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HomeMy WebLinkAboutMiscellaneous - 100 OLD FARM ROAD 4/30/2018 (2)1; m 7-U Date.. �w l l� #(;v .... o? '`' TOWN OF NORTH ANDOVER PE MIT FOR GAS INSTALLATION • a . h SACHUS This certifies that ......f2..>.... . .. .... r !."............ . has permission for gas installation ..........'3 ...1�� :......... . in the buildings of .... ..:...... ...\ ..................... at ................ F. -,...t. ��.. , North Andover Mass., Fee... Lic. No...:?�.':� .r. `...:.P.�x�o, .. . GAS INSPECTOR Check # f} G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date OCT. 15, 2010 Permit # Building Location 100 OLD FARM RD Owner Tel# 978-258-2998 Owner's Name SCOTT A. BOWMAN Type of Occupancy RESIDENTIAL New 7 Renovation❑ Replacement Fl Plan Submitted: YesE] No[] FIXTURES Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter &vA ec . c - f -lay P 1- H AS INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have ```c ecked rtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy d 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: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I herebv certify that all of the details and information I have submitted (or entered) in above aonlication are true and accurate to the hest of m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter By Typ of License: 142 of the Geneaws. 'J( lumber Signature of Licensed Plumber or Gas Fitter Title • •Gas fitter • -Master •� O License Number J d O City/Town • -Journeyman APPROVED (OFFICE USE ONLY) Ll Aug, 12. 2010 9:36AM 14 0 No. 3096 P. 2 The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigadans 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance_ Affidavit: Builders/ContractorsMectricians/Plumbers Applicant Information Please Print Legibly Name (Busises00rpni2adorvUdivi&4, Address.-_ City/State/Zip: Phone ,a Are you.an employer? Check the appropriate box: 1. I S 4. ❑ I am a contractor and I Type of project (required): am_ a employer with general 6. New construction employees (fiil) and/or part-time).* 2: ❑ 1 am a sole proprietor or partner- - have hired the sub -contractors listed on the attached sheet: t 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. [] Demolition working for me in any capacity. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9, ❑ Building addition [No workers' comp, 10.11 Electrical repairs or additions required,] officers have exercised their 3. ❑ I am a homeowner doing all work -right of exemption per MGL 1 LE) 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'r 13.� Other �7dS comp. insurance required.] *My appliceat that cbedcs baa #1 must also fll cat the secdao below showing their wud=' moon poltry hAmudom t Homeowners who submit tbes affidavit and = teg they ate doing all work and then hire outside camtractots moat submit a bury affidavit hN iaama such. 1Ccntru:oots that ebeck this box mase uftched au sddon-1 l abeet showing the name of the stub cmaamus and tbaa workers' camp. polity ia�om .I am an employer that is provi ft woorken''. compensation i>ls/wunce for pry employees Below Is the policy and job site Insurance Company Name.- Policy ame:Policy # or Self -ins, Lic..#: tVC 7—,/ y/ 4.? X66 0,3a Expiration Date• /hall Eck Site Address: A-) O 0Ic l rQ V _^,\ e� -- City/Swwzip: 4tie)ou ✓rA l C, (' Attach a copy of the workers' compenutiou policy declaration page (showing the policy ouunber 2nd expiration dste). Failtm to secure coverage as required under Section 25A of MGL c,152 can lead to the uuposition of cdminal penalties of a futc up to S 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 W the Office of Investigations of the DIA for instuance coverage verification. X do-harby certify under thepains and p e informadon provided above is true and correct. Phone # -- Official use only. Do not write is this area, to be completed by city or town of7elal City or Town: Permit Ucense # Issuing Authority (circle one)-- 1. ne)_1. Board of health 2. Building Department 3. Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Phone Date, -5-0' 9'/!� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING N4ACMUSE` This certifies that ................ has permission to performe ...................... plumbing in the building of .................................. at ..................... , North And r, Mass. Fee13�1 ........... .f .1 : Lic. No. v ...... ....... PLUMBING INSPECTOR Check # 8 6 :-,) 1>1 } MASSACHUSETTS UNU ORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date `Q NORTH ANDOVER, MASSACHUSETTS Building Locations � ow ,�j9.��'1 Permit # Amount $ Owner's Name ,70yWW ,� , New Renovation • Replacement Plans Submitted �T�/ d (Print or typ� (' Name_ •�/{JWA414+J ��uOt i�U.6 JC/LV ICP S Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No13 If you have checked yes, please in .'zate the type coverage by checking the appropriate box. Liability insurance policy IT Other type of indemnity Bond 13 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 E] Agent 0 7 1,Arni,cr ..o.rt:�,+l,.,+ ..11 ,.C+L ,. .]..+...1_ __ � ��r_-__ _.• _ _ __ ___, ____ ___ ..- ..... .0 ...........-11— , --a ,uUL.u«u, kur cinerea) in aoove 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 the General Laws. (Title City/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 0 Gas Fitter 1-icense Nurnoer Master 1.=1 Heyman O, w � U � c. F o m x cz w z z F z � � w w w zd WD z o z c W � � ° z° > o ° � p SUB -BASE ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or typ� (' Name_ •�/{JWA414+J ��uOt i�U.6 JC/LV ICP S Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No13 If you have checked yes, please in .'zate the type coverage by checking the appropriate box. Liability insurance policy IT Other type of indemnity Bond 13 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 E] Agent 0 7 1,Arni,cr ..o.rt:�,+l,.,+ ..11 ,.C+L ,. .]..+...1_ __ � ��r_-__ _.• _ _ __ ___, ____ ___ ..- ..... .0 ...........-11— , --a ,uUL.u«u, kur cinerea) in aoove 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 the General Laws. (Title City/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 0 Gas Fitter 1-icense Nurnoer Master 1.=1 Heyman O, e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): — IZIVI"Wry Address: City/State/Zip: /�i'J►¢��►icG�/i�/� Q/�,j,5 Phone #: 97 f 9,941— Are ,941 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ElI am a general contractor and I employees (full and/or part-time).* 2• EE Tam a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other t:comaensatson p6IiC}' information. t Homeowners who submit this affidavit indicating they are doing all work and then Lure 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 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 n caldes of perjury that the information provided above is true and correct Si ature: 17ate S/a7�/) 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 #: #61 Information an d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every pe=rson in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs.persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal ofa license or permit to operate a business or to construct Suildings 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 r 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 —,turned to the city or town that the application for the pera it or license is being requested, not the Department of Industrial Accidents. Should you have any questions regardinLg the law or if you are required to .obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. . The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The 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-MASSAFF- Revised 5-26-05 Fax # 617-727-7749 v<rvcrvv.mass.. g ov/dia Date .....x.410... /...o TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...................... . ; .... . has permission for, gas installation in the buildings ofd...... at ...... , North Andover, Mass. Fee. ...:.. Lic. No...%.3.t/ .................... . GAS INSPECTOR Check # 72L.2 L-:] MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS / S !? Building Location < U �/Q �j¢,�y� %�� Date % It 0 Permit Owner N i!i✓ Amount New 0 Renovation M Replacement ❑ Plans Submitted Yes n No FTXTITRFC (Print or type) f,Q�// Check one: Certificate Installing Company Name )W Yt ,l td (l t1 rlt i .0 4 ��- 0 8. S Corp. Address hb��c 61: ❑Farmer. Business Telephone-7311,A42,07Firm/Co. Name of Licensed Plumber: 1-7ieh1~ 1-5jM1A1V0¢^) Insurance Coverage: Indicate the W of insurance coverage by checking the appropriate box: `.J Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent El 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 Stab' Code Cpter 142 of the General Laws. ' 4ma e o icy um /� Title Type of Plumbing License City/Townrcense um77 Der Master Master Journeyman APPIPROROVED tomcE usE orrLY !_I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 3Q jy ,) Pivot ",IAj Se,L Ukk_S Address: City/State/Zip: 3/4,0� 0+11 AW O/8 S Phone #: 4;2,0 "7 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I e;atployees (full and/or part-time).* have hired the sub -contractors 2. Uef I am a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other U.A. ruruSL also SIL out Loe section ^elnv. enna.n�b +.WVSr won- :Mpt— .-satioii pof.'cy information. fi 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 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 certifjtnder the pains a*enalties of perjury that the information provided above is true and correct !� // ., S127 Official use only. Do not write in this area, to be completed by city or town off ciaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: r 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 anotlier wlio 'employs persons to do maintenatice; 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 15.2, §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 cerdficate(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 cit or town that the application for the perni t or license is being requested, not the Departrmernt of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The 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. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/din Date . ` � ^ .�...... rJ ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ^l This certifies that v OEG �.!V .�G4,! ................................. .... .............................. has permission to perform ..... 3-52!�?" 5.... ........................ wiring in the building of .................1.--�!...................................... at ......,f DO �L jf ....�.................. . North Andover, Mass. 3s�4 E- /.... Fee .. 3�E._� -,T---.. Lic. No .............. ...................... .................. ELE&RICALINSPECTOR Check #- 8053 N Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. en ,�-) Occupancy and Fee Checked [Rev. 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 INK OR TYPE ALL INFORMATION) Date: 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) /15'n 6 L TI) rU m Owner or Tenant Owner's Address t,a Telephone No. Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building ,� i I D Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Ce loon of fl.., ! 11.. ..1.L . i _ _ 11 No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans .0 .G "t" ut: W"IVUu Vy Inc Ins ector o wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ nd grnd. No.—Of mergency Lighting Batteg Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of pones ' No. of Switches No. of Gas Burners No. of Detection and Devices No. of Ranges TotaInitiatin No. of Air Cond. Tons l No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: IN umber I.Tons KW No. of Se f -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances Kul No. of of No. Signs Ballasts Security Syst ems:* No. of Devices or E uivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications iring: No. of Devices or E uivalent OTHER: Attach additional detail !f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 2" BOND ❑ OTHER ❑ (Specify:) I certify, under the Eqj= and penalties of perjury, that the information on this application is true and complete. FIRM NAME: / LIC. NO.: Licensee: Signa C LIC. NO.:, 017 (If applicable enter " ,exempt in the license num e_r line. Bus. Tel. No.: ' 9�7 Address: IS 0380Alt. Tel. No.• G " - ` 33 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ m p4u,,t vi fiA,." I "I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 AEashington Street Boston, MA 02111 www ntass.gov/dia . Workers' Compensation Insiuranee Affidavit: Builders/Contractors/Electricians/Plumbers Aaplicant Information Please Print Le-vibly Name (Business/Organization/Individual) _ A I x Address: City/State/Zip:_ Q3� 1� Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2.. I am a sole proprietor or partner- listed on the attached sheet. _ ship and have no employees These sub -contractors have working for mein any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4),'and we have no insurance required.] t employees. [No workers' comp, insurance required.] Type of Project (required): 6. ❑ New construction 7. ❑ Remodeling 8. 0 Demolition 9. [] Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13.0 Other -Any applicant that checks bo)C # l must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit• indimting they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box mustattaehed an additional sheet -showing the name ofthe sub -contractors and their workers' comp. policy infom>ation. 14M an employer that is.providing workers' compensation insurance for my. employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 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 celify under the pains�a�alties n�nerjury that the information provided above is true and correct use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: f� 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 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 insumnce'coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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 pehnit 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/iicense applications in any given year, need. only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and. fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia 7777 0� % 2 CD /� _ \j »/ go o \9� go 2/t©>� _■ J5 S �\ 2� , \\ } 23 C-ALCt4L.19-r1fl/Cr �-, LLD(/f//�l3L/= DjS7-fZ16tiTEl,) 20190 w = PSF ,xI (nz/ps, 4n��) 6M LENGTN (L) TnIB Atz5A /C�#X IS, M //11, S Ala U,,y A4 11V, F z- OaQ, Z- 0/,5/3 IAI /V, }, 297 ,g cr-,Y //I/ ,gt ,VD ir✓& &0 is i a- N ~ } 1 TM by Weyerhaeuser March 17, 2008 Jackson Lumber Attn: Dennis Torrissi 215 Market Street Lawrence, MA Attached are TJ -Beam calculations based upon design information provided by Jackson Lumber of Lawrence, MA. These calculations can be identified by the following date and time in the upper left hand corner of each sheet: DESIGN DATE/TIME 3/17/2008 @ 7:42:30 AM The professional engineer's stamp on this letter verifies that the TJ -Beam® analyses for the member(s) shown conform to accepted engineering practice and use code accepted product design values. Each analysis reflects that the iLevel by Weyerhaeuser products, as shown, have adequate capacity for the loading conditions indicated. The input has not been produced nor reviewed for completeness or accuracy by a professional engineer. All notes, figures and design load information shown on these calculations must be reviewed to ensure the design loads, spans, bearing conditions and deflection criteria are acceptable for the specific application. Also, please verify that the roducts installed have the "Silent Floor®", "TJI ", "Microllame LVL", "Parallame PSL", or "Timberstrand LSU markings to confirm that this letter is valid for the products used. Please feel free to contact me if there are any questions regarding the analyses. Sincerely, Kathy J,"ougUrty, P.E. Structural}�i�me Engineer NE TC# 62560 �oW-or H Ab. '90 9\NAL Eta6� Northeast Technical Support ♦360 Route 101, Suite 2 ♦ Bedford, NH 03110 ♦ Phone 866-295-2170 ♦ Fax 603-218-6167 Pg 1 of 2 ■ 14 kmn-1. by Weyerhaeuser TJ -Beam 6.30 Serial Number: User: 2 3/17/2008 7:42:30 AM Page 1 Engine Version: 6.30.14 figured as self-supporting hip -roof system 3 PCS of 1 3/4" x 24" 1.9E Microllam® LVL THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE APPLICATION AND LOADS LISTED b 19" A Product Diagram is Corweptual. LOADS: Analysis is for a Header (Flush Beam) Member. Tributary Load Width: 7' 1 1/2" Primary Load Group - Residential - Sleeping Areas (psf): 30.0 Live at 100 % duration, 15.0 Dead Vertical Loads: Type Class Live Dead Location Application Comment Uniform(plf) Floor(1.00) 0.0 80.0 0 To 19' Adds To WALL Uniform(psf) Floor(1.00) 20.0 10.0 0 To 19' Adds To CEILING Uniform(plf) Snow(1.15) 300.0 90.0 0 To 19' Adds To ADDITION ROOF Uniform(plf) Snow(1.15) 713.0 214.0 0 To 19' Adds To MAIN ROOF SUPPORTS: Input Bearing Vertical Reactions (lbs) Detail Other Width Length Live/Dead/Uplift/Total 1 Stud wall 3.50" 8.37" 13008 / 5671 / 0 118679 A1: Blocking Custom Blocking 2 Stud wall 3.50" 8.37" 13008 / 5671 / 0 / 18679 A1: Blocking Custom Blocking -See iLevel® Specifier's/Builder's Guide for detail(s): Al: Blocking -Bearing length requirement exceeds input at support(s) 1, 2. Supplemental hardware is required to satisfy bearing requirements. DESIGN CONTROLS: Maximum Shear (lbs) 18351 Moment (Ft -Lbs) 85638 Live Load Defl (in) Total Load Defl (in) Design Control Result -14173 27531 Passed (51%) 85638 114283 Passed (75%) 0.383 0.467 Passed (L1585) 0.550 0.933 Passed (L1407) Location Rt. end Span 1 under Snow loading MID Span 1 under Snow loading MID Span 1 under Snow loading MID Span 1 under Snow loading q/1 -Deflection Criteria: STAN DARD(LL:L/480,TL:L/240). -Bracing(Lu): All compression edges (top and bottom) must be braced at 3' 10" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability. ADDITIONAL NOTES: -IMPORTANT! The analysis presented is output from software developed by iLevel®. iLevel® warrants the sizing of its products by this software will be accomplished in accordance with iLevel® product design criteria and code accepted design values. The specific product application, input design loads, and stated dimensions have been provided by the software user. This output has not been reviewed by an iLevel® Associate. -Not all products are readily available. Check with your supplier or iLevel® technical representative for product availability. -THIS ANALYSIS FOR iLevel® PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. -Allowable Stress Design methodology was used for Building Code IBC analyzing the iLevel® Distribution product listed above. -Note: See iLevel® Specifier's/Builder's Guide for multiple ply connection. Operator Notes: The professional engineer's stamp verifies the analysis shown conforms to accepted engineering practice and uses code accepted design properties. Weyerhaeuser Engineering has not reviewed the project plans or visited the job site, however, Weyerhaeuser guarantees the member shown has adequate capacity for the design conditions indicated. This calculation must be reviewed with the designer of record and/or the local code official to ensure the information shown is acceptable for the specific application. DESIGN LOADS AND DIMENSIONS HAVE BEEN PROVIDED BY DENNIS TORRISSI, JACKSON LUMBER PROJECT INFORMATION: Jackson Lumber Lawrence, MA Attn: Dennis T. Joe Blanchet Job 100 Old Farm Road North Andover, MA Copyright 0 2007 by iLevel©, Federal Way, WA. Microllam® is a registered trademark of iLevelO. D:\Documents and Settings\doughek\Desktop\header.sms OPERATOR INFORMATION: iLevel 360 Route 101, Suite 2 Bedford, NH 03110 Phone: (603) 472-6730 Fax :(603)472.6733 y 03•/18/2008 TUE 14:09 FAX 603 472 6733 New England Region Q002/002 figured as self-supporting hip -roof system r�I 3 Pes of 13/4" x 14" 1.9E Microllam® LVL by „vYn.hocusC. TJ-Beam96.30 Serial Number: THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE ,24 User: 2 3118/2008 2:04:59 PM Pagel Engine Version: 6.30.14 APPLICATION AND LOADS LISTED 52 Z a, a d 12• Product diagram is Conceptual. LOADS: Input Analysis is for a Header (Flush Beam) Member. Tributary Load Width: 7' 1 1/2" Width Primary Load Group - Residential - Living Areas (psf): 30.0 Live at 100 % duration. 15.0 Dead Vertical Loads: 5.25" 8216/ 3495 /0 /11710 2 Stud wall 3.50" Type Class Live Dead Location Application Comment Uniform(plf) Floor(1.00) 0.0 80.0 0 To 12' Adds To WALL Uniform(psf) Floor(1.00) 20.0 10.0 0 To 12' Adds To CEILING Uniform(plf) Snow(1.15) 300.0 90.0 0 To 12' Adds To ADDITION ROOF Uniform(plf) Snow(1.15) 713.0 214.0 0 To 12' Adds To MAIN ROOF SUPPORTS: Input Bearing Vertical Reactions (lbs) Width Length LivelDead/Upliff/Total 1 Slud wall 3.50" 5.25" 8216/ 3495 /0 /11710 2 Stud wall 3.50" 5,25" 8216 / 3495/0111710 Detail Other A1: Blocking 1 Ply 1 314" x 14" 1.9E Micro0an* LVL At: Blocking 1 Ply 1 3/4" x 14" 1.9E Miciollam5l LVL -See iLevel® Specifier's/Builder s Guide for detail(s): AV Blocking -Bearing length requirement exceeds input at support(s)1. 2. Supplemental hardware is required to satisfy bearing requirements. DESIGN CONTROLS: Maximum Design Control Result Location Shear Obs) 11385 -8864 16060 Passed (55%) Rt. end Span 1 under Snow loading Moment (Ft -lbs) 33206 33206 41646 Passed (79%) MID Span 1 under Snow loading Live Load Deft (in) 0,289 0.292 Passed (U485) MID Span 1 under Snow loading Total Load Deft (in) 0.411 0,583 Passed (L/340) MID Span 1 under Snow loading -Defleclion Criteria: STANDARD(LL:L/480,TL:L/240). -Braang(Lu): All compression edges (lop and bottom) must be braced at V 9° o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability. ADDITIONAL NOTES: -IMPORTANT! The analysis presented is output from software developed by iLevei�. il.eve!(Dwarrants the sizing of its products by this software will be accomplished in accordance with iLevel® product design criteria and code accepted design values. The specific product application, input design loads, and stated dimensions have been provided by the software user. This output has not been reviewed by an iLevel© Associate. -Not all products are readily available. Check with your supplier or ileve[O technical representative for product availability. -THIS ANALYSIS FOR iLevel0 PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. -Allowable Stress Design methodology was used for Building Code IBC analyzing the iLevel® Distribution product listed above. -Note: See iLeve);D Specifier's/Builder•s Guide for multiple ply connection. PROJECT INFORMATION: Jackson Lumber Lawrence, MA Attn: Dennis T. Joe B!anchet Job 100 Old Farm Road North Andover, MA Copyright ° 2007 by iLevel°, Federal way, TVA, aw, is a registered trademark of i.Levein. z4icro!). D<\Documents and Settings\doughek\Desktop\lteaderKSD.sms OPERATOR INFORMATION: iLevel 360 Route 101, Suite 2 Bedford, NH 03110 Phone: (603) 472-6730 Fax :(603)472.6733 „0l -,Fl „9-,Zl =� II cn II I � w (I M v r (I r II `� Z II Jo 4 II O O J N ¢ O� L� DESIGN PROPERTIES Z/q Design Stresses (1) Reference modulus of elasticity for beam stability and column stability calculations, per NDS® 2005. (2) For 12" depth. For other depths, multiply F6 by the appropriate factor as follows: 0.092 Beam — For TimberStrand® LSL, multiply by �d12� 12 0.136 — For Microllam® LVL, multiply by d 12 0.111 — For Parallam® PSL, multiply by d (3) F, has been adjusted to reflect the volume effects for most standard applications. (4) Fcl shall not be increased for duration of load. (5) For lateral connection design only. (6) Specific gravity of 0.58 may be used for bolts installed perpendicular to face and loaded perpendicular to grain. (7) Values are for thickness up to W?. (8) Values account for large hole capabilities. See Allowable Holes on page 36. (9) Values are for plank orientation. Column General Assumptions for iLevel® Trus Joist® Residential Beams i ■ Lateral support is required at bearing and along the span at 24" on -center, II maximum. ■ Bearing lengths are based on each product's bearing stress for applicable grade and orientation. J ■ All members 714" and less in depth are restricted to a maximum deflection of 5/16". ■ Beams that are 1Y4" x 16" and deeper require multiple plies. ■ No camber. ■ Tables on pages 8-15 include load reductions applied in accordance with code. Plank For applications not covered in this brochure, contact your iLevel representative. See pages 38 and 39 for multiple -member beam connections. TimberStrand® LSL, Nicrollam0 LVL, and untreated Parallam® PSL are intended for dry -use applications Product Storage Protect product from sun and water CAUTION. Wrap is slippery when wet or icy Use support blocks at Won -center to keep bundles out of mud and water Level Trus Joist- Beam, Header, and Column Specifier's Guide TJ -9000 March 2008 5 6 E Emin F' Fcl Fcu Fr SG Shear Modulus Adjusted Flexural ral Tension Compression Compression Horizontal Equivalent Grade Orientation Modulus of Elasticity Modulus Stress(2) Stress(3) Perpendicular Parallel Shear Parallel Specific of Elasticity (psi) of Elasticity nl (psi) (psi) to brain to Grain to Grain Gravity(5) (psi) (psi) (psi) (psi) (psi) Beam/Column 81,250 1.3 x 106 660,750 1,700 1,075 680 1,400 400 0.50(6) 1.3E Plank 81,250 1 1.3 x 106 660,750 1,900(7) 1,075 435 1,400 150 0.50(fi) 1.55E Beam 96,875 1.55 x 106 787,815 2 325 1070(8) 800 2 050 310(8) 0.50(6) 1.9E Beam 118,750 1.9 x 106 965,710 2,600 ( 1,555 750 I 2,510 1 285 1 0.50 1.8E Column 112,500 1.8 x 106 914,880 2,400(9) 1,755 425191 2,500 190191 0.50 2.0E Beam 125,000 2.0 x 106 1016,535 2,900 2,025 750 T 2,900 ; 290 0.50 (1) Reference modulus of elasticity for beam stability and column stability calculations, per NDS® 2005. (2) For 12" depth. For other depths, multiply F6 by the appropriate factor as follows: 0.092 Beam — For TimberStrand® LSL, multiply by �d12� 12 0.136 — For Microllam® LVL, multiply by d 12 0.111 — For Parallam® PSL, multiply by d (3) F, has been adjusted to reflect the volume effects for most standard applications. (4) Fcl shall not be increased for duration of load. (5) For lateral connection design only. (6) Specific gravity of 0.58 may be used for bolts installed perpendicular to face and loaded perpendicular to grain. (7) Values are for thickness up to W?. (8) Values account for large hole capabilities. See Allowable Holes on page 36. (9) Values are for plank orientation. Column General Assumptions for iLevel® Trus Joist® Residential Beams i ■ Lateral support is required at bearing and along the span at 24" on -center, II maximum. ■ Bearing lengths are based on each product's bearing stress for applicable grade and orientation. J ■ All members 714" and less in depth are restricted to a maximum deflection of 5/16". ■ Beams that are 1Y4" x 16" and deeper require multiple plies. ■ No camber. ■ Tables on pages 8-15 include load reductions applied in accordance with code. Plank For applications not covered in this brochure, contact your iLevel representative. See pages 38 and 39 for multiple -member beam connections. TimberStrand® LSL, Nicrollam0 LVL, and untreated Parallam® PSL are intended for dry -use applications Product Storage Protect product from sun and water CAUTION. Wrap is slippery when wet or icy Use support blocks at Won -center to keep bundles out of mud and water Level Trus Joist- Beam, Header, and Column Specifier's Guide TJ -9000 March 2008 5 PER311T NO.__�u "v L L m APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER. MASS. / PAGE 1 MAP KVO. I LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK :PAGE NE �.� SUB DIV. LOT NO. LOCATION % PURPOSE ( Z S L� NER'S NAME�JN1c7 —D ' 1 NO. OF STORIES SIZE OWNER'S ADDRESS.,gA BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME f t -4,\S' �H Stj-C_6S ` j ' DISTANCE TO NEAREST BUILDING SPAN DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET 00 T -, —I + DISTANCE FROM LOT LINES — SIDES36 REAR JCg GIRDERS AREA OF LOT - FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS-UUILDING ALTERATION () IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Y¢s L IS BUILDING CONNECTED TO TOWN WATER /avARD OF APPEALS ACTION. IF ANY Nrr L'� ���••: IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES L� PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST %E Fl�p APPROVED BY BUILDING INSPECTOR h L OR AUTHORIZED AGENT FEE r PERMIT GRANTED 19 OCT - 7 1998 3 PROPERTY INFORMATION LAND COST BLDG. COST Zd00 OLS EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. #5D? 0 3 CONTR. TEL. # CONTR. LIC. # H.I.C. # BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH d t 2 I3 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE P PIERS PLASTER DRY VJALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 'J, 72 �/, FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS DROP SIDING WOOD SHINGLES CONCRETE EARTH B 1 2 3 _ _ _ ASPHALT SIDING ASBESTOS SIDING VERT. SIDING HARDVJ'D COMMON ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR BRICK ON FRAME I_ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE HIP BATH 13 FIX.) GAMBQEL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. S COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL ELECTRIC B'M'T 2nd _ t:r 13rd NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. ) CO) C � o O H n CD -v o a Z to CL Og C� d ? C CO) O CD CD O Q CD CD O CD C CD ViCDm CZ O y CC CD � v CO2 O 10 Z CD a O • CD O CCD Im cn cn J 0 cn 0 cn c cncn C C ?=o ca o d = rO -- Q N 0 1'Y � �7 p CL Elm pm n1 O CD co N C.) y p Z ?= CA -� m CL C Mn =rm a =r m o m O N O .► .0 ; p —1 > Emm > a o: o,� o o 0 Zseo-i CD C aN �•� CL to o ? CD N . CD ' C O m O. N OIW N N C d p=j : Q C o o. O y m c D m t0 N 9 _? N :E N m m Z7 ' m .-► O O no c. moi G z ff CD CD =r Cl) m o N .� CD o m : 1 4 o. C-) o 0 0;, C, c o per. O { cncn O R 1w.l �$ 0 1'Y � O 0 p O 0• y p x M 0 x H 0 9 0 c FORM U - VERIFICATION FORM 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 local or state law, regulations or requirements. * ***********_****Applicant fil out this section********_********* APPLICANT. 1 YEA I/� (� 1 J , 1 1A Phone LOCATION: Assessor's Map Number 035 Parcel C>0��^ Subdivision Lots) Street /00 04(D F'&9::g., St. Number /vy ********************** Official Use Only************************ OMMENDATTONS T AGENTS: -'� Date Approved Conservation Admini trator Date Re'ected Comments _ � � /`I li W e �,5 !� /Od Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected Date Approved Septic Inspector -Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire.Department Received by Building InspectorDate —_ '�T�--r� Ire