HomeMy WebLinkAboutMiscellaneous - 10 SURREY DRIVE 4/30/2018TV
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I N Commonwealth of Massachusetts
MEW
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. _ ' Z ;7—
Occupancy and Fee Checked
[Rev. 1/07] (leave hlanlrl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
WORK
(PLEASE PRINIDV IAW OR TYPE ALL INFORMATION Date: `% ?I d!?
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) / /;, S,,, r
Owner or Tenant e p Lh, fc ` N Telephone No.
Owner's Address / ® tA , t y
Is this permit in conjunction with a building permit? Yes � No
❑ (Check Appropriate Box)
Purpose of Building less Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
r� dam. «��»»•»uu..�.0ueiuu g aestrea, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: �11_2 2 - 6 g 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 9 BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: tr
LIC. NO.: S 3
Licensee: l c Signature
r LIC. NO.:
(If applicable, enter "exempt •' in the license number line)
Address: y2 114 4 o Ce>C, oc 144( .fir `� K (SJ S� Bus. Tel. No.: G 6 ? 2 2017 ce2
*Per M.G.L c. 147, s. 57-61, security work requires Department o Public Safety "S" License: Alt. L cl. No**
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage 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. n ' ft7 PERMIT FEE: $
N
�,Q eu s s .a9 AV
: 08
V
Date ..... q- n.0�...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...................l."... .aVSAF. . /7 ..................................
has permission to perform ........
wiring in the building of ............... & ..........................................
at .... &Q ..... S. ZME.Y.. .................. North Andover, Mass.
............
Fee ... Lic. No..? ............. ............ ....................
ELECTRICAL INSP
Check 4 34
8724
A
The Commonwealth of Massachusetts
Department of .Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
t' j www massgov/dia .
Workers' Compensation Insurance Affidavit. Builders/Contractors/Electric ians/Plnmbers
Applicant Information Please Print Legibly.,
Name (Business/Organization/Individual):
Address: yla`coc�
City/state/Zip: /l/P w d ✓ !-/ Phone k 60 3 7 20 ! 7 Y2 _
Are you an employer? Cheek.the appropriate box:'
. ❑ I am a employer with 4. F1 am a general contractor and I
Type of project (required):I
mployeea (full and/or part-time),*
have hired the sub -contractors
6. ❑ New construction
2. I am a.sole proprietor or partner-
listed on the attached sheet. _
7• ❑Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for mei any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
q• ❑ Building addition
required.]
3. ❑ I am a homeowner doing
officershave exercised their
MGL
10. [1 Electrical repairs or additions
all work
right of exemption per
I I.❑ Plumbing repairs or additions
myself. [No-worke'rs' comp.
c. 152, § I (4),'and we have no
12. Roof
❑ repairs
insurance required.] t
q ]
.employees. [No workers'
13.❑.Other
comp. insurance required..]
_'Jr oi,r� ���� uwi uicum oox 8 t must also fitt 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.
4contractors drat check this box must attached an additional sheet showing the name of the sub. contractors and their worker:' comp. policy information.
I am an employer that is prgviding:workers' compensation hzsurawefor my employees:
information Below is the policy and job site .
Insurance Company Name:
Policy # or Self -ins. Lie. #:
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 e. 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 certify under the pains andpenalties ofperjury that the information provided above is true and correct.
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 shaU 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."
ti
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, notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the nurnber. listed below. Self-insured companies should enter their..
self insurance'license number on the'appropfiate 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 NvilI 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 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 1-977-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia
4
MASSACHUSETTS UNIFORIV4 ,AppLICATION FOR PERMIT TO DO PL
(Type or print) UMBING
NORTH ANDOVER, MASSACHUSETTS
FT --'TITRES
(Print or type)
Insta ag-Company Name
Address
....•10 13uu,maea Yes U No
Check one: Certificate
ElCorp.
E] Partner.
Name of Licensed Plumber a Firm/Co.
Insurance Coverage: Indicatethe
a of insurance cov
Lierage by checkin
Lability insurance policy Lj Other of � g the appropriate box:
nP� inde�ty Bond El
Insurance Waiver. I, the undersigned, have been made aware that the lic
three insurance enseq of this application does not have an
} one of the above
Signature ❑
Owner ❑
Agent
I hereby certify that all of the details and information I have su mitted (or entered) above application are true anda7wm
best of my knowledge and that all plumbing work and insta o s
compliance with all Performed under P to the
pertinent provisions of the Massachus Permit Issued for this applicatioinBy:gCode and Chapter 142 of the General .
afgn of l.:fcensra furnoer
Title �ype. °f Plumbing License
City/Town ?�
APPP License ivuMDer ❑
D (OFFICE USE ONLY Journeyman
Date ..........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
S cmus
This certifies that .......... Q.................................
has permission to perform
plumbing in the buildings of ..............
a .. . ... .. . . . . . . . . Andover, Mass.
Fee Lic. No'. ...
PLU _IN, INSPECTOR
Check,
�.?� 1, ►�, .
rly
r;
uffL uinwealth of Mass;achurettc
Department o
f Industrial Accidents _
DfJtce of jRvestie ations
600 Washin,,ton Street
loston, M4 02111
W WFLr. m4SS.s OV/4a
Workers' Compensation Insurance Afa�,.It. g'ders/Contractors/Eleciric'
DIicant Information ians/Piumbers
Name (Business/Organization/Individual): , /J/�{�, j
Address:
Qty/State/Zip:_ )/�/S�✓v
Are you an empioyer? Check the appropriate box:
1❑Tarn 1
Phone #: /=,,(03
a emp oyer with 4. ❑ I amEpilla general contractor and I
move -s (full and/or part-time).*
2. !(.d' I an a sole proprietor or partner_
ship and have no employees
woricing for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed ani the attached sheet I
These su,b-contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
Officers have-xercised.their
right of exemption per MGL
c. 152, § 1(4), and we have no
emplayees, [No workers'
Type of project (required):
.6. ❑ New construction
?• ❑ Remodeling .
8. ❑ Demolition
9. ❑ Building addition
10:[] Electrical repairs or additions
1 l.❑ Plumbing r�airs or additions
12:j❑ Roof repairs
COMP. insurance re 13•❑ Other
"Any appiicant.thar checks box # 1 .must also fill out the section below showing their workr�]
t pion; owners who subnut •Uiis a�idavh indicating liiei' ere duin� e ` ;,:r, ers`compertsation policy information.
IC ontractors that check this box .must tae
at>sched an additional shit show, �+nir'aciors must srimnii a ne„v
the name of the sub -con ameavit in:i ing seen.
f am an emnloVer J*dv & n - , di g r. �,�aactots and their workers' comp. policy information.
r L1..tFZe worriers compensadotz incur
information ante for ny employem Beiow is theoft
P Cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lid. #:
Expiration Dai-:
Job Site Address:
Attach a Copy of the workers' comCity/State/Zip-
pen
sation policy declaration page (showing
Failure to secure coverage as required tinder Section 25A of b ( ng the policy number and expiration date).
fine up to $1,500.00 and/or one- tar imprisonment -e MGL e. 152 can lead to the imposition of criminal penahies of a
of up to 5250.00 a da against yV as H..1t as civil penalties in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insur'ancatcov, :a advised that a copy of this statein-nt may be forwarded to the Off.ic� of
coverage c-rificati.on,
I do hereby cerg6, r e pains and
penaiti„s oJperjurJ, than the in or
f mafion provided
Signature: above is true and correct
Date:
Phone #:
oflcial use "4- Dn not write in this areg to be completed b3, city or town OffixiaL
City or Town:
Issuing Authority (circle one): PermittL'cense #
1. Board of Health 2. Building Department 3. City/Town 4. Electrical Inspector 5. Piumbi o
6. Other ab Inspector
Contact Person:
Phone #
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
j
BUILDING PERMIT NUMBER:4/0 1 / DATE ISSUED: � /0-41
SIGNATURE:
Building Cd&m ssioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Number Parcel Number
/ t
(�?i I v i! -t �
l
�� � �t
1.3 Zoning Information:
Zoning Distrid Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Reqtiired Provide
Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54)
Public ❑ Private ❑ 1 Zone
1.5. Flood Zone Information:
Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record R
Name Q?rint)
Address for Service
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature
Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature
Telephone
R <
u
SECTION 4 - WORKERS COMPENSATION (KG.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 .......❑ No ....... 0
SECTION 5 Description of Proposed Work check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE -ONLY
�l
1. Building
(a) Building Permit Fee
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
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, iru all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, :B -NU, ? . as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A §ent Date
-11RU NMI Fm
NO. OF STORIES SIZE
BASEMENT OR SLAB
RD
SIZE OF FLOOR TIMBERS I 2 3
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
Location
i
Date
TOWN OF NORTH ANDOVER
L
Certificate Occupancy $
of
.► ;,S',^��'<�
s+cHusE
Building/Frame /Frame Permit Fee $
9
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #
1373
r- 60
r I( / l" L ,
Building Inspector
FORM U - LOT RELEASE FORM
li
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from -
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECT ION*" *********
APPLICANT S GCR� Q. Y1okrr' PHONEZ 1 Z"b
LOCATION: Assessors Map Number l PARCEL 51
SUBDIVISION LOT (S)
STRE_T � ST. NUMEER��
OFrICIAL USE ONLY
REC MENDATIONS OF TOWN AGENTS:
CONS :-,VATION ADMINISTRATOR DATE APPROVED KI l6 0
f DATE REJECTED
COMMENTS �l f7 �c a/?X 5 `'-, k1 __ k�6'/
TOWN PLANNER
COMMENTS
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATEAPPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT t
FIRE DEPARTMENT �BUILU NC ' Mi EENT
RECEIVED EY EUILDING ! ISPECTOR � DATE
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MASSACHUSETTS UNIFORM APPLICATION FOR P
Y!s,�t or Type) RMIT TO DO GASFIT-TING 7.5a
ass. Date L4 iq q 0o
Permit
Wilding
Owner's or's Nam
-type 01
New E3 I'llaxwallon C] Replacement: W--**'
V I-Tmvi
Plans Submitted: Ye2r-i an m.
Inst Ing
xi
Name d Licensed Plumber Or Gas'F_Hler
INSURANC
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Inst Ing
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Name d Licensed Plumber Or Gas'F_Hler
INSURANC
I have &'CUr
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U you hm,
. %I
Check onc.
E3 Corporation
13 prinaft
Insurance Pok-Yi Or As substantial -equivAlerA WhIc
No M h meets the requirements of
a the type coverage by checking the -appropriate box.
Other type -ofladonrifty 13 Bond Q
OWNER'S INSURANCE WAIVER"
: I am aware that the licensee
:tupter 142 of the Mass.General Laws. and that My signature does not have the Insurance coverage.required,by
on this Permit application waives this requke!'.t,
Check -one:
'a Adoot OwnerO Agent
ftof4byCW*tW_*&"' the detaps end InI01inAtI0n I have submitted (or entered) In above appitcation me bug and
owfodge and that git umbIng work and Installations 0=214 to UW best W my
odk,ont pioviale".01 Massachusetts Slate Code
undo( the permit issued for t
(a a his Application wig buhn =--moun—os *04�
and Chapter 142 of the Go Laws,
1j o"NuLicense:
itte Plumber gValurgof UC um of s at
OastitlorI
ri
. or Uconse Number %
Aulneyman
I .. - -*r-;: .1. '*.r
177
aftbamr-W,
ya
Check onc.
E3 Corporation
13 prinaft
Insurance Pok-Yi Or As substantial -equivAlerA WhIc
No M h meets the requirements of
a the type coverage by checking the -appropriate box.
Other type -ofladonrifty 13 Bond Q
OWNER'S INSURANCE WAIVER"
: I am aware that the licensee
:tupter 142 of the Mass.General Laws. and that My signature does not have the Insurance coverage.required,by
on this Permit application waives this requke!'.t,
Check -one:
'a Adoot OwnerO Agent
ftof4byCW*tW_*&"' the detaps end InI01inAtI0n I have submitted (or entered) In above appitcation me bug and
owfodge and that git umbIng work and Installations 0=214 to UW best W my
odk,ont pioviale".01 Massachusetts Slate Code
undo( the permit issued for t
(a a his Application wig buhn =--moun—os *04�
and Chapter 142 of the Go Laws,
1j o"NuLicense:
itte Plumber gValurgof UC um of s at
OastitlorI
ri
. or Uconse Number %
Aulneyman
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,ORToq TOWN OF NORTH ANDOVER a
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PERMIT FOR GAS INSTALLATION
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This certifies that
has permission for gas installation .. RA /-L y C .............. .
in the buildings of . ,q K y-4 -!'!............................
at ../. 9.5' -%t? 1 �.Z............. North Andover, Mass.
Fee.,;2.5- , Lic. No., . ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer