Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 101 CROSSBOW LANE 4/30/2018 (2)
AIP' Date -n ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ................................................................................................................... has permission to perform ......... .... ....................................... . .. wiring in the b of ................... ** at ........................�....J........................................ . North Andover, Mass. ..................................... Fee...��...— Lic. N14 71 .............................. ELECTRICAL INSPECTOR Check # KAI q _C*1\ Commonwealth of Massachusetts o Department of Fire Services a BOARD OF FIRE PREVENTION REGULATIONS 0ficial Use Only Permit No. I bs� — I Occupancy and Fee Checked tev.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 INFORM51TIOA9 Date: 3 6 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 -T, ov, 4 Owner's Address Is this permit in conjunction with a building permit? Yes C Purpose of Building U We_ (1 1, A Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps 19-6 / `I DVolts Overhead ❑ New Service Amps / Volts Overhead ❑ Undgrd No. of Meters Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I.,j i -T j j 2L a `,�,� q pkv &j (`o �;•h j yl ' Cmmnlatinn nfthp fnllnwintr tahle may he waived by the Inspector of Wires. No. of Recessed Luminaires 9- No. of Ceil: Susp. (Paddle) Fans ✓ No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. No. of Luminaires Swimming Pool Above ❑ In- El 1711. rnd. o. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Connection No. of Dryers Y Heating Appliances Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if -desired or as required by the inspector of n Cres. Estimated Value o Electrical Work: DO (When required by municipal policy.) Work to Start: 31111110 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 cover is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under t)te'puins and penalties o (te— erjury, that the information on this application is true and complete. FIRM NAME:.{', lig Ivwt C� LIC. NO.: Licensee: ,_ fU 1,4 Signature LTC. NO.: (If applicable, n r ,"e�xempt" in the license number line.) /�/� _ Bus. Tel. No.: Address: 91 l (A"Ok k i�1 ��` CjG i f'c"Ve (I Q e, /, 4. 001' 4/ S Alt. Tel. No.: *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 PEZMIT 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 t electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPKTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature. Date: 3 FINAL INSP TION: Pass - Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ,e f /y. ,�_t 41 Date: 4 `—/--/4 DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com !J The Commonwealth of Massachusetts Department oflndustrialAccidents - d 1 Congress Street, Suite 100 Boston, MA 02114-2017 - www mass.gov/dia yV Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): 5 tU 6 n l' Z L 1 eC Address: _ 3 r r(A LLJ A City/State/Zip: Sora r't9,i Phone #: Are you an employer? Check th1.e appiopriaie box: Type of project (required): I.Ei I am a employer with L,, , : employees (full and/or part-time).* 7. ❑ New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers' compensation insurance or are sole 11.�Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ � 13. � Roof repairs These sub -contractors have employees and have workers' comp. insurance.# 6T1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑Other 152, § 1(4), and we have no..enployees. [No workers' comp. insurance required.] *Any applicant that checks box #i 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 anew affidavit indicating such. #Contractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-coriiractors have employees, they must provide their workers' comp. policy number. I aisi 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: 101 e (`O.5 !L b (%•y I" � n _ City/State/Zip: o ro k A O d o d f /' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cefy under lie pains and penalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: . d Instructions In format10n an enation for their employees. rovide workers' comp contract of hire, eneral Laws chapter 152 requires all employers to p G ed as "...every person in the service of another under an Massachusetts � eYyiployee is defined .t�,,,° or more pursuant to this statute, hen„ al entity, or any lied, oral or wri oration or other leg to er, or the eXpress or imp partnership, association, corporation the legal representatives of a dee�pl 9emp HOWever the lv er is defined as"an individual, p and including al entity, employing ant of the An emp Y in a joint enterprise, or the Occup engagedassociation or other d wh°resides therein, house of the foregoingindividual, partnership, three apahments an air work on such dwelling° use receiver or trustee of ouse having not more than construction or rep ex of a dwelling persons to do mai t' anSe'of such employment be deemed to be an emp y own dwelling house of another who employs thereto shall not shallwithhold the issuance or or on the grounds or building app agency onwealth for any °`every state or local licensing g s in the coma► - e required." ter 152, §25C(6) also states that ess or to construct building MGL chap permit to operate a basin of its political subdivisions shall, able evidence of compliance with the insurance coves renewal of a license or p rmit to accept ,Neither the commonwealth n°r any lianCe v,ith the insurance applicant who has not produced er 152, §25C(7) states N til acceptable evidence of comp Additionally, MGL chap erformanee of public work un authority °' enter into any contract fo tehhave been presented to the contracting requirements of this chap our situation and, if the boxes that apply to y Applicants letely, by checking s along with their certificates) of ' compensation affidavit comp an p with no employees other than the address() d' hone number() s LP) does have please fill out the workers name(s), partnerships (L or LLP supply sub=contractors) es (LLC) or Limited Liability Pam ce If an LLC ent d Industrial necessary, itedLiability Compar workers' compensationinsuran davit should insurance• Lim aired to cant' be submitted to the Depahm The affidavit of partners, are not req and date the affidavit, members or paten is required. Be advised that this affidavit me to sign re nested, not the Deparlm employees, a policy Ce coverage. permit or license is being q aired to obtain a workers' ation of insurance plication for the p the law or if you are req . Accidents for confirmation town that the app arding self-iiisur6d companies should' enter thea be returned to the'. ity • you have any questions reg , ent at the number listed below• Industrial Accidents. Should call the Deparhn ate line. compensation policy, p lise number on the appy p self -insurancecen provided a space at the bottom Officials The Department hasp regarding the applicant. City or TOS printed legibly• ou reg an applicant complete and p ations has to contact y In addition, current please be sure that the affidavit is comp submit one affidavit indicating or for you to fill out in the event the Office of Investig year, need only locations in _—(°i ' 'cense number which will be unsed as a reference number• of the affidavitgiver y lication in any g applicant should write"alla be provided to the i Please be sure to fill in the e prinit/licene app the city ox town nay that must submit multiple ud necessary) and under "lob Site Asta ped or mar ed by commercial venture ation ( is or licenses. Anew affidavit must out each policy inforin business A copy of the affida at da been fi el for future perp r t not related to a lete this affidavit. town)• roof that a vale a license or perrrn applicant as P person is NOT required to comp year. Where ahome Owner t to bturznrnleaveste n) said (i•e. a dog license or p umber: ents address, telephone and fax n assachusetts The Department's of M The Commo -Department of Industrial Accidents ess Street, Suite 100 1 Congr MA 02114-2017 Boston, 877_MASSAF Fax # Tel. # 617-727-4900 e617_727-7749 www.mass.gov/dia Revised 02-23-15 0 r. ' k'n �AVtfii'Fi IIVY&7.� i iris certifies that . .0-e 5`.�!'Cl.. r% ..... r....... . has permission to perform plumbing in the buildings of .. :� �.�.�_................. . at ...I. U -� ..1, ; �;,r,,,r.. ��.! , ...... , North Andover, Mass. Fee. �) �.. Li c. No..) Wt. . M� .................... ... PLUMBING INSPECTOR Check # —J� 6 i i` 3� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK TK CITY F MA DATE -1 PERMIT # JOBSITE ADDRESS 0 C )�0 P w A i,J � OWNER'S NAME POWNER ADDRESS TEL AX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW RENOVATION: REPLACEMENT:PLANS SUBMITTED: YES NOQ FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _! i �f 1 ( f E J ( I __j __I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM .___....__i DEDICATED GRAY WATER SYSTEM ! ( I _._ _ _I DEDICATED WATER RECYCLE SYSTEM f _._..._...( ...._.._._f 1 ...___J —_-.i I .---._-! i ....... _ J DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN' INTERCEPTOR INTERIOR I _i .._.__. I _.I ...1 I __.-.__.-I _.__.1 KITCHEN SINK LAVATORY ROOF DRAIN I J f f (! l ._._J __-_-- Gr ER STALL SERVICE / MOP SINK _f J ( I _._�_� -_._J _._--_._I .--__.� (_._i —I I FLET URINAL i ..-...___ ! -__—fJ J _...... _.J .__.-_-_-1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES J i WATER PIPING OTHER �_ ___ _ __.____ _ ► _! .._.__.._J _.--___J I I --.._._..I ___._.i .______I .��I _..._...._I _ i _ f INSURANCE COVERAGE:- have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESNa NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND E-1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT ��!] SIGNATURE OF OWNER OR AGENT E hereby certify that all of the details and information I have submitted or entered regarding this application are and accurate t he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in omp ance with all nent provision of the Massachusetts State Plumbing and Chapter 142 of the General Laws. —Code PLUMBER'S NAME ,JI ,--fly % _ �t ►A ill LICENSE # I GNAT E MP, 4 JP © CORPORATION 04 PARTNERSHIP _.I #� _ E LLC COMPANY NAME C� ADDRESS CITY J1 STATE ZIP I[ v'-���._ Il TEL 1 FAX ;CELL EMAIL ..0_ 3� ME N ❑ } W 0. u.i w U- 9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): `J 1 tesr. y, yp rryn P fc� • v Address:C-2 "t - xi City/State/Zip :)Af 14 P Y)Phone #: ���,�CC Are you an employer?i Check the appropriate box: 1. ❑ I 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. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. J?�Ve 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 I Lf j4 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. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:. Job Site Address: Expiration Date: 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. [doh ereby fy under Ithe pain a dpenalties ofperjury that the information provided/;bo/v9e is true and correct. 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 i Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia I LLJ O LU oco L U) LJ 0 LLI m 00 IT to (n. I COMMONWEALTH OF MASSACHUSETTS I Date ... !.Z This certifies that .......8je!.,fn,,...4o UO has permission to perform ....... k -(7 -7T -k4 --A—?............... wiring in the building of ....... Et-LU?j ................. Q ��2o y at .. �.. f ........ S ,.�.f.3o.Gc,.1........... , rth Andover, Mass. Fee —TS.. Lic. No.. r $6�y ........ P ELECTRICAL INSPECTOR Check # i 11243 Commonwealth of Massachusetts Officrial Us�e /Only - Department of Fire Services Permit No. I ! 7 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] geaveblank M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: _ City or Town of: NORTH ANDOVER To the Inspe for o Wires: By this application the undersigned gives notice of his or heIOU— 'ention to perform the electrical work described below. C Location (Street & Number) Y ®/ C—R05-5 0 WI& Owner or Tenant Telephone No. Owner's Address 5 19 M >✓ Is this permit in conjunction with a building permit? Yes No E] (Check Appropriate Box) Purpose of Building 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: Completion of the followinje table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires ! Swimming Pool Above ❑In- E] rnd. grnd. IN o. of Emergency Lighting Batterjr Units No. of Receptacle Outlets lyNo. 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 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify) X certify, under the nains and penalties of perjury, that the information on this tion ' r e and complete. FIRM NAME:. V tp / LTC. NO.:��� Licensee: Signature LTC. NO.: (If applicable, enter " xempt" 'n the license number line.) Bus. Tel. No.: Q72 - / -f .P63 Address: O �10 j / V 0100 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License- Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. 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 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 P Failed 0 Re- Inspection Required ($.j ❑ Inspectors Comments: Inspectors Signature: Date: ROUGLI INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: 4) n (Ir i iI-141�� Inspectors Signature: Date: FINAL INSPECTION: P ailed Re- Inspection Required ($.) ❑ Inspecto Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 UV. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatidn/Individual): A VQz/0LL& /,-,09 Address: . A eX Q P 1/ Q City/State/Zip: /)�_� v e n,,-,7 •i1 o ) ,? 1/ l/ Phone #: C / 3- - /?;> Are you an employer? Check the appropriate box: 1.0d am a employer with _3 4. ❑ I am a general contractor and I .employees (full and/or part-time).* have hired the sub -contractors 2. 4I am a sole proprietor or partner- listed on the attached sheet. t 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. ❑ 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.0 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. 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site :formal Jfn. isuranctompany Name: T/2 19 VL' /PR S olicy # or Self -ins. Lic. #: / j Expiration Date: ib Site Address: f '� C l� O Ss hQ l t— Z x9d e City/State/Zip: dzo av ,o .ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 "up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurce coverage verification. do hereby certifv under that the information provided above is true and correct. 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 a Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased'employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall �' enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 �J 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 Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1.877-MASSAFE evised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia /t / n'( � fJ, ,— /N Location - No. 3 3 Date s NORT" TOWN OF NORTH ANDOVER � a Certificate }�� of Occupancy $ s°••°' E•�' AC NUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ D O — ggk(3 Check # '1 68o,1 Building Inspector to .. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPM12 RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING y5tir7777=7 BUU,DING PERMIT NUMBER: n DATE ISSUED: / f L3 /WV SIGNATURE: Building CommissionerAnsmaor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: U �\_�. 1.2 Assessors Map and Parcel Number. Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin Ni; d osed Use ; Lat Area (so Frontage ft 1.6 BUBDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RNuired Provided aired Provided 1.7 water supply M.GJ-C.40, 54) , 1.5. .FlimAZona lefomntion: 1.8 sewerage Disposal System: Zone Oadside Flood Zove , D Mmiciptl ❑ c)n site Disposd 5yatem Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED, AGENT Historic District: Yes No 2.1 Owner of Record Name ( ' t)Address for Service: �\ Signatu el hone 2.2 Owner of Record: Name Print r - Address for Service: - -- -- - ----- ---� Signature - Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: �Z � C@SC-z)ek jjf License Number � tz�' 4'�� . ✓ Ads- — --�-- - Signature Te hone Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ 16 s� C-� xCompany Name C -td c, Addr 25 - ^� ?2- ` ,�� Registration Number Expiration Date ^�— ------ Si nature ele hone IV M ,Z 0 W W an svp 'Id2Ifl yx O.I. maorII,IN07 JMC mne S1 CENV I Cld'TO 210 CH IOS NO JNICI'Ilflg SI AgNWMJ 10 'IdRIrIIVW X 9NI.L00110 971S SSHN?IJIH L NOI.L' (MI011O 11401 S21gQ?IIO 10 SN0ISN3WlU SS.SOd d0 SN0I'8N3 ICI S'i IIS 10 SNOISM2MG NVdS ax£ aHz Sd MMI 110011 10 9ZIS 9VTS No i Nawil svg Uls KRU LS *IRG u y .-m (2 f I tS Qm,-6FUTjd Jallaq Pus a2palmoml Amp Isaq atp of `a)emoov pus a" ase wguaildds 2utoSa.toJ atp uo 11011gw0jut pus sluatuale)s atp Isga aleloap Agaw A)sadosd Ioafgns Jo jwSv pazts0tpnd/.taun%0 se' I NOI.Lvay'IJdQ ,I:N dZIdoiu y U M01 LJ3S tat o asst NO J Z �i 4 11 uotleotldde Intuad tl3 g p—azuoqu ) atI t s t I qaq Cyy I , : lu uo Iae � azuot�Ine (galall kI1adold Ioafgns Jo IuaSd pazpotpndjtaunt0 s73' 3;;; I ,LINRIdd 9NIQ'Ima 2103 sayiddv 2IO,LJv-dIN03 2I0 Imlov SHZNM0 NIIM (EHITUMOJ RH OZ NOIV712IOH.LaV HIRM0 8L KOI.LJdS saqumN xoaqo S+b+£+Z+l 11401 9 uotlaalold astl g OVAH PeotusgoaW 4 1 ` (v) Y (*) aaJ Ind $PltnS utgum id £ uorlonllsuoD O Jo POO MOI pa)suu)sg (q) lsauloalg Z satl tllnyti =1 Ittutad Butplmg (s) �n 8utppng JL �' .t Iueatl a ITEm q palal of utalI oq o3 (mlloC[) WOO Polsunls3 SZSO�I NOI1,JtlulsNOJ Qa,LNNiI.LSa - 9 NOI.LJdS v�, a - :jloAj pasod Jo uotldposaa joug 4padS ❑ 1aq)O ❑ uoptloutao ❑ •Splg fjossaooy ❑ uo.lT (s)Suotlslally 0 (S* da2I 0 $mPP.ng• 8ut)stxg ❑ uotlon SUOD MIN . a�qs • De7l�ga �,aoM pat oad;o ao4l 1.taca([ S I�lOLI.J�S . a..... "ON Q....... saA I"gMV I!ngPgp Pa IS -Ituuod Ilut.plinq aqa Jo wusnsst DIP JO Ieiuop aqa T alnsa� film 1yiepWr ssgl apinoid of alnlre3 •uopaogdde slga pm you}wgns put palaldwoo aq asnw pnapUp aoumnsul uogesuodutoa slolloM A .T-TTvt9kt�-tTA7A'1 &4%IQN )in" - b unil_11514C F7iJ'�iG 3 G)� J 1 •J 1rV nvaw� 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) Signature of Permit Applicant 1i 13 U'� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ACORD, CERTIFICATE OF LlABlLlTY INSURANCE DATE 11/13/2003 PRODUCER NORTH ANDOVER INSURANCE AGENCY, INC 9 WAVERLY ROAD NORTH ANDOVER NA 01845-2415 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED L Michael Rodden 47 Prescott :Street North Andover MA 01845— INSURER A: NATIONAL GRANGE MUTUAL INSURER B: TRAVELERS PROPERTY & CASUALTY INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSRI TYPEDF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDNY POLICY EXPIRATION DATE MMIDDIYY LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 500,000 X COMMERCIAL GENERAL LIABILITY CLAIMSMADE YOCCUR MPP37395 02/01/2003 02/01/2004 MEDEXP (Any oneperson) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 . GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 2,000,000 POLICY PEC LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $ BODILY INJURY ALL OWNED AUTOS', / / / / SCHEDULED AUTOS (Per person) $ BODILY INJURY HIRED AUTOS / / / / NON -OWNED AUTOS'. (Per accident) $ PROPERTY DAMAGE (PeraccIdent) $ GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO / / / / AUTOONLY: AGO $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR E-71 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ EMPLOY RSOMAPBLSATION AND / / / / X TORY LIMITS E_R_ E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYE9$ 100,000 $ 849X419 01/01/2003 01/01/2004 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS TOWN OF NORTH ANDOVER North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1.0 DAYS WRITTEN'. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE ACORD 25-S (7/97) © AcvRo coRrUKA I ION IN55 A,M INS026S (9910).01 ELECTRONIC LASER FORMS, INC. - (800)327-0545 Page 1 of 2 L 00 Fm C- CAd .0 = 0 y O Q y °= W)0 n o CL CO) CM) S _ O m C) CD y O d= d C� p %Z y = d d o �• d, m =r W O Cf) CLy C3 m m— C a = o : C7 m o v CD � CDCL coo- Tm o o Z.n O y.n . o o' m H CD C 0 CD O CCD m � CD . _. L CD y —• o CL y toCD .d►� ' S- s D1 H o CD Z C ;� : a- � OCO) CDa N H O 0 dc 'O CD 00 Fm El �°- d o C• w = 0 y O Q y °= W)0 n o CL CT7 'r] w S _ O m C) CD Z y O d= d C� p = .n p � = d d Vl � a .. d m =r W 0 =r M O CD ti O y C3 f m C a = o : -� o � 4— coo- ' o Z.n O y.n . o o' 00 H Jo ZL O O H + CL y .d►� ' s D1 H y�EL OCA •C d C ;� : a- � OCO) N H O 'O a/ 0: c � ACD a !1 om =W C, C dF% Od w CL O �' CA C = Cp C) El �°- d 4 0 dto M w O yGO) °= W)0 A CT7 'r] w "jJ C b O ni E n Pd C G 0 d C� p b � .n p � to tx p doom 1 w 1 Q z 0 0 c Date.. g/z 7. 6 .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.. L' ......( . .................................................... has permission to perform . r. -e- K .... ............................. wiring in the building of ...... ..... /?2 . : ............................ at ... Ad!.J ...... . ........................... . North Andover, Mass. Fee,33�.O ...... Lic. No. .................... I .................. /11LECTRICAL IIAPECMR Check # "� 4 � 6 0 commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No:� d BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/2 leave blank) APPLICATION FOR PERMIT TO-'PE�FORM ELECTRICAL WORK All work to be performed in accordance with the Masaclttusetts EIectrical Code (MEC), 527 CMR 1200 (PLEASE PRINI'IYMOR TYPE ALL INFORALIYDate: //- /J - G � City or Town of:. /Z/_ < <z _ 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) /G,/ Cry- s s /:1" ,- Owner or Tenant rw G/e Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes �INO ❑ (Check Appropriate Box) Purpose of Building r Utility Authorization No. Existin22 g Service 2PIE` ps Z G Volts Over end [ �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: No. of Recessed Fixtures yf v, ..Q -10 i< No. of Ceil.-Susp. (Paddle) Fans <uuhe ,nuv be: waived ov me Inspector of Wires. No' of Total Transformers KVA No. of Lighting; Outlets No. of Hot Tubs Generators KV A No. of Lighting,Fixtures Swimming Pool Above Q In- ❑ i o. o mergency Lighting grnd. d. Battery Units No. of Receptacle Outlets Z_ No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches, ref No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons 'Number No. of Alerting Devices No. of Waste Disposers eat Pump Jons IKW N o. of Self- ontained _ Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other . Connection No. of Dryers Heating Appliances r Security Systems: No. o. of Water-0---o o. of i o. of No. of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Mres. 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 Covera a ism force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (� BOND ❑ OTHER ❑ (Specify:) --� (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: P -/ 7 -0 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete - FIRM NAIL: --,- g /1 -fl/ /4 /G /41� LIC. NO.• `f _ Licensee:C- 5F f % , F /P" Signature LIC. N.O.: 3 3 (If applicable, a tpt" in the license number line.) - Address: o Bus. lel. No.:.6�?� �� �Y� Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's aeent. Owner/Agent Signature Telephone No. PEIZIWT FEE. 5 S5_, 9D Date. �' •otic TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING • no •�.4y This certifies that ... has permission to perform ...CK..c:-.�-?.:n plumbing in the buildings of ... 1/. ....................... at ... J. LA-... ji � ,North Andover, Mass. Fee. Lic. No..... .. �.. ........ PLUMBING INSPECTOR Check # ?'1 55u3 a 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS I Building Location 161l.i'Z.�.�,5,�QW wnei ) s N of Occup Date + f a r P Permit # —Z J Amount (4 New P Renovation Ja Replacement Plans Submitted Yes No ❑ PIYTT TR F_C (Print or type) / Ch❑eck one: Certificate Installing Company ame 11 !- 6 Corp. Adkess s S '� El Partner. Business Telephone T-7777 ZoFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policyZ Other type of indemnity 11Bond ❑ Insurance Waiver: I, the ndersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner I hereby certify that all of the details and inf best of my knowledge and that all plumbing compliance with all pertinent provisions of By: Title City/Town APPROVED (OFFICE USE ONLY ion I have and instal] Agent ted (ore ered) in above plication are true and accurate to the )erfo -un e d for this application will be in u m o and er 142 of the General Laws. Type of Plum 1636 / /King LicelyaC ❑icense IN UMDer Mastero Journeyman �Z°8©S _` --- .91 — — — - — — — — — --- — 1 _301ASJ3 3iVM dd z w I OS 006 i "Zd i Ln > d3�Jb I w o i 3/1�13S3� (pawnsse) 00.00 L A3�3 '31b'd NTSdB i I j HOibO 30 631N30 d0i :>1ddIN ON38 �L I ONC'LO! 11333 ?�►IS q Z l�3Ma 5Nl1SIX3'CID _CPC I NOTidO OOS: o D W006 Ol 0 NO ANdAl. 3Iid3S - ONIiSIX3 ; Q //N3360S 13: IN I I / \ r------- ---- - ----- - - _. 039 NOd31 ONI1S; - / NOIid00 31VMXO2 X08 id T NOIin8ldiSic v. 000, 1 /Z � i �/ L d ® : ! ]Cz min 8 ON ;05 S� }'n o s ° t 1 ' i Lo d 10diN00 NOIS063 �' LC OOti co t I, r 96 f r.0 ZV o S0Ntf113M 3C 3903 Pv Alo 0� 388V tl3 M3138 „9 O1dBdA 1-llJ � Location too C-Zc sszow SAN No. tai Date 3 Zq ,v— TOTAL 4 t Building Inspector 799 Div. Public Works A TOWN OF NORTH ANDOVEF� Certificate of Occupancy $ b Building/Frame Permit Fee $ 3 Foundation Permit Fee $ _ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ M TOTAL 4 t Building Inspector 799 Div. Public Works m z � a i 3 C v 4 Z N A c 0 0 Z N OO Z z r { n m m; A > a -ai i01 n n .4 n z v W SII 0 ..... r4 V, Oz MA m o a V r N \ c o �o o 0 Q z >rwwmmA r > > D D = 5> .9 a 0 z T 3 4 O 10 v z O M 4 x D z O m T D H {/1 f w a> tl v v`m > o o r N 3 o In >rwwmmA r > > D D = 5> '9 C C C r n o n z m 0- o v o m n0 0 m r r m m m N > z > O O O O 0 -1 m A m A - 0 z i 0 > z 0>> 3 z 3 z A m� A O m3 m > m V rr 0 A 0 i A m aoo. Z> -i O i rnn Umi fol 0 z CIS r m -4 A 0 z i m oel N c r O; ? i z ` H O` I U r o W 0 m N z O Z > 0 O 0 Z C Uy G Aool r. m 0 m ' 1 H tE/° 0 0 r' n O A m o -4 m 10 �1 D / A O 0 m C c, N N a N 3 T IN� ZO C N m m m m D m m m z m m m C C C C A 0= z 0 3 0 0 r r r r m -i - N r m a v v v v i r 6 Inz a m m 0 z z z z O m z r A O O O O O 0 0 n 0 m C N 0 O A A A m O O O O Z Z a fA C Z Z Z U1 = 0 Z 0 A N i r r 0 z Z z 0 Z > N m m RCC1 i o N Z 4 A 0 -<0 m a A 0 O 0 Z N N G z 0 0 0 A '� - m r I N -4 A N A* f p I I 2 z z Jt v A rN F r > m > z a N M A m A m O p z x = m m m I ' I� N 0 c w 0 o T m .9 a 0 z T 3 4 O 10 v z O M 4 x D z O m T D H {/1 r i� I I I 00 Ul UI y0 _a o= �I TI�w o� 43z I- a ui J 0f. ------- LL 0 0 N ZEN Omu xnl LL. W0 a. « 8 0 W -' � ✓Q O z « p FZM ON ... z O o XW} W10 °a a z T Z m " 3ouWi « Z Q °C = u a 0 F X 0WW ¢« W I I 1 I I ZQN N r W Y 0 0Nu < W WWZW « z 0 O N , j W V. N 10< I� I I I �I TI�w xnl « 8 0 O -' O z « p z O o O °a a z T Z m " « Z Q °C > 0 ¢« W I I 1 I I f N r W Y 0 « r < W Z¢ « z 0 O N Z 0 W ►_' -' ¢ r V w- V Y w �— O X Q >wm0 Z Z 3 LL« 00 x u r 0 O « r~ it W Z N N W W F' °«¢ 3 N 'y Z i m¢ ¢ Z a« w rc O 2 .w, Z_ yr ,n « r Oj w« air V« Wp27���Q i a i 0° W 0 = NO r f 3 Z r¢ 0zx Vf<-Oz LL U � CD �?¢ aiaaD �� Z Z zo Q 0 01 V OaaO� 2 ¢ V W 0 �o = J a0¢Qr0a0� r Q= J Q •'a0O¢z<✓�O . U V Q rO LL,�,� V W 2 V ¢ ,n¢ mr3-�YZ�nf,-r a �n2¢«O(:IOw i, FTTT ITib � �� z 111 I I I 0 ,n U° i G ~ '" J « z W« > m� « Z° Z a O r O W < W UZ �¢Ow « Z O F . O _a ¢ 2Fw W W OVO p c� J 7 YZ m� W m 3 l7z C7� W <�OQ� W >�,, — :E `�¢ W O J :E f �0 O pzz «02o' yZ Ejoozz«zz iLL V J 2Z "'2 o¢c0 vi 0 0 vidLL Zvi Z W O �_ W ¢ w J O w O O O O OOO Jihl" 0 « m « r C7� Zia orc N U V OOcU-c Y IA u, l'� W �::zZI2 m« O :Sm a m a O¢ d 02 ¢�0v,in,«u�UV W �- Y Y V (./ W zz Z00 W 1�'°i m ¢ r2 ¢a« .d tp O 0 mw iw0 1� NI� Q U Uma « ¢ zo V ° ¢ ¢> NNmmOV r « r N m C') 0 z m —DI 0 z T Z D v CA C � � d CA10 C CD n Z y CL O 0 • r IM C C == C4 C.7 CD CD O d CD CCD O CCD C CD y� _G. Cl CA Cc CD � v CA O .0 I z CD CD O CD I I C c ?"9 p O = O —• oA O v of O.Odcm -0 y � m O m Cl) C co CD 2 CL 3 m o� = �m c CD nim O y CD Cp .. CD O O —1 N O =m m = n C92 p• CD O •+ O Z C-3 p m C =r _ al d a p O m CL CO ,..� CO O�? m m OA:1 m C-3 m CD CL m of o m d, tpA CL C ccl CL rp O N 91 C m ? m .. o O m m m ami r. 3 Wim. ma O 0 ^« O CD � 3�H o ED LPN i+ N CD ns CD gym: 0: CA O : � p � m omi 0 0 c PTJ a b aGO) GO �7 r a�a ,� m 3 w an z z Cn C) n. O o M omi 0 0 c FORM U - IAT 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. ****************App 'cant fills out this section***************** �� APPLICANT: Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) _ .,�Street —10k C, �c �� �` • St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections driveway peit ire Department Received by Building Inspector r, Date Approved Date Rejected Date Approved _ Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date I -�' �::.�e `� � •- •_ - v sew.-w.��+++-w.r...._......�.....w.._......_w._ ....r .._ .. 1 QkCOMMOONWEALTH .DEPARTMENT OF PUBLIC SAFETY `YIF ftdlrr�tOpO��##vi/irRt :ONE ASHBORTON PLACE �MaBUld/ap " " = MASSACHUSETTS BOSTON, MA 02108 i.�Od1/stens lost +taap L I LENS F_ altA/s//tin. T EXPIRATION DATE F CAUTION n A.».. 1 ^UPzRVISOR • _ . R s c�i-ION19 9 S ca ' •� + FOR PROTECTION AGAINST I EFFECTIVE DATE LIC -N0. THEFT, PUT RIGHT THUMB Pi01v£ 1 /30/1 y )3"28533PRINT IN ,• "`i3 " �' APPROPRIATE w`f MICHAEL 'J 3OVDDEh �R BOX ON LICENSE. s `"� 4 7 P R E S C 0 T r e+ BLASTING OPERATORS r �� SS I# 033 38-7014 � N A=aDDVL Z �a 71845 r. MUST INCLUDE PHOTO. _ PHOTO (B LASTING OPR ONL'Y},E �:=``-• -- _ ., _ }. F ' _ ?df, OTHERS - RIGHT THUMB PRINT 1 S :i MOT VALR} tKi7L SKaND BY LICENSEE AND OFF� 14 - 3 f 1 �6■: � 1.. STAMPED - OR SIGTM _` `HEIGHT. _ i TU6iEaFTHECDwaSSIDNER --4 sC. i..,� DOB: SUL 09/05/1948,' THIS DOCUMENT MUST BE jlGNUAE�0FVlJCENSEECARSIGN NATHE HOLD TH WHEN NOfD ABOV RE U THE HOLDER WHEN EN- a GAGED INTHISOCCUPATiON. O __.___, COMMISSIONER HOME IMPROVEMENT CONTRACTOR Registration 105903 Iva TYPe - INDIVIDUAL -- J EXPiration` 07/21/96 Michael V. Rodden -;f, vQ 47 Prescott Street AD—MasTRATOR moo. Andover MA 01845 -�' �::.�e `� � •- •_ - v sew.-w.��+++-w.r...._......�.....w.._......_w._ ....r .._ .. 1 QkCOMMOONWEALTH .DEPARTMENT OF PUBLIC SAFETY `YIF ftdlrr�tOpO��##vi/irRt :ONE ASHBORTON PLACE �MaBUld/ap " " = MASSACHUSETTS BOSTON, MA 02108 i.�Od1/stens lost +taap L I LENS F_ altA/s//tin. T EXPIRATION DATE F CAUTION n A.».. 1 ^UPzRVISOR • _ . R s c�i-ION19 9 S ca ' •� + FOR PROTECTION AGAINST I EFFECTIVE DATE LIC -N0. THEFT, PUT RIGHT THUMB Pi01v£ 1 /30/1 y )3"28533PRINT IN ,• "`i3 " �' APPROPRIATE w`f MICHAEL 'J 3OVDDEh �R BOX ON LICENSE. s `"� 4 7 P R E S C 0 T r e+ BLASTING OPERATORS r �� SS I# 033 38-7014 � N A=aDDVL Z �a 71845 r. MUST INCLUDE PHOTO. _ PHOTO (B LASTING OPR ONL'Y},E �:=``-• -- _ ., _ }. F ' _ ?df, OTHERS - RIGHT THUMB PRINT 1 S :i MOT VALR} tKi7L SKaND BY LICENSEE AND OFF� 14 - 3 f 1 �6■: � 1.. STAMPED - OR SIGTM _` `HEIGHT. _ i TU6iEaFTHECDwaSSIDNER --4 sC. i..,� DOB: SUL 09/05/1948,' THIS DOCUMENT MUST BE jlGNUAE�0FVlJCENSEECARSIGN NATHE HOLD TH WHEN NOfD ABOV RE U THE HOLDER WHEN EN- a GAGED INTHISOCCUPATiON. O __.___, COMMISSIONER HOME IMPROVEMENT CONTRACTOR Registration 105903 Iva TYPe - INDIVIDUAL -- J EXPiration` 07/21/96 Michael V. Rodden -;f, vQ 47 Prescott Street AD—MasTRATOR moo. Andover MA 01845 -ft Location / { ( • -X��r✓,'- No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ ,,N Other Permit Fee $ ' E c) Sewer Connection Fee $ RECEIVE -,D PAY40dInnection Fee $ TOTAL My 1 1991 Building Inspector ` No, Andover Collector Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE I MAP i-40. LOT NO. 12 1. RECORD OF OWNERSHIP IDATE BOOK "PAGE ZONE I SUB DIV. LOT NO. F— LOCATIO d - O .� t PURPOSE OF BUILDING ,I OWNER' AME RS C L NO. OF STORIES SIft X z2 X OWNEP ADDRESS /D / ��.S.�dw cam' ,L►L`t tel/,/ BASEMENT OR SLAB ARCHITECT'S NAME LA4�/2r'IJG� —_ SIZE OF FLOOR TIMBERS 1ST 2ND $ SPAN � ) 3RD BUILDER'S NAME / , 4412S , ./ !!77 �J �V DISTANCE TO NEAREST BUILDING -- DIMENS16NNSS OF SILLS DISTANCE FROM STREET " POSTS DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING W X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE / 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 ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AG F E E • CONTR. TEL. #606-mD5.) CONTR. LIC. PERMIT GRANTE 3 PROPERTY INFORMATION LAND COST ,p EST. BLDG. BLDG. COST 3�eO• 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 NV"ld lO1d S3DV1d3M SIHl 'a3S0dWM3df1S '013 'S39VU 'V9 'S3H0M0d HIM 'SE)NIa'1if19 d0 SNOISN3WIa 10VX3 ONV S3N11 101 W02ld 30NV1SIa aNV 101dOSNOISN3Wla 1DVX3 MOHS1Sf1W N01103S SIHl Zt abOD3b ONIa11na ` _wry ti ONIIV3H ON I Pic I p +sl i P -L 1.W.9 13SOID a31VM C.,OIa1�313 O3HS ll0 SWOON d0 'ON L SVJ Sa31V3H 11Nfl 13a9WVJ V.1.H 1NVI'QVa ONINOI110NO3 6IV _ Sa31dVa QOOM aOdVA a0 a.1.M IOH Mawnld OL 'SI03 'B 'SW9 1331S 37 �I 3aOld3d 'Ndf13 aIV IOH 03DNOd 3:)VNaf13 SS313dld _ 'S10J V 'SW9 a39W11 1SIOf QOOM 9NIIV3H ( 1 11 ONIWVad 9 ONIaIM OOVQ 3111 3WVNJ NO 3NO1S ANNOSVW NO 3NO1S _ ilOOl3 3111 3wyd1 NO N0I89 _ _ _ S321f11X13 NN300W d3MOHS 11VIS JNI9Wflld ON 110013 ON1300a 110a 13AVSO 8 SVI 31V1S 2 'S211S DMV NNIS N3HD11N kdNOSVW NO ND169 S30NIHS DOOM NV"ld lO1d S3DV1d3M SIHl 'a3S0dWM3df1S '013 'S39VU 'V9 'S3H0M0d HIM 'SE)NIa'1if19 d0 SNOISN3WIa 10VX3 ONV S3N11 101 W02ld 30NV1SIa aNV 101dOSNOISN3Wla 1DVX3 MOHS1Sf1W N01103S SIHl Zt abOD3b ONIa11na kdOiVAV1 S319NIHS 11VHdSV 13SOID a31VM O3HS 1V13 ('X13 Z) WN 131101 OSVSNVW 13a9WVJ X13 cl H1V9 dIH 319VO Mawnld OL II 400a 9 37 �I 3aOld3d 1 2lOO17 d S ONIaIM 3WVNJ NO 3NO1S ANNOSVW NO 3NO1S NIS M3(1NID 80 'JNO:) 3wyd1 NO N0I89 _I 110013 2 'S211S DMV kdNOSVW NO ND169 — _ _ E I � F—, 9 3111 'HdSV N7NJW0:) 3WVa3 NO nis 03F— AaNOSVW NO O»f11S ;JNIOIS 'IN3A1b3A — `JNIOIS SO1S39SV dtAGBVH F ONIOIS 11VHdSV HldV3 S310NIHS OOOM 313dDN0� `ONMIS dOb0 SOaV09dV1:) Sa001d 6 II S11VM b dV HD11N Nd30OW WOOd OV3H , S3�V d 3dlA\ I.W 9 ON V3dV :)II1V 'N13 '/c 1/1 '/, V38V .1.W,9 'N13 11f1d V38V 1N3W3SV9 £ — E L _ i Q N13Nf1 11VlA ANO a31SVId O MOBVH 3NId Sa31d 3NO1S 80 N7189 'N.19 313M:)NOJ —_ 3138:)NOD HSINId a01113INl 9 NOIIVONnOd Z NOI.L:)nUISNOD —JA S1N3WIdVdV S3710 AIIWVd I11f1W S3IM0!S _— A11WV3 316N—IS ADN Vdf10D0 l i `At i LARSEN ENTERPRISES HOMES • REMODELING • ADDITIONS • PORCHES Ex�s7irv� t-fa�St " SAG l3 at" / LAI' Y .. ... __ � F7 6 � r t i - --------- :J Y t AF 7` l R 4+. _174 INGALLS STREET • NO. ANDOVER, MASS. 01845 • 686-0528 ixv FIR p41,--Kffa(. 70,J1 N4tl(:d1,( 4e 0 X IAI /I'!•.�� i % PA C, FORM U. TOWN OF NORTH ANDOVER LOT RELEASE FOIUI SUBDIVISION ASSESSORS MAP SUBDIVISIOR LOTS) PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET l0/ C,�OSS�30l.0 ,C�}NEr` APPLICANT�Qrr>/2ENGt /� / l PHONE DATE OF APPLICATION cy,I TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED (C ONSERVATION.,CO MI)SION /—R& CONSER 01w4' J\1 ON ADMIN. DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE DATE APPROVED LC 31191 DATE REJECTED DATE APPROVED MATE REJECTED This form shall be signed by the agents of the Planning and health Boards, the Conservation Commission prior to _the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. L Poo POO 0 G. A �v O s 0 M Pa m Me 3 n 0. muse 0 C z r 'T V I z H N WICD m -ncpm m 210m 3 ? °c w c° w c° w c° w I17 ? =r CD T S r C W o D 7o p o .� M PM rm n (I Q ore X Z z 0 tr.bk co 0 m .ecce �I N m m m Location No. _��.�P)-S Date if - ,.ORTIy TOWN OF NORTH ANDOVER •.... , OC Certificate of Occupancy $ Building/Frame Permit Fee $ �,s'•^� • j, / /; j n Permit Fee $ +icHus "' Ot Permit Fee $ Sewer Connection Feed $ Water Connection Fa $ TOTAL co $ Building Inspector \ Div. Public Works PERMIT NO. mow/ V APPLICATION FOR PERMIT TO BUILD —NORTH ANDOVER, MASS. Y PAGE I MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP iDATIIBOOK 'PAGE ZONE SUB DIV. LOT NO. — LOCATION CO J!2 PURPOSE OF BUILDING /A I�v� �( �U � RNs pm V `+ OWNER'S NAME /vJ p ly1 1/ FA„/�) NO. OF STORIES SIZE /�-G LC OWNER'S ADDRESS �, n ,ISS hX/W L/ BASEMENT OR SLAB `••`. 1/' �C-J1 ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND BUILDER'S, NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR ” " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE 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 ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED 1// 4 I / v SIGNATURE OF FEE ID .-Y� AGENT PERMIT GRANTED 19!✓ 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST /✓ UD 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 OYILYI"WA IPIfY6'siTuR WHITE: Building Dept. CREAM: Assessors CANARY: Treasurer 'NV -Id 10'Id S301'/1d321 SIH1 'a350dW12i3dnS '013 's3ovu -VE) 'S3H::)2lOd H11M 'S°9NIO11n8 d0 SNOISN3W1a 17VX3 C3NV S3N1'1 101 W02ld 3:)NV1S1a ONV 10'1dOSNOISN3Wld lZ)VX3 MOHS1SnW NOLUMS SIHl zi I AONvdn000 I, aVOD3b JNiaiina ONIIV3H ON _I PIC I +'I P"L IMA JIa0313 110 SWOON dO 'ON L SVO S831V3H llNfl O1.H 1NV10V8 ONINOI110NOJ 81V aOdVA a0 a.1.M IOH _ Sa313Va DOOM 'S10J '8 'sW9 1331S WV31S Nana a1V IOH 03JaOJ 3JVNdn3 SS313dld _ _ 'S10J'8 'SWS a39WIl 1slof DOOM 'JNIlV3H ll I 9NIWVad 9 00V0 3111 aoo13 3111 _ s38n1X13 Na300W ON13008 1108 83MOH3 11VIS 13AVa0 F dVl ON19Wnld ON 31VIS ANIS N3HJ11X S30NIHS DOOM ABOIVnV1 S310NIHS ilVHdSV 13SOlJ 831VM 03HS 131101 OaVSNVW�klVll WV0 X13 EI H1V9 dIH 19V0 ONl9wnld of dooa S �I r d00d 70la3dOs ONI81M 3WVa3 NO 3N�O1S ABNOSVW N( 3NOE ')i19 830NIJ bO 'JNOJ _I doo13 8 'sass J111v 3WVa3 NO XJIaS ABNOSVW NO XJI89 —� I— j C I E — F F—,, 3111 'HdSV NOYlWOJ 3WVa3 No omnis Aallosvw No oJJnls ONIOIS '1a3A ONI0IS SOIS39SV 0 MO8VH ON10IS 11VHdSV HAV3 S319NIHS DOOM 3138JNOJ SO8V109dOdj SM0013 6 II S11VM b N3HJ11X N8300W WOOa 0V3H S3JVld 3813 1.W 9 ON V38V JI11V 'NH 71 1A %i V3aV .1.W.9 'N13 11nd V36V 1N3W3SV9 £ _ E L I 4 N13Nn llVM Aa0 831SV1d S83ld 0.M08VH 3NO1S 80 XJI89 3NId ')1.19 313aJNOJ 3138JNOJ HSINU VOIM31NI 9 NOUVONnoj Z NOIlonNISNOD S1N3WIdVdV S3JI33o —_ Aliwy3 all 53180!S kIIWV3 310NIS zi I AONvdn000 I, aVOD3b JNiaiina WOOD STOVE INSTALLA11ON CHECKLIST Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. ` :•; Stove �•,.�` A. New Z7,6ft7In/GS /Qrr7atiePr a .rZ Used B. Type/radiantCirculating C. Manufacturer _Lab. No. — Name/Model No. n -ir Cellar size Dimensions/ Height W la 7w z i Y11 It _Length _ I %ff 1'4 13 a] It Width Chimney Yr A. New Existing B. Size (flue area) C. Other appliances attached to flue (Number and flue size) ._ D. Prefab (Manufacturer—name and type) (56td E. Masonry/Lined Flue liner Ga Ij- s V101.� e,1117MN£ Unlined Type 3 manufacturer) F. Height (refer,to diagrams) cap OVER IC) 2� Mlty S Ml4 io �Ipy��I "All ti 3',11 rt. n CHIMNEY HEIGHT Hearth (non-combustible)�� A. Materials B. Sub -floor construction C. Minimum dimensions (refer to diagram) IZ�) Nilri. ! 2" MIN. Ig" MIN. ( FU EL, :x_1-1 SCG c yy 7IC> HEARTH andWallProtection (see stove installation gfe s chart) A. Type of wall protection provided STbSA%E:�crM Ane_�i A-777"7 !A~S' B. Clearances (refer to diagrams) FIREPLACE CORNER WALL/CENTER 13 Intrepid II Clearance Chart Clearance from stove to: Unprotected surfaces Protected surfaces Parallel Corner installations installations Side Rear Corner Parallel Corner installations installations Side Rear Corner With no heat shield 24" 30" 20" 12" 16" 10" 610mm 760mm 510min 300mm 410mm 250mm Rear heat shield, 24" 14" NA 12" 9" NA rear exit 610mm 360mrn 300mm 230mm Both rear and 24" 14" 12" 12" 9" 10" connectorshields12 610min 360nnn 300rtmt 300nnn 230nun 250mm Clearance from chimney connector to: With no connector heat shields With connector heat shields Clearances for fireplace installations: Unprotected surfaces All installations 26" 660mm 10" 250mm Protected surfaces 12" 300mm 50 130mm To unprotected surfaces To protected surfaces Top Side Top Side Mantel trim trim Mantel trim trim 30" 24" 15" 14" 14" 10" 760mm 610nun 380mm 355mm 360mm 250mm Front clearance to combustibles: All installations 48" 1200nun 'Shielding for atop exit stove must include the stove rear heat shield insert to protect the area behind the flue collar. 'Chimney connector heat shields in an installation which goes through a combustible ceiling must extend to 1 " (25mm.) below the ceiling heat shield, which is 22 " (560mm.) in diameter. The ceiling shield should be 24Rauge or heavies slieetmetal, centered on the chimney connector, and mounted on noncombustible spacers. 'The ceiling heat shield required when chimney connector shields are used should meet the wall protector. This will require trimming the ceiling shield along the line of intersection will? the wall protector. 14 Installation overheat. Do not store firewood within the clearance distance. The clearances approved for your Intrepid Il have been established by testing to Ul, and ULC standards to determine safe distances hctwcen your stove, its venting system, and combustible surfaces. In testing, heat sensors installed in all surfaces near the stove and chimney connector, including floors and ceilings, show the temperatures reached during o varietyy of combustion situations. Clear- ancedistances are accepted only when the sensors show the stove is far enough from nearby surfaces to meet strict UL or ULC standards. Using the Clearance Chart Separate tests are done for parallel and corner installations, for installations using stove heat shields and chimney connec- tor heat shields, and for installations using ventilated wall shields. If your stove will be parallel to the wall behind it (parallel installation), use the columns of the chart labelled "side" and "rear". If your stove will be installed in a corner (corner installation), use the columns Corner installation Parallel installation t of corner and para installations. unectc for proper cnnnney connector clearance, too. labelled "corner". Use only the part of the chart that applies to your installation. Note: Side clearances do not apply to corner installations. Measure clearance between the edge of the stove's top plate and the nearby combustible surface. It is important to double check all installations for proper chimney connector clearance, as well as stove clearance. The clearance distance must be empty except for non-combustible heat shields. Air flowing between the stove (and/or chimney connector) and nearby shields carries away heat. Do not block the air flow by filling this empty space with any insulating material. d%� NIX;, tpl j4 It 1 3d T{ ......... . . . . . . . . 14 "_A t-0 c0 1 , Op GO 1o0 00 . (7 to 0-4 •pp 0 N, www, 0.7�tr ol 0 ar 01 Iv 0 0 0 > o 0 0 U t: 4) 0 U't U., r 0 CO `,1�4 1,15 , 0 C; U ba tOD -ri , , �. 4 U,I 41' M-0 r U 5 1 0 1 f It ws � I0 > V jt 1OJ U) Irl 0 cd 0 0. 'Cs— A. 0 0 0 cd oj� Atli;, co V t10 co V, 4) Pt 0' 0 'o =, - t.0 IV 12 9 L*4. " , p P, I I to d . I CA 04 0 04 C" 8 Owl. 10. Cd I _� 2 >; 0 1 0 S l- 0 0 75 IN o o?, -to *0 - D I . r . lb?, M': cd, t I 0,T) 4) 0 '01 CFJ X31 uj cd as u 13, z CO ol J0, 0� V o 0 40, 4tj 7 -- q. Q. n, g p, 'i.vlll 'r la, 0 2', cc r o'' s' .00 0 0. >. U., 0 ..o, 01 4) 07� U > V o" 4) co X 43 4j,. -4, co V to 4) •3 vC Zojo S 11 a -14 -N = e . V I !1. a.m. ca cr -0 -'v 4) ch "s : -4) col" 0 M o o 0 cd C,3 U 41 U. .. 7, L,U z, 0 O'� 0 > C> 11 w to "0 0 -z'g 4t�) o 4) 1 :) ", �:li. g � W G 9: '0, .0, 0 o 4) u O'd), 0.0 0 'o sz � w -.0 .8: > 0 en GL I Z.0 IV , > — 4), 40, C's E5 4 -co tko M 0 0.0 0 ox is— CM0 -6 J - co 4 1 It u _ — I 1 ,0- Cd 4) 4ilp I . I — o La 'z;, u,—'hrp";z . u X tf .1A I VA sl Z, j P �10 780 CMR: STATE BUILDING CODE COMMISSION Figure 2109-4 CLEARANCES FOR SOLID FUEL BURNING APPLIANCES CT CAP FACTORY -BUILT CHIMNEY a n t —SUPPORT @RACKET NON-COMBUSTIBLE B �J -� MALL PROTECTION -- coNNECTOR n►E I A CONN CTO" OVERLAP 1 VOODOURNINO STOVE ' A ,IIS AIR SPACE � I� M 12" 1 I� L 18„ Iz" NON -COMBUST ISLE FLOOR PROTECTION STOVE INSTALLATION CLEARANCES F. Prong: ruct or asn access sere. 2. Thimble required for passage through combustible construction. ). Non-combustible spacers required. i. Clearances an each side of a radiant stove with a heat shield shall be measured as If a circulating type. i ' 1 Combustible Asbestos Mlilboard Concrete/Masonry 4"Brick Veneer Stove Components Meterlal Spaced Out 1" ) Foundatlon WellSpaced Out „ Radiant Steve 1. 761 —Fr Circulating Stove 1. 2180 —Front A. Radiant Stove 6• )6" t8" 6" 1811 — Side sack A. Circulating Stove 12" 6" 6" 6" — Slde//ack I. Single Matt 2. face 12" 6" Q" Connector Flpe • Insulated 211 211 211 211 Connector Pipe C. Chimney Height Three ()) feet above adJmcent roof and (Metal or Masonry) two (2) feet above an roof ridge within 10 feet . Denver If a damper Is not Included In e stove construction. It must be installed In the connector pipe. F. Prong: ruct or asn access sere. 2. Thimble required for passage through combustible construction. ). Non-combustible spacers required. i. Clearances an each side of a radiant stove with a heat shield shall be measured as If a circulating type. i ' 1 044 cfommonwml� of massaoll t s Eeparttnwt of Public *afetq BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only aLA Permit No. 0=pancy & Fee Checked 5 v 9p (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK p� All work to be performed in accordance with the Massachusetts Electrical Code,;527 CMR 12:00 r (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date //_ O's or Town of NORTH ANDOVER ' To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) _w Gross �Uw Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes (Ssbo ❑ (Check Appropriate Box) Purpose of Building f� �t 4 �� Utility Authorization No. Existing Service 20 Amps% ZYr1 V Volts Overhead Undgrnd t�'� No. of Meters New Service Amps —J Voits Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity 1L Location and Nature of Proposed Electricai Work No. of Lighting Outlets I No. of Hot Tubs No. of Transformers Total iii KVA No. of Lighting 9 9 Fixtures � Swimming Pool Above. SiiPl grind. :_. 1n -i gmd. _ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets ( No. of Oil Burners I Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of es Ran 9 i No. of Air Cond. tons Initiating Devices Heat Total Total I No. of 'Disposals No.of Pumps Tons K16V No. of Sounding Devices No. of Self Contained No. of Dishwashers I Soace/Area Heating KW Detection/Sounding Devices Local Municipal Other L✓ Connection t_ No. of Dryers I Heating Devices KW ry No. of No. of Low Voltage No. of Water Heaters KW I Sions Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Ccmolete erasions Coverage or its substantial equivalent. YES have submitted valid proof of same to the Office. YES '— If you have checked YES. please indicate the type of coverage by checking the appropr' box. INSURANCE BOND Z OTHER = (Please Specify) (Expiration Date) Estimated Value of Electrical Work 5 Work to Startti- Z $-- y,' Inspection Date Recuested: Rough 7 -�s Final Signed under the Penalties of perjury: FIRM NAME, / LIC. NO. Licensee � s /.� ,fir. a Signature <LIC. NO. 33 Bus. Tel. No. ,tZ-7 2/Gyt Address _ Alt. Tel. No. ` OWNER'S INSURANCE WAIVER: I am aware that the Licensee goes not hay% the insurance coverage or its substantial equivalent as re- Quired by Massachusetts General Laws. and that my signature on th;s permit application waives this requirement. Owner Agent (Please check one) d/ / Teieonone No. PERMIT FEE 5 (/ V (Signature of Owner or Agent) x-6565 C Of NORTH a O .yam a •° OL O A M o + • �,SSACHUSE� Date ....7..., .. �.. TOWN OF NORTH ANDOVER 8 PERMIT FOR WIRING lu This certifies that - .----',� :-..'�:"' �-� r ................................................................ In has permission to perform.......................� r ...............................................&.............L wiring in the building of .......:......... .:.:.!.!.:'{ i .. ...:... ........................ / r / at .....f.f .0 ......... r..''.0.` .....f�.. V .... '........, North Andover, Mass. r 7 Fee ...h. .d.... Lic. No....t...... : .............................................................. J ELECTRICAL INSPECTOR r ( ! e! WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File The Commonwealth of Massachul etts ° `" b"Q"i Deportment of Ribfic Softly 'o«.,r.�r a lea Qiecte� - BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 tte.•e a.�tl APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 1lIlOR All Work to be performed In accordance With the Maaa.achurens EJectrieal Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date h City or Town of jy . G d���_ Io the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described belo,,, Location (Street Number)-- Owner umber)_Owner or Tenant_�,L �- t!G Owner's Address Sir 2 Is this permit in conjunction with a building permit: YesNo (Check Appropriate Box) •. Purpose of Building_ i� '/ Utility Authorization NO. Existing Ser -.ice 2y6 Am'� ps / Volts Overiltid i—j undgrd C. No. of New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work i✓•i No. of Lightisig Outlets No. of Hot Iubs ':o. of Lighting Fixtures Swimming Pool AboveIn- grnd. ❑ xrnd. ❑ No. of Receptacle Outlets 40' No. of Oil Burners No. of Switch Outlets / No. of Gas Burners No. of Ranges No. of Air Cond. Total tons Na of Disposals No. of Heat Total Total P1=3 Tons KW Yo. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW - No. of Water Neaters KW No, of-60-7—or— Signs o, o Si s Ballasts No. Hydro Massage Iubs No. of Motors Total HP OTHER: No. of Transformers Generators VIVA No. of Emergency Lighting Battery Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local 1:1 Connect Connection❑ Other Low Voltage 1 INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Lava I have a current Liab t Insurance Policy including Completed Operations Coverage or ,� ,it�s s antial equivalent, YES HO.LJ I have submitted valid proof of same to this office. YESINO I__!t If you have checked YE$; please indicate the type of coverage by checking the appropriate box. INSURANCE /BOND [-] OTTER ❑ (Please Specify) ;F —IfS Estimated Value of Electrical Work S piration ate Work to Start S Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAMEF�L / 33 IVIC.. N0. Licensee - f _ rw Y ,�/ Signature. LIC. Address r- �! Bus. Tel. No c s Alt. Tel. No. OWNED S INSURANCE WAIVER; I am aware that the Licensee does not have the insurance coverage or is sub - application valves this requirement. stantial equivalent as required by Massachusetts General vsTa s. and that my signature on this permit Owner Agent (Please check one) Signature of Owner or Agent Telephone No. PERMIT FEE S l V 24 � NORTH O 9 r c r ,SSAcmt) Date............ .......... 4..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Q i This certifies that..........I..................... haspermission to perform............................................................................... wiring in the building of' ...................................................................... at .. f.............!.....:............./....................:..:...:........... , North Andover, Mass. Fee....:........5......... Lic. No.; .......... .............................................................. ELECTRICAL INSPECTOR r 08/03195 14:58 55.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File KAREN H.P. NELSON M Town of Director . =� NORTH ANDOVER BUILDING CONSERVATION DIVISION OF PLANNING PLANNING & COMMUNITY DEVELOPMENT Date: June 12, 1992 To: Et i.zabeth Bnak.etey 101 Chozzbow Lane Notth Andoveh, MA From: North Andover Building Department Re: Wood Stove Installation 120 Main Street, 01845 (508)682=6483 It' appears, by the visible aspects of your wood stove available at the time of my inspection that the installation complies with the requirements of the Massachusetts State Building Code. Yours truly, D. Robert N i cet t a, Building Inspector DRN:gb c/K. Nelson, Dir.