Compensation Insurance Affidavit: Builders/CGnttract AUTHORITY' tricians/plumbers. Workers Comp Please Print TO BE FILED WITH THE PERMIT Name (Business/organization/lndividu : Address:y Phone #: City/State/Zip: a project re •uired): Type of proj (, �1 Are you an employer? Check the appropriate box: Z: employees (full and/or part-time).* �. [] New construction 1 •��loy' er with for in 8. xamodeling 2.❑I am a sole proprietor or partnership and have no employees working 9 �] Demolition any capacity. [No workers' comp. insurance required.] insurance required.] t all work myself. [No workers' comp. 10 ❑Building addition g.❑ I am ahomeowner doing Iwill it E] I am a homeowner and will be hiring contractors.to conduct all work ce or property. Q] Electrical repairs or additions ensure that all contractors either have workers' comp ensation insurance or are sole 12. � Plumbing repairs or additions proprietors with no employees. 13.E] Roof repairs rs listed on the 5.E] I am a general contractor oyees and have workers, comp. insurance attached sheet. 14 ❑ Other These sub contra of exemption per MGL c. r A its officers have exercised their rightfired ] 6,❑ We are a corporation an " ` t., eI [No workers' comp. insurance requ 152, § 1(4), and.we have no, emp Y ensation olicy information. Any ppthe are doing all work and theme e o eoutside ontratos and state whethereor not thoseavit �entities have such - ant * a licthat checks box #1 must also fill out the section below showing their workers' coco mp t must submit � P ub I Homeowners who submit this affidavit indicating Y the n showing policy number. #Contractors that check this box must attachlod an a( 1. eY t protvide their workers_' comp. p Y employees. ff the sub contractors gave em Y or my employees.' Below is the policy and job site Iain an employer that is providing workers' compensation insurance f information. Insurance Company Expiration Date: Policy # or Self -ins. Lic. #: City/State/Zip: Job Site Address: ensation policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' comp .. punishable by a fine up to $1,500.00 e as re uired under MGL c. 152, §25A is a criminal violation p ti ER a of the DIA for $25insurance Failure to secure coverag 9 Office of Inves g t as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.0 a and/or one-year vnprisonmen , be forwarded to the Off day against the violator. A copy of this statement may coverage viScation. f erjury that the information provided above is true and correct I do here rtifyjlunder the penaltces o p _ q /4 - one P: } Do not write i ficiat . Official use only. n this area, to be completed by city or town of Permit/License # City or Town: Authority (circle one): Cling Inspector erk 4. Electrical Inspector I. Plumb Issuing Department 3. City/Town 1. Board of Health 2. Building p 6. other Phone #: Contact Person: Information and Instructions. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, or employee is defined as "...every person in the service of another under any coniraot of hire, express or implied, oral or written," ' �` f An elnployer 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, owner of a dwelling house having not more than three apartments and employing However the dwelling house of another who employs perswho resides theein or the occupant the ons 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." Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to our 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 tha members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have n the employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial . Accidents &o confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers compensation policy, please call the Department at the number listed below. Self-insured r self-insurance license number on the appropriate line. companies should'enter thei 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 town)" A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the (city or applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Revised 02-23-15 Fax # 617-727-7749 www.mass-gov/dia. r I Date. ...... IV 0; ox TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... ............ / ................ has permission for gas installation . . in the buildings of . � ....................... at N,/ .......... North Andover, Mass. Fee. Lic. No.. ? 7 ... ................. ..... GASINSPECTOR Check # 4 C 3 2 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO CASFITTING 4 -a�� (Print or Type) ?� �} Mass. Date J \� 0 L, permit # 7 3 �— i� Building Location 1Owner's Name, f s' Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name Address Haverhill, MA 01830 (978) 372-999�r— Business Telephone Lic. Plumber Michael H Hous Name of Licensed Plumber or Gas Fitter Check one: Certificate `'"Corporation = Partnership Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes i✓ No C If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy,- Other type of indemnity G 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. �)lgnature of Owner or Owner's Agent Check one: Owner ' Agent C I hereby ceniry that all of the details and information I have submitted for entered) in the above application aretrue and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. B Type of License: By `= Plumber Gasfiner 2 Title"MasterSignature(Licensed Plumber or as Finer Journeyman \\ 1 City/Town License Numt�,1 � APPROVED (OFFICE USE ONLY) T— ■■■■■®■■■■■■■■■■■■■■■■■■■ BASEMENT ■■■■■■■■■■■■■■■■■■■■■■■■■ FLOORist ■■■■■■■■■■■■■■■■■■■■■■■■■ 2nd FLOOR ■■■■■■■■■■■■■■■■■■■■■■■■■ ...• ■■■■■■■■■■■■■■■■■■■■■■■■■ ...■■■■■■■■■■■■■■■■■■■■■■■ ... ■■■■■■■■■■■■■■■■■■■■■■■■ 6th FLOOR ■■■■■■■■■■■■■■■■■■■■■■■■■ ..• ■■■■■■■■■■■■■■■■■■■■■■■■ : .. • ■■■■■■■■■■■■■■■■■■■■■■ Installing Company Name Address Haverhill, MA 01830 (978) 372-999�r— Business Telephone Lic. Plumber Michael H Hous Name of Licensed Plumber or Gas Fitter Check one: Certificate `'"Corporation = Partnership Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes i✓ No C If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy,- Other type of indemnity G 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. �)lgnature of Owner or Owner's Agent Check one: Owner ' Agent C I hereby ceniry that all of the details and information I have submitted for entered) in the above application aretrue and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. B Type of License: By `= Plumber Gasfiner 2 Title"MasterSignature(Licensed Plumber or as Finer Journeyman \\ 1 City/Town License Numt�,1 � APPROVED (OFFICE USE ONLY) T— W, 2 W - z M rm 0 z C: rm r- z it I r79 0 > > rm W - z M rm 0 z C: rm