HomeMy WebLinkAboutMiscellaneous - 101 BRUIN HILL ROAD 4/30/2018 (2)Date ......r......-'� ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that.......�� ........................
has permission to perform ........ 5y.Y1.tJ (�R �,Pl, �.
............... ........ ...........................
wiring in the building of.................7%.Cap"j .................................................................
at .....:..I. D . � -A .)
............................................, dover, Mass.
Fee .............................. Lic. No.IOXI`1! f ................ ,.............. ...
ELE ALINSP OR
Check 4 - of, olL_0.. C' t CJS v�^ 3 Or t
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official
,Use
r Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code QfQ, 5 7 CMR 12.00
(PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: X1114?11 3
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)
Owner or Tenant
Owner's Address %a /
Is this permit in conjunction with a building permit?
No.
Yes ❑ No EA--" (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Number of Feeders and Ampacity
w Location and Nature of Proposed Electrical Work:
ya
Completion ofthe followine table may be 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
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool rnd. ❑ rnd. E]Batte
o. o Emergency Lighting
Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste;Disposers
Heat Pump
Totals:
Number
Tons
"
KW
"'..
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of El ctric Work: (When required by municipal policy.)
Work to Start: Z Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO RAGE: 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 pen Ities of perjury, 1 t the information on this pplication is true and complete.
FIRMNAME: /��_ r��_L.rct//C� �. LIC. NO.:osD.
Licensee: /H�.�
LIC. NO.
(If applicable, enter "exempt" in t e license nu er line.) / Bus. Tel. No.•
Address: /'!� v3D % Alt. Tel. No -
*Per M.G.L c. 147, s. 5776 , security work requires b6parinierit of Public afety "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 PERMIT FEE. $
Signature � Telephone No.
❑ 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
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
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
i✓'
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSIVECTION..
Pass IN
Failed ❑
Re- Inspection Required ($.) ❑
Inspectors COMM
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts -
Department of Industrial Accidents
Office of Investigations
qV 600 Washington Street
.Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Address:
City/State/Zip: 2 �/L l�i���/ jX ��3� Phone #: SV el r9 f L5 6
Are you an employer? Check the appropriate box:
Type of project (required):
1.P44 -am a employer with //
T
4. El am a general contractor and I
6. E] New construction
employees (full and/or part-time). �
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.1
7. ❑ Remodeling
ship and'haveno employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
g, E] Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.F1 Electrical repairs or additions
required.]
officers have exercised they
3111 am a homeowner doing all work
right of exemption per MGL
11. ❑ Plumbing repairs or additions
myself. [No4orkers' comp.
c. 152, §1(4), and we have no
12.❑ Roof repairs
insurance required.] t
employees. [No workers'
13.❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 N
Policy # or Self -ins. Lic. #: Expiration Date: z y
Job Site Address:%6/ &—oz4 4Tjl 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 requiredunder 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 Izereby certder tyre pry' rs and penalti�of perjury that the information provided above is trye and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitUcense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone #:
Information and Instructions -
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, •
express or implied, oral or. written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -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 maybe 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 retained 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 (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 l dustdal ,A,ccidents
Office of Investigations
600 Wa.sbingtm Street
Boston, MA. 02111
Tel # 617-727-4900 oxt 406 or 1-877:MASSAFE
Revised 5-26-05 Fax # 617-727-7749
__www-mass,govldia
IF,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... #
....................................................
has permission to perform .....
.4 . ... ................................
wiring in the building of. -gill ....................................... ...........................................
.......... ........ ........................... Andover, Mss.
Fee .�?-.r ........ Lic. No -413.44'.....
.... . ..... ...
LE CAL INSPECTOR
Check #
11712 V
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 111 �7 12 -
Occupancy and Fee Checked
[Rev- 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC / 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: J 1" 3
City or Town oh NORTH ANDOVER To the Inspec or of Wires:
By this application the undersigned gives notice of his or her intention perform the ele ical work described below.
Location (Street & Number) /0 1 4?te0j-V //"//%�7 / LV/ cb nk 3 h� 4 )
Owner or Tenant
Owner's Address
Is this permit in conjunction with a bull ing permit? Yes Q
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Telephone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work: &//P,,a
Completion of the.followinQ table may be 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
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool rnd. ❑ rnd. ❑
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Number"
Tons
'""".........."'.....""'"......""'.'"
KW
No. of Self -Contained
Detection/Alerting Devices
No. of -Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as regtdred by the Inspector of Wires.
Estimated Value of E ct cal Work: (When required by municipal policy.)
Work to Start: l e /2 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 ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:)
X certify, antler the pains and enalties of perj ry tha�e f nfor�zation on this application is true and complete.
FIRM NAME:. r �l cxG ���� LIC. NO.: /030 lt12
Licensee: ok.d A2 Signature LIC. NO.: 3G I/O
(If applicable, enter "exempt" 'n the lice a number line) �� Bus. Tel. Ng.-
Address: , (��,�lt�/ fjfj c� % s`� 0 3a3j Alt. Tel.d ® G
*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 PERMIT FEE: $
Signature Telephone No.
❑ 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
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. y
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.
1
❑ 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 R — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL, ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
.z
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Commen s:
Inspectors Signature:
Date:
FINAL., INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors m nts:
Cwt. ��Z o -
3 M
Inspector ignature: t
Date:
DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of IndustrialAccidints
Office of Investigations
UT 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:__
City/State/Zip: �ce/L�,`r���� 42&7 Phone #:
Are you an employer? Check the appropriate box:
1
1.91 am a employer with /
4. ❑ I am a general contractor and I
_
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. t
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself.- [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
ILEI Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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:. R— /V _z/,: -
Policy # or Self -ins. Lic. #: - Expiration Date:
Job Site Address:_ City/State/Zip:___�,�
�ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 cero under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, •
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -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, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom .
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or t�
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. Anew 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, # 617-7274900 oxt 406 or 1-877, MASSAE&
Revised 5-26-05 Fax # 617-727-7749
www.n�ass,govfdxa
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Date.....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that,
............ ...........................................................................
has permission to perform........0677x/ ......................................................
wiring in the building of
at ......t 0/
... U........North
—Andover, Mass.
Fee.. .... Lic. No PAS... M'.`........ �' .1�/ ... .!...
2 ELECTRICAL INSPECTORS
Check # J i14J(/
4�
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] nrava hi,,,v�
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrica4Insectorof
5 CMR 12.00
(PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 11 p V
City or Town of. NORTH ANDOVER To the Wires:
By this application the undersigned gives notice of his or her intentio` to perform the electrical work described below.
Location (Street & Number) / p/ Seol /./"// .4
Owner or Tenant'1
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service
APs / Volts
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
Yes ® No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Estimated Value oflectri al Work:
ntiucn aaamonai aetait Ydesired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start:—Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VERAGLf
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 g BOND ❑ OTHER ❑ (Specify:)
I certify, p �'�)
under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME:
Licensee: .e ._ .� Signature � LIC. NO.: Zd_ ;j o V4
(If applicable, enter "exempt " in the license number line) - LIC. NO.:
Address: Bus. Tel. No..�G3I�3
*Per M.G.L c. 147, s. 57-61, security work requires D ty "S" Alt. Tel. No.& I�Ji� e�
cense: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Lecens a 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. $
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
c ` www »:assgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ppllcant InfilrMni-inn
Name (Business/Organization/individual):
City/State/Zip:
Phone #: Gn 4 ,i'ye
Type of project (required):
6. []New construction
7. ❑ Remodeling
8. [] Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11 -El Plumbing repairs or additions
I2.[] Roof repairs
13.[] Other
Homeowners who submit this affidavit n.
indicating they are doing all work and then hire outside c ntractors mustubmitt aanew affidavit indicating such.
$Contractors that check this box must attached an additional sheat showing the Hama of the sub -contractors and their Worts camp. , .tick infonna6n.
I ant an employer that is providing:workers' compensation insurance for my. employees: Below is the policy and job site
informatior4
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date: G 3e
Job Site Address: 1,:o l �ll/ti
CityYState/Zip. 14
Attach a copy of the workers' co
policy 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.
do
penalties of perjury that the information provided oho is truc*d correct
Official ase 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 #:
Are you an employer? Check the appropriate box:
1. J� i' am a employer with
4. ❑ I am a general contractorand I
employees (full and/or part-time).*
2. ❑ I am a.sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet. t
ship and have no employees
These subs -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 ain a homeowner doing
officers have exercised their
exemption
all work
right of per MGL
myself. [No -workers' comp,
c. 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
'Any applicant that checks boy(# 1 must also fit, out the section below showing their workers' Com sat'
Type of project (required):
6. []New construction
7. ❑ Remodeling
8. [] Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11 -El Plumbing repairs or additions
I2.[] Roof repairs
13.[] Other
Homeowners who submit this affidavit n.
indicating they are doing all work and then hire outside c ntractors mustubmitt aanew affidavit indicating such.
$Contractors that check this box must attached an additional sheat showing the Hama of the sub -contractors and their Worts camp. , .tick infonna6n.
I ant an employer that is providing:workers' compensation insurance for my. employees: Below is the policy and job site
informatior4
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date: G 3e
Job Site Address: 1,:o l �ll/ti
CityYState/Zip. 14
Attach a copy of the workers' co
policy 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.
do
penalties of perjury that the information provided oho is truc*d correct
Official ase 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 #:
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 insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cant' 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 paliFy, 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 %bill be used as a reference number. in addition, an applicant
that must submit multiple permit/liaerm 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 InvestigAptions 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-770�
www.mass.gov/dia
Date. .............
SaTOWN OF NORTH ANDOVER
, o
p PERMIT FOR PLUMBING
This certifies that ./' .A' !!.J..t fit .................
has permission to perform..........................
...............
plumbing in the buildings of 20!-? i/4 -n. ....... .
at ..w.. `'!'" j''�j ......... North Andover, Mass.
Fee .377! ? ' . Lic. No. .........................
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PE
(Type or print)' TO DO PLUMgIIVG
NORTH ANDOVER, MASSACHUSETTS '
Building Location
New ❑
Renovation
Type of
Replacement '❑
FUTURES
,z / Date.
/'�li Permit #
Amount
Plans Submitted yesElElNo
.
y Name iG `jl Check one: Certificate
ElCorp.
)ne D 29' S3S��
Name of Licensed Plumber: L�..I Firrii/Co'
Insurance Coverage: Indicate the type of insurance g h c
Liability insurance policy tang the appropriate box:
W1 Other type of inderrtuity ElBond
;
Insurance Waiver I the undersigned, have been made aware that the licensee of application does not have
three insurance
any one of the above
slam Ire ❑
Owner ❑
I hereby certify that all of the details and infor4Massac
Agent
best of my knowledge, and that all plumbing ws'ted (OI entered) m above application are true and accurate to the
compliance with all pertinent provisions of thete POanj er Permit issued for this application will be in
umbm� ae d Cha ter l42BF. P of fhe General Laws.
ra 1uTitle ing License
City/Town a/
APPROVED comics usa oNLY 1-1Len�umoer meter
ElJourneyman [�j
I he Commonwealth of Massachusetts
Department of Industrial Accidents
Office of jrn,estigatiorrs
600 .-Thinvon Street
Bostorn, 1SIA 02111
Ww'N.'-h?4SS.e01��dil1
Workers' Compensation Itisurance.A�da�,t_ guilders/Contractors/Eleciricia
Acant Information ns/Piumbers
Maine (Busines`s//OOrganization/individual):
City/State/Zi.:
F ---
Are you an employer? Check the appropriate box:
Phone
amp oyer with 4. ❑ I am a general contractor and I
. ❑emp}oyees (full and/or part-time).* have. hired the sub -contractors
i am a sole proprietor or partner_ listed on the attached sheet t
ship and have no employees These sul>-con�a rs have
working for me in any capacity. workers'
[No workers' comp. insurance 5.. ❑ We are . comp. insurance.
Of;;,required_] a corporation and its
3. ❑ I am a homeowner doing all work
Myself . [No workers' comp.
insurance required,] t
ers have erercised.their
right of exemption per MGL
C. 152, § 1, (4), and we have no
'employees. [No .workers'
comp, ins
Type of project (required):
.6, ❑ New construction
7• ❑ Remodeling .
8. ❑ Demolition
9• ❑ Building addition
0:❑ Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12:[l Roof repairs
urance required.] I 13 ❑Other
`Any applicant that checks box # 1 .must also fill Out the section below showing their workers' compensation pobcy �nrormat�on.
t hlomcowners wlio submh •flus affidevit indicarinb t,`�ep are .sing �t t.;
7Conuarrors that check this box must a=hed an additional sheet showi 'u Eren hire outsi& contraciurs roust submit a new
tt� the name of the sub ocn�zctors affidavit irdi=bng sash.
and their w—i,-
-- pru "Jame iijrirfierS ' CO - --"'r• rte= �Y �momlariorl,
information. mpensatioa insurance for ng' employees, Below is throff
P cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
.lob Site Address:
Attach a copy of the workers' compensation policy declaration o City/3tate-/Gip.
.Failure to secure coverage as required under Section 25A of pace (showing, the policy number and expiration date),
fine up to $1,500.00 and/or one-year imprisonment as well MGL c. 152 can lead to the imposition of
as civil p aminal penalties of 8_
of up to .5250.00 a day against the violator. Be advised that a Penalties in the form of a STOP WORK ORDER and a fine
Investigations of.the DIA for insurance cov,,;-age verification, copy of this statement may be forwarded, to the Office of
n
J au nereoy cent; fjre2e, er the pains �e�� of perjury' that the informailon provided above is frac and correct
S}Qriature: .
Official use only. Do not write in this area, to be cornpletedh
)% city or town ofj-
iciaL
Cite or Town:
lssuiag Authority (circle one):
Permit/License #
d?i/09
I. Board of Health 2. Building Department 3. CifylTown Clerk 4. --
6. Other Electrical Inspector S. Plumbino
Inspector
Contact Person:
Phone tr
N2 1804
Date.. �9_ ;2. - �;r
...........................
TOWN OF -NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
.0 I ..j . ...................... ........................................
has permission to perform . .............................
wiring in the building
of ..................../..................�...............................................
at ..../q/........ ...... .......?1........ Norhkhdover, Mas.
Fees �._.,. go ...... Lic. No&Z:v
.... . ...ELECTRICAL ---...............
- --INSPECTOR
P. -E. C. -T. 0.- R- ..
08/04/99 11:18
'50E
PAID
WHITE: Appildaht --.,,,.q,�NARY: Building ept. PINK: Treasurer
THE C.PWONWE4LTHOFM45S4aA:SEM Office Use only
I DEPARTMF.NTOFPUBLICSAPEIY Permit No. Atr
BO* OF PVE PRL11=0NREGULA770AS527CMR12:00
Occupancy &Fees Checked
FORWARD v7 9
APPLI IIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRLNT IN INK OR TYPE ALL INFORMATION) Date4�"
Town of North .Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
V; Y7 141,2�
Owner or Tenant 9/91 L Z:L 0 ,
Owner's .Address S fiyvj F
MAP ,�;Z J O %o �To the
PARCEL 00 '/ 2-0 0 ff
-tor of Wires:
Is this permit in conjunction with a building permit: YesNo (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existine Service Amps / Volts Overhead Underground ® No. of?vleters
New Service Amps / Volts Overhead Underground No. of�leters
Number of Feeders and Ampaciry
Location and Nature of Proposed Electrical Work W INg /2 54c, "Oa0 L
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
and Fy
around
No. of Reccptacie Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No orf nges
No. of Air Cond. Total
j
Tons
No. of Detection and
No of tJ sTosals
No.' of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
i
No of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Locala Municipal
Other
No of Dryers
Heating Devices KW
Connections
No of Water Heaters KW
No. of No. of
Signs
Bailasis
No Hvcro ,`tassage TubS
No. of Motors
Total HP
OTHER
lrr a. Com Raaartt so the reatmt: c€I l-ssad gets Gataai Laws
Itie a arra tt Liabitay hmrarre Pdicy ° Crn>plcle OpffawCaeca or' s sttaral E YES ti0
I ha`e s bri tined \,atid pcofofsame io the OffL-- YES ►;rNlo 1 Ifjcu have d YES pl�e tt� type dcavg by g
bcx
�
NSL'R.ANCE /BOND ® OTHM ® (Please Spa*)
Tgcprm
�^ 3^ %�' Etat D=
�y E V'aluedE'�uiCal Wait S
Wort; to Scan _! C -Z ''kq)ec r_n Dap. Rid Rcxigh Feral
Sig l ta-J±rT
FIRM N,A,'v>E ZLF- ► l v► &7,6 Y,ie- 7W L Co 47- Lr=-tse iVa _ I > a zl 3 �
Lime Z I -KC 13n �d Y �%' Sim lae ._ L rrseNo �/� 3 '60
Bts�sTel 77�64EZ 5-2/2'
T-1 vk-// rr k9 a P /,1L Ai Td \a
OWNER'S LNEL RANGE W.AIVtR 1 an axare tirac Lxa�z des the icsu- Q ¢s su r al mmaiaa as to uzd by is C� -� Lays
i�d tip rrry sz2f>aasern tics p� � tis tax�errix.
(Please check one) Owner Agent
' Telephone No. PERMIT FEL 5
-y
W _
ocationz D�_-�
No. c� Dr Date
JUNE
r
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
i3uiJ_dpg/Frame Permit Fee $
Foan�ion�i�� "'�-•�-
G�,eui
Other Permit Fe $ S 0
Sewer Connection Fee $
'Z4,44*36onnection Fee $
TOQT*LA $
Building Inspector
6261
Div. Public Works
PER11IT NO.. Q � APPLICATION FOR PERMIT TO BUILD — NORTH\ANDOVER, MASS. 1'A
1,
v
MAP 4.40.
I LOT NO.
2 RECORD O OWNERSHIP iDATE
BOOK 'PAGE
ZONE
SUB DIV. LOT NO//.
-
OCATION 40Z ,✓ ,�-�S.LP/✓
PURPOSE OF BUILDING
JCY�-
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS i�/��/j/ i'J/L� �f,
BASEMENT OR SLAB /!ten 6 �z
T'S NAME
SPANSIZE OF FLOOR TIMBERS IST 2N „ /r-
dq
BUCILOERCS NAME �./�I�
DISTANCE TO NEAREST B DING �^�
DIMENSIONS OF SILLS
DISTANCE
DISTANCE FROM STREET /C�
L-
"" POSTS��x
DISTANCE FROM LOT LINESSIDES 00 REAR `
"' GIRDERS'
R,�E-E4�
AREA OF LOT Z,,%�. /1('Qs �. FRONTAGE,41!5nn
! �7LJ
HEIGHT OF FOUNDATION f Orf,)frsG ICKNESS
"]' V"l �+iv/,>X
IS BUILDING NEW
SIZE OF FOOTING
IS BUILDING ADDITION'Mx,Lm.ikt:
S �jti
OF Gil MNSV o �//n,,,�p
IS BUILDING ALTERATION
IS BUILDING O SOLID R FILLED LAND �,(dx�
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE >oe
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER z ��
IS BUILDING CONNECTED TO NATURAL GAS LINE T J�l �.✓/��4�^�Z
INSTRUCTIONS
SEE BOTH SIDES
/d1
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
PI ANS MUST BE FILED Np QPROVED BY BUILDING INSPECTOR
�YDIyT, FILED
SI
GNATURE OF OWNER OR AUTHORIZED AGENT
FEE �fScS V
NER TEL.
PERMIT GRANTED CONTR. TEL. # �<
+.q 19 A- CONTR. LIC. # -
T-
JUN 2 3 199 �ego
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST e7�j
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
IllVILL7INa INN
.r
1 OCCUPANCY
SINGLE FAMILY
CLAPBOARDS
-DROP SIDING
WOOD SHINGLES
STORIES
MULTI. FAMILY
1
OFFICES
_
APARTMENTS
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
_
CONSTRUCTION
2 FOUNDATION
—I
8 INTERIOR FINISH
CONCRETE
PINE
HARDW D
3
1
2 13
CONCRETE BL K.
BRICK OR STONE
PIERS
PLASTER
B'M'T 2nd _
1st 13rd, I
DRY WALL
5 ROOF
GABLE f I HIP
GAMBREL MANSARD
FL AT SHED
—yf
�I
BATH (3 FIX.)
WATER CLOSET
_
—
_
UNFIN.
3 BASEMENT
AREA FULL
FIN. B M'T' AREA
'/ 1/7 1/.
FIN. ATTIC AREA
_
N_O B M T
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
_
BUILDING RECORD 1
12
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.
4 WALLS
I, . 9 FLOORS
STEAM
CLAPBOARDS
-DROP SIDING
WOOD SHINGLES
B
_
1
2
�_
3
_
_
_
CONCRETE
EARTH
HARDV''D
COMMON
ASPH. TILE
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
STUCCO ON MASONRY
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR_J_
CONC. OR CINDER BLK.
UNIT HEATERS
WIRING
STONE ON MASONRY
GAS
STONE ON FRAME
_
B'M'T 2nd _
1st 13rd, I
SUPERIOR I� POOR
ADEQUATE NONE
10 PLUMBING
5 ROOF
GABLE f I HIP
GAMBREL MANSARD
FL AT SHED
—yf
�I
BATH (3 FIX.)
WATER CLOSET
_
—
ASPHALT SHINGLES
LAVATORY
TAR 8 GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING II 11 HEATING
TIMBER BMS. 3 COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd _
1st 13rd, I
ELECTRIC
NO HEATING
i'
Y
FORM U - LOT RELEASE 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 fills out this section*****************
APPLICANT: �����i/✓�� Phone �� S =X 309
LOCATION: Assessor's Map Number Parcel
Subdivision 15.&//4141G� Lot (s)
Street ��� ��'y//)/ /��GL St. Number
************************Official Use Only************************
RECOMMENDATIO S OF TOWN AGENTS:
Date
Approved
Conservation Administrator
Date
Rejected
Comments
Date
Approved
Town Planner
Date
Rejected
Comments
Date
Approved
Food Inspector -Health
Date
Rejected
���
Date
Approved
J
� /,23AZ,3
Septic Inspector -Health
Date
Rejected
Comments
Public Works - sewer/water connections i r! f4 Lru � H W
- driveway permit
ZMA r. VE
Fire Department ,
Received by Building Inspector ---Date
OCT— 4-92 SUM 9: 1 1 RE. -MAX P.0,2 t
Y
�'ILOT NOFLOT 4
Ilk.;y N -
�,
DANA: t+ PERKINS !rw•
CIVIL ENGINEERS and SURVEYORS
READING j�,�I.�fs�►��'I-, MASS.
v h II sub '
o 2
.� 9, yT.
rn
� o
st
� I
D
Fx=�,Jjq r�.� •aJ
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No. Date'5/14/14D
Check # -,;) 3 I
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
$ as -
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
u.
BUILDING PERMIT NUMBER: DATE ISSUED: /
1(4"*4006�
SIGNATURE:
Building Commissi er/In for of Buildings Date
SECTION 1- SITE INFORMATION '
1.1 Property Address: 011
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide ReqWred Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) - 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
�r
2.1 Owner of Record
Name 14 P ' Address for Service
7
Signal* Telephone
2.2 Owner of Record:
Name Print Address for Service:
ature Telephone
CTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: 1
\
Not Applicable ❑
V
_ 1.\
Licensed Construction Supervisor: �\ ,t\l _
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
X
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Descri tion of Proposed Work check au 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 a22licant
- OFFICIAI; USE:(QNLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
_
(b) Estimated Total Cost of
Construction
p? tq cq D
3 Plumbing
—
Building Permit fee (a) X (b)
_
as �-
4 Mechanical HVAC
—
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN -T
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize \ - to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION/7b OWNER/AUTHORIZEDAGENT DECLARATION ., .
--
1, 7, �, 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 r
Print 3��e,/
� dd
Signature of Owner/A entD e
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 191,2ND 3 RD
SPAN
DINIENSIONS OF SILLS
DUV ENSIONS OF POSTS
DINIENSIONS 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
Town of North Andover
Building Department
27 Charles Street
North Andover, MA. 01845
D. Robert Nicetta
Building Commissioner
(978)' 688-9545
°(978) 688-9542 Fax
Please print.
DATEA��'��
JOB LOCATION
Number
"HOMEOWNER GG1me
Name
HOMEOWNER LICENSE EXEMPTION
Street Address
Home
PRESENT MAILING ADDRESS //0/ /
City Town
10-1-4
Map / lot
Work Phone
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or.intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirei4n HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
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FORM U - LOT RELEASE FORM _--T
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INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from -
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the applicant and/or landowner from compliance with any applicable or requirements.
*AFPLICANT FILLS OUT THIS
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PUBLIC WORKS-SEWER/WATER CONNECTIONS
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Revised 919; lm
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No. 3d. Date �%9
TOWN OF NORTH ANDOVER
�? _ •' O0
p Certificate of Occupancy $
r
* Building/Frame Permit Fee $
Foundation Permit Fee $
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13 2 49/16/99 14:17
91.40 RAID Div. Public Works
m
I- FORM U - LOT RELEASE FORM
Y
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 SECTION
�G APPLICANT
LOCATION: Assessors Map Number PARCEL 19?
SUBDIVISION LOT (S)
STREET 3d)U1A) Z/1 l / ! `� , ST. NUMBER(
OFFICIAL USE ONLY ����
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RECOMMENDATIONS OF TOWN AGENTS: - S�� Q o Rw�all►ny
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FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED _
DATE- REJECTED_
LkJr I ah
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
R—ECEEIVED BY BUILDING INSPECTO
DATE
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Location
No. C/y Date ?
Check #
17437
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
$
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI RENOVATE,OR DEMOLISH A ONE FAMILY DWELLING
yOR�jTWO
. a .�.
BUILDING PERMIT NUMBER: D 6 q
DATE ISSUED:
SIGNATURE: L
Building mmissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
IDI Baha Road
1.2 Assessors Map and Parcel Number:
99
Map Number Parcel Number
/mdo va - 17?�
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
Required Provide Required Provided
RcqjIjred Provided
11
1.7 WaterSupply M.GL.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
LU l tDistrict:
2.1 Owner of Record r
11/j liam A . � Z. % /o/ 25 �"l/ Y -/LC
Nam tint Address for Service
5.�1
Si re Telephone � � Z � A
2. 1,9wner 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 ❑
�k
Company Name
_
Registration Number
Gy
Address
Expiration Date
Signature Telephone
T
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SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building it.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Pro osed Work check all applicable
New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify
Brief Description of Proposed Work:
�V_VWX o 0� -4- l 1c �, _�
I SRCTTnN 6 - RSTTMATF.D CnNCTRTTf TTnNV rncTc I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building,
O m D
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinE
Building Permit fee (a) x (b)
D
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
OM -11V14 /a VW11MKAU1nVXJ.LAl1VPN 1Uwb UUMl'LhmD WtMN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Omer/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
'Signature of Owner Date
"SECTION 7b OWNERR/AUTHORIZED,� AGENT DECLARATION
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
l C LG�j / /csD IV
Print Nam /
Signature of Owner Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST2 No 3
SPAN
DIN ENSIONS OF SILLS
DIN ENSIONS OF POSTS
QIN ENSIONS 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
Town of North Andover4a
Building Department
27 Charles Street'�o
North Andover, MA. 01845,�� a-:Yr�aq
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542. Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE �2
JOB LOCATION 1�l �/01e-'1— AAP
Number Street Address Map / lot
"HOMEOWNER lam[ o�!'- %�cF���r -� c6/7_5 'n
Name Home Phone Work Phone
` s
PRESENT MAILING ADDRESS
City Town State Zip Code
The current exemption for "homedwners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and require ents.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFIC
s_
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.'
The debris will be disposed of in:
(Location of Facility)
/%"X1,
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ ... ...........................................
has permission to perform ....... ,./. ... ...
wiring in the building of . .....
North Andover, Mass.
.4-,1 .. . .... ..... ........
at ............. . .... ..... .
Fee�,�;P.. Lic. No�;I�j Mroe,�—� ........... i�E- C*'r*I*U* A -L* *1* N*'S* P**E* C- r*0-R-
Check # HY
5335
THECOAMONWEUTHOFMASSACHUSEM Office Use only
L
DEPARTAfiMOFPUBIICSAFM Permit No. �.i ✓ S
BOARD OF FIRE PREVE MON R F,G ULAHONS 527 CMR 12 M
r' Occupancy & Fees Checked 6.
APPLICATION FOR PERMIT TO PERFORM ELECTRI�Rl WO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 C0
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) e Date �L D
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) C .�
Owner or Tenant
Owner's Address o U '// k1�
Is this permit in conjunction with a building permit: Yes ® No a (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead E3 Underground No. of Meters
New Service Amps Volts Overhead r --J Underground r --J No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
round
1:3round
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges /
No. of Air Cond. Total
L
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Si ns
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER•
invtanoeC0WrV. Pur =tDtheregtmerr MofMassadmseMGertaalLaws
Ihawa=utLdxTiyInst==PbkyinchidagCmipice CDwWoritswbsutWgtridem YES ® NO
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DOWNER'S INSURANCEWAIVER,IamawarethattheLioamedoesnothavethem canoecoverageoritssubstanbalegtw4wastegmdbyMassad usettsG=ialLaws
a,-dthatmysignatureon thispetrritapplicationwai" sthis ragtrirentait
(}'lease check one) OwnerM Agent
Telephone No. PERMIT FEE $
igna u�i wner or Agent
Location % 2 Zs j �'.�! •,�-t /�f'/`; ' Pt,��'
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No. `f Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $$Z-7_—_'-7 _I-
Building/Fram
_'-7-I-
Building/Frame Permit Fee $ 3 - ` Q
Foundation Permit Fee $�:,�^�" ��-
Other Permit ��FF�e++e $ --
wClso�rac f'ion Fee $
Water Connection Fee $;
trst,�Cl Cot.
r, ��E%�i Building Inspector
L
Div. Public Works
,fit ^+.�yw�w^: �+:.-::,ner +1-• -,. _ ,.
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L,6cation /-0 7 zs¢ /v / l� : Au
�2 Date
j~
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ SUS
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee,y $'
Sewer Connectibr Fee $
Wate?n'n"ectionFe//#-//7)
Conne'be1�$ 1,
TOTAL
�,.V� Building Inspector009 I
Div. Public Works
.6cation M/ I.Y'
'3 N Date /- FZ"
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
PA' Sewer Connection Fee
) : _WCtr fggection Fee
f
TOTAL
Buficling Inspector
51 L.1+
Div. Public Works
.APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
IJIAF K�O�.�
ZONE
I LOT NO.—�
SUB DIV. LOT NO.�
SEE BOTH SIDES
2 RECORD OF OWNERSHIP IDATE
/y) 51,
BOOK 'PAGE —
LOCATION I j�i(/�h .1 1` 1 fi..� 1 /O /
PURPOSE OF BUILDING
OWNER'S NAME , - /.'^-I-rT off j C()�j j y
V 'Jp�
Iufy,
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NO. OF STORIES 'C SIZE / ,CI�/
Ot 7 Po 1Q 7 �o
OWNER'S ADDRESS�/�'7� GJ v`
J a JJ 4u
ff FOUNIUM OXY
BASEMENT OR SLAB
��
�i�VJ�J�i01lU
ARCHITECT'S NAME
PLANS MUST BE FILED AND APPRO D BY BUILDI G INSPE
SIZE OF FLOOR TIMBERS 1ST�x�O 2ND �> ( 3RD
J�
BUILDER'S NAME (A_1j ;-}-pl�✓�
�?
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS ./
POSTS
J
DISTANCE FROM STREET /_
DISTANCE FROM LOT LINES - SIDES (fc REAR
[
(�
J�
GIRDERS &x I
AREA OF LOT "9 FRONTAGE
r+v
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HEIGHT OF FOUNDATION THICKNESS /0
IS BUILDING NEW l /e �-
SIZE OF FOOTING J X
(�
IS BUILDING ADDITION J>e'
MATERIAL OF CHIMNEY
C K
I�
IS BUILDING ALTERATION 1-y
IS BUILDING ON SOLID OR FILLED LAND fO
IS
WILL BUILDING CONFORM TORE%QUIIREMENTS OF CODE )Ia
J
!
IS BUILDING CONNECTED TO TOWN WATER ye/
BOARD OF APPEALS ACTION. IF ANY A/ Q
i
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE y
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
-�
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ff FOUNIUM OXY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE
�!
R C.
PLANS MUST BE FILED AND APPRO D BY BUILDI G INSPE
R
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S DATE FILED fta
LV
244. Fff PAIDd 2-
' SIGNATURE OF OWNER OR AUTHO
FEE
P
IT FOR FRAME/BUILDING
PERMIT GRANTED
`-- 19 D l t: _ ..._...,_ FEE PAID•
ro
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3 PROPERTY INFORMATION
LAND COST2 f /i /2g Yj7/O�
-EST. BLDG. COST .t f,l fmLDG. COST 2l fm ^
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO. (t/
4 APPROVED BY l�
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
90 YIM53q
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Reg* P I �K J
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No. 30747
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FORM U - LOT RELEASE 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.
t
***************/-*Applicant fills out this section*****************
APPLICANT: / "C ,iS/ F heti �j' �� C. Phone f� 63� 9 0?
LOCATION: Assessor's s Map Number Parcel
Subdivision , /[ A 11 i� Lot(s)
Street �f�c%�-�•';t) �� St. Number / y
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Health Agent
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections
- driveway permitL6:L4����
Fire Department
Received by Building Inspector Date
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdictions
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
**************`**Applica`nt�fills out this section*****************
APPLICANT: Phone 0 ID
LOCATION: Assessor's1 Map Number Parcel
Subdivision �i W- /I i I 1 Lot(s)
Street �Z�hE� Z St. Number�V l
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved tP- •2.4(0 •
To n Planner Date Rejected
Comments
Health Agent
Comments
Date Approved
Date Rejected
Public Works - sewe7rfwater connections 2'iCjZ /
- driveway permit
Fire
I;D U >�
Received by Building Inspector
Date
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