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HomeMy WebLinkAboutMiscellaneous - 103 JOHNNY CAKE STREET 4/30/2018i { Date.. ................... . NORTH TOWN OF NORTH ANDOVER o? p� PERMIT FOR GAS INSTALLATION 1- P i • ♦ i •' e �9SSACHUSEtS This certifies that ........................................... has permission for gas installation ............................. in the buildings of .......................................... at .................................... North Andover, Mass. Fee ... 1012VI94 &iU No... ....... .......................... 12.50 PAID GASINSPECTOR WHITE: Applicant CANARY: Building Ddpt. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATIONFOR PERMIT TO DO GASFITTINO (Print or T y /pyey, Mass. Date f� kuilding Location d o Zn Permit # • —owners Name ROZ.4 Y♦ New ' 71 Renovation D Replacement Plans Submitted f _rI =( (Print or Type)Chec one: Certificate Installing Company Name ANDOVER PLG. & NTG. CO. INC. V Corp. 1051 Address 57.31 SO. UNION STREET 0 Partner. LAWRENCE MA. 01843 F-1 Firm/Co. Business Telephone: 508-685-8383 ,Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of. insurance coverage by checking the I appropriate box:j Liability insurance policy 01"Other type of indemnity 0 Bond Insurance Waiver: 1 the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner u Agent u .. I I hereby certify that all of the deuds and information 1 have submitted (or entered) in above apPlicalion are true and accurate to the best of my knowledge and flat al! plumbing work and installations petfornted under Permit issued for this application will be In compliance with all MtlU ent provisions of the Massachusetts Stale Cas Code and Ci apter 142 of the General Laws, Jd BY TYPE LICENSE:PlumberTitle Gasfitter Signature of Licen CityJTown I Plumber or Gasfitter Master . ,_ Journeyman 6739 ``'' `" APPROVED (6PFICE USE ONLY) License 14umber • • Y • • ♦ • . • • . a a . ■= NEEMENNEEMEN on no, CM • • ����n�������������������� (Print or Type)Chec one: Certificate Installing Company Name ANDOVER PLG. & NTG. CO. INC. V Corp. 1051 Address 57.31 SO. UNION STREET 0 Partner. LAWRENCE MA. 01843 F-1 Firm/Co. Business Telephone: 508-685-8383 ,Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of. insurance coverage by checking the I appropriate box:j Liability insurance policy 01"Other type of indemnity 0 Bond Insurance Waiver: 1 the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner u Agent u .. I I hereby certify that all of the deuds and information 1 have submitted (or entered) in above apPlicalion are true and accurate to the best of my knowledge and flat al! plumbing work and installations petfornted under Permit issued for this application will be In compliance with all MtlU ent provisions of the Massachusetts Stale Cas Code and Ci apter 142 of the General Laws, Jd BY TYPE LICENSE:PlumberTitle Gasfitter Signature of Licen CityJTown I Plumber or Gasfitter Master . ,_ Journeyman 6739 ``'' `" APPROVED (6PFICE USE ONLY) License 14umber Date ..... ....... ..-.... ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that -�.. o St fin• t ............................................... has permission for gas installation ......Q �� k�T ................................................. in the buildings of ........Zo.k.-A 13r C �-'� at .... l.. ° .......-� � �. ` .. (..- -c ................................. North Andover, Mass. Fee .36: oo... Lic. /No :3.l og `�....... GAS INSPECTOR Check #L S t.J � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �J Ai__-_, ._.__ __- MA DATE q—(,PERMIT# JOBSITE ADDRESSG,?f.- OWNER'SNAME GOWNER ADDRESS i` r _ _. TE 6nFAX TYPE OR OCCUPANCY TYPE COMMERCIAL [ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: CR-�-`RENOVATION: Ej REPLACEMENT: Ej PLANS SUBMITTED: YES F --1l NO®--*� APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5L[-6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER -- COOK STOVE �] ��� - i- �.,M1.4 _ ��I I. -_ , J -.r,- _.sa _. . DIRECT VENT HEATER - -I --1 - DRYER E FIREPLACE C_., I L 1 __-.__. I� f --I _1E. _ _ FRYOLATORI- FURNACE-.: ----j L.I MSL GENERATOR [-- --- -GRILLE GRILLE --� :_ -.- --_ — (-- I. I_ I .._.�_ J _1 �- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN I_^ J F--j=Imo— _. I .r__ ._ l_ Lai I — - _LL._ POOL HEATER ROOM [SPACE HEATER ROOFTOPKNIT TEST UNIT HEATER UNVENTED ROOM HEATER -_j WATER HEATER� OTHER _ I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY D. I( BOND E] 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 [�]I AGENT �I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge the issued for this application will be in compliance with all Pertinent provision of the and that all plumbing work and installations performed under permit Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # IOo�!__.._� SIGNATURE MP Ej MGF --1I JP 'JGF []_I LPGI 0 CORPORATION E]# PARTNERSHIP�].I#�--___�_..__ i1 LLC COMPANY NAME: _er.1U�i�.w ._....._ II ADDRESS CITY STATE ZIP Qj_ TEL - 3�2- FAX 39. CELL[ EMAIL-- 0 E z fA ❑ } W IL J ui w LL . The Commonwealth of Massachusetts Department q f Industrigl Accidents Office o fInvestigations 600 Washington Street Boston, M4 0211.1 www.massgov/dia 'workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 71�\e_ Address: City/Stale/Zip: Phone #: -73 9 Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. Ptliew construction employees (full and/or part-time,),* have hired the sub -contractors 2. ❑ I am a sole proprietor orpartner- listed on the attached sheet. x 7. ❑ Remodeling ship and'have no employees These sub -contractors have S. Q Demolition working for me in any capacity. workers' comp, insurance. g, Q Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.Q Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.QRoofrepairs insurance required.] t employees. [No workers'. comp. insurance required.] 13.Q Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submitthis affidavit indicating they dre doing all work and then hire outside contractors must submit anew 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:. Policy 4 or S elf -ins. Lic. #: _ Expiration Date: Job Site Address: City/State/Zip: Attach a. copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 andpenaldes ofperjury 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): I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Wormadon end bstruefl®ns 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 ofhire,• express or implied, oral or written." An employd 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 chapterhave 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, 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 to appropriate line. City or Town Officials Please be sure that -the affidavit is -complete -andprinted legibly: The D eparfrrierit has provided a space at the bofiom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "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 maybe 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 homeowner 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 shquld you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: TN Gax monmaIth of assacl?l�.sPfts Department offadustdat Accidents Office ofinvestaigationa 690 Washioou Strec Boston? MA 02111 TO, # 617-72 7 4900 at 406 or -1-877:N ASS.AFB P., 4 41 r/_ VY)7 e7t7A n Commonwealth of Massachusetts RECEIVED City/Town of MAY 1 1 2015 System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be *used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house,O righ si a ofhou , Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address L0 - ® �\" Cityfrown 2. System Owner. Address (d different from location) Cityirown B. Pumping Record 1. Date of Pumping 3. Type -of system: ❑ ❑ Other (describe): A State Zip Code state ip Code Telephone Number r Date 2. Quantity Pumped: Cesspools)eptic Tank 4. Effluent Tee Filter present? ❑ Yes LSO ' 5. Condition of 6.- System Pumped By: Gallons —? ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc - Company 7. Location where contents were disposed: Lowell Waste Water t5form4.doc- 06103 System Pumping Record • Page 1 of 1 11 This certifies that.... Date ... !..�. (.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Cole U_e4�c_ has permission to perform... & j 0--, a4o- ....................................................................................... wiring in the building of .................... Y ................................................................................ at ........ ... P.Ajo . .............................. . North Andover, Mass. -AIR Fee .... 4c,,.,* ......... Lic. No.!....!...,h' ELECTRICAL IwEcrm Check # `IIt . Jik Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No upanc BOARD OF FIRE PREVENTION REGULATIONS [RevCl/0 I]yandFeeChecked •(leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC), 7 CMR 12.00 (PLEASE PRINT WINK OR TYPEALL INFORMATION) Date: of j�' / 3 City or Town oh NORTH ANDOVER To the Inspector of Wires: t By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /03 �'oi��•�y a��e St Owner or Tenant�p�� �V-P `� 1 g Telephone No. S - 4� Owner's Address V- C_ C Is this permit in conj unction with a buildingpermit? Yes k P ❑ No � (Check Appropriate Box) 4 k, IW 4A 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 a Location and Nature of Proposed Electrical Work: comn7vi;A nfFla{ Il ,,.;ti 4 LT _ T .,. a._�z_.w_ �-----`-_. rrrr_..-_ No. of Recessed Luminaires --•• �••–••••.. �, ....-J vrrv.r r. No. of Cell: Susp. (Paddle) Fans cu�4c I—V UG rrc,4m" fly wtGjrlapc tur Uj rr If tu. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA fit% No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. of Emergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burgers No. of Detection and InitiatinE, Devices No. of Ranges No. of Air Cond. Total Tons No. of Alertin Devices g No. of Waste Disposers Heat Pump Number,. Totals: Tons•,.....•.. KW" "' No. of Self -Contained Detection/AlertinLy Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water KW Heaters Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or E uivalent 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. _ S, 6ZJ-9 (When required by municipal pohcy.) 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 n BOND ❑ OTHER ❑ (Specify:) � I certify, tinder the ains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. L C Ire r-C.•c L LIC. NO.: Licensee: ,,Vf LQ Nr Signature LTC. NO.: afapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 403 - 8G� -&&C/ Address: Alt. Tel. No. (co3-6tc/— 7g70 *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 L Signature Telephone No. 1PERwTFEE--s J ❑ 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 F?] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: I i i Inspectors Signature: Date: FINAL IN CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: vY at Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts - Department oflndustruclAccidents Office of Investigations 600 Washington. Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance ,Affidavit: Builders/Contractors/Electriicians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):. &%etc z(_ c Address: City/State/Zip: yav� e,lr- 4 �ft3�6&hone#: 663 -6,2Y -7g70 Ayou an employer? Check the appropriate box: 1 a employer with A— 4. ❑ I am a general contractor and 1 Type of project (required): New L 6. ❑ construction employees (full and/or part-time). 2. ❑ 1 am a sole proprietor or partner- haveliiredthe sub -contractors listed on the attached sheet. x �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E1 Electrical repairs or additions required.] 3111 am a homeowner doing all work officers have exercised their right of exemption per MGL 1111 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.Q Roof repairs required.] insurance . re uired employees. [No workers' 1311 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 tie 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: eeeldegs Policy # or Self -ins. Lic. #: ���� S �� y 1 �D Expiration Date: Job Site Address: Z 3 City/State/Zip: TUU Attach a copy of the workers' compensation policy $eclaration 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 maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. I do hereby cerfiflv and a pawns d nalties ofperjury that the information provided above is trr a and correct. ria+P- 0/ �i�/l 3 Phone#• 603`6ay-7LO 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. PIumbing Inspector 6. Other - - Contact Person: Phone Information and Inst ucti®.ns - 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 ofhire, express or implied, oral or. written." An employer 1s defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint 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 ofpublic 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 LL C 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 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 "Many given year, need only. submit one affidavit indicating current Policy information (ifnecessary) 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 maybe 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 Com. onwealthofM,9ssaehvsetts Departm.eztt of fadustrial .A,ccidants Office o£Iavestigatioas 600 Wada Voa Sheet Boston? MA 421 i Z Tel, # 617-72.7-4900 ext 406 ox 1-577, M'ASSAFF, Revised 5-26-05 Fax # 617-727-7749 n n GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: GENERATOR kw d t NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: r,k PHONE NUMBER: 0263- %0' ld�.CV ELECTTS�p RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: S��- 4)kv-Ltse-- '-l!*f *ZONING DISTRICT: R 2- *PLANNING APPROVAL (IF IN WATERSHED) � � � ��-j *CONSERVATION APPROVAL Sl a � ✓�� 1/LCI1� r JprWYGAr-e �C oc'T r- -, tL-==�-�( 7 l U h LAS L I�IE5, of corn . MORI GAGE INSPECTION PLAN OYER � LOOP LOCATED IN I�--06fAIA:0\/Erc. TO THE A�p�LE� �Av..l511�K AND ITS TITLE INSURERS MASSACHUSETTS I HEREBY CERTIFY THAT I HAVE EXAMINED THE PREMISES AND ALL EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN. Z FURTHER CERTIFY THAT THE BUILDING SHOWN DO( ) CONFORM TO THE r ' ZONING LAWS AND AMENDMENTS, 1.9. ( FRONT, SIDE a REAR YARD SET BACK , ONLY) OF WHEN CONSTRUCTED. I FURTHER CERTIFY THAT THIS PROPERTY 11 LOCATED IN THE ESTABLISHED FLOOD HAZARD AREA. NOTE : THIS CERTIFICATION IS BASED ON THE LOCATION OF SURVEY MARKERS OF OTHERS, AND DEED p DOES NOT REPRESENT A PROPERTY SURVEY. BOOK EXAMINATION OF THE RECOROS IS MADE ONLY SUBSEQUENT TO THE RECORDED DATE OF THE PAGE y3 LATEST DEED AND DOES NOT INCLUDE VERIFYING THE .ACCURACY OF THE DEED DESCRIPTION PREVIOUS TO ITS DATE OF RECORD. PLAN THIS COMPANY IS NOT RESPONSIBLE .FOR ANY INDENTURES MADE SUBSEQUENT TO THE N0. RECORDED DATE OF THE LATEST DEED OF RECORD. — WHENEVER BUILDINGS ARE SHOWN LESS THAN ONE FOOT FROM THE PROPERTY LINE IT 11 BOOK ADVISED THAT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE MESUREMENTS. PAGE .�., THIS CERTIFICATION TO 8E USED FOR MORTGAGE PURPOSES ONLY CERT NO.. �l•RDAI1t(1DC1 CAt�1�lCcn�w�r_ rr� v N ro o cn.� FORM - U - LOT RELEASE FORM c- -,- S- -�S-- 03 INSTRUCTIONS: This form is used to verify that allnecessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT J 6JJ���6�%� PPIONE ASSESSORS MAP NUMBER 040 %D 1 ' LOT NUMBER 0/ t SUBDIVISION LOT NUMBER _ STREET I �/B/'¢I�N `!' C +�i STREET NUMBER OFFICIAL USE ONLY REC WAENDATIONS OF TOWN AGENTS 1DATE APPROVED CONSERVATION ADM71RATOR rSATE�REJECTED C. TOWN PLANNER CON VIENTS F D _INSPECTOR - BEALTH SEPTIC INSPECTOR - HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED _ DATE APPROVED T� U DATE REJECTED f a' PUBLIC WORDS - SEWER / WATER CONNECTIONS DRIVEWAYPERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DCT -15-2203 03:18 PM GILES, P.L.S. 979 663 2645 P.01 ,:.M.a..a.o. Les> , to CERT/F/ED FOUNDATION PLAN LOCATED /N O o=:� 1 t- XAIX% DATE`: q a s S.L.0/LES R.L.S. LAWRENCE 8 NORTH ANDOVER 21,bo le) �F L ,-r q 4%,oz S.F; AVL o D IEk� srr� F.�-Ly, "It it r " _ Is, P CERTIFY THAT ME OFFSETS SHOWN ARE FOR THE USE OF ���,►ti" OFFSETS SHOWN THE BUILDING INSPECTOR ON4Y, E9 SUCH CONFORM TO THE USE /$ FOR DETERMINATION OFZON/NG ZONING B Y L AW OF CONFORM/T Y OR NON COliiFORMI rY�a T u . awe WHEN TAKEN. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING u 1� BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: / 0,3 1d�No/Cr&we 1.2 Assessors Map and Parcel Number: a�io • e �i Map Number Parcel Number Ata AJ D ® V& --e2 a' 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: �ICF6 7 Lot Areas Frontage ft 1.6 BUMI)ING SETBACKS ft Front Yard Side Yard Rear Yard Required PrOVl RegWred Pr vided R red Provided D d 1.7 Water S M.G.L.C.40. 54) 1.5. Flood Zone Information: Private ❑ Zone Outside Flood Zone Public Pri tem 1.8 Sewerage Disposal ys: Municipal 0 ae Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Ja? N (Pri,.,. Address for Service e 71' ig lure Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTIONSERVICES 3.1 Lice rvis Construction Supe 7 raction Supervisor: L' n d770(,Pe-, V� Address ( �U� Sign r Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor G t'A/z41-Cper7o� cm .©� Not Applicable ❑ Company N e ��079 Registration Number Add s Expiration Date Si na Telephone Ma M Z O z M go 0 Mn r M r s z^ Q 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 ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ 1 Existing Building ❑ I Repair(s) ❑ Alterations(s) ❑ 1 Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief DesAption of Proposed Work: I SECTION 6 - ESTTMATEiI VONCTRirrTTnN MQTQ t Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical ,2. (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 45b Check Number ar%-JL1U1'4 isVW11LKAUMUKILA11U1N 1U BEUUMPL!'TEDWHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date to act on 1, as O er/Authorized Agent f subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belied /1 P Date M NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1' 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Name Name: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Affidavit Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for rry employees working on this job. ComR@fly name: Addrfts. . Imo* Failme to secure coverage as required under Section 25A or MGL 152 cage lead to the kripwition dtri rkW peva andfor one years' Fmpnsonnxetasvm was-ctW4=akiesAo-t6eSormjof�aMDP fne-f_ M understand=PQis- statement may be to the office of Investigations of the DIA for coverage do hereby and papd1b of Mai the it unneBarr provided above is &w and correct: Date l//Zt�D3 Print Official use only do not write in this area to be completed by city or town dfiaaf City or Town Q Btrftng DWt. aC heck f mmmKhate response is required E sicertsi BM p SelechmWs O contact* person: Phone # Health Uepark Other 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: M4 roman s.xy. Locatio Facility) 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 ..^ •� �._... _�.....__ .__.__�__-�-x__._::_0'1 BOARD OF BUILDING REGULATIONS icense: CONSTRUCTION SUPERVISOR i r Number.-. 043575 t Birthdate: 026/19/1939 �t Exp}res:;06 119/2005 Tr. no: 11957 Restricted: Q0_ t ANDREW A SCHWAB'. i 8 STONE POST RD r� 3SALEM, NH 03079 Administrator f Curran Construction Co., Inc. Proposal No. 167 8 Stone Post Road Sheet No. 1 Salem, NH 03079 Date 9/15/03 Phone (603) 894-6902 FAX (603) 894-6341 Proposal Submitted To Work to be Performed at Name WILMA & JOHN BRIELAND Street 103 JOHNNY CAKE Street 103 JOHNNY CAKE City NORTH ANDOVERState MA City NORTH ANDOVER, MA 01845 Architect CURRAN CONSTRUCTION Telephone 978/687-0054 We hereby propose to furnish all the materials and perform all the labor necessary for the completion of PROVIDE SUNROOM ADDITION, DECK AND RENOVATE IN ACCORDANCE WITH CURRAN CONSTRUCTION CO., INC. PLANS AND SPECIFICATIONS DATED SEPTEMBER 15, 2003 AND CURRAN CONSTRUCTION CO.,INC. TERMS AND CONDITIONS All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of SEVENTY THREE THOUSAND Dollars ($73,000.00) with payments as follows: $7,000.00 UPON ACCEPTANCE OF CONTRACT AND THE BALANCE TO BE PAID IN PROGRESS PAYMENTS TO BE DETERMINED PRIOR TO EXECUTING CONTRACT Any item not specifically detailed in the specifications is not included. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on above work to be taken out by Curran Construction Co., Inc. MASS. BUILDER'S LICENSE 043575 MASS REMODELING LICENSE 108386 Respectf y s e y ran nstruction Co., Inc. Per Note -- This proposal may be withdrawn by us if not accepted within 10 days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Accepted Signature Date Signature 1.1/21/2003 08:42 978-6858069 COLLOPY ENGINEERING PAGE 01, %C COLLOPY ENGINEERING CONSULTANTS 65 APER STREET METHUEN, MA 01,W FRANCIS K COLLOPY �lpotNe! (87� BaS-7969 11K4. MOrrCttoNAl tNdN!!!1t ornc! i ruxs ((''9977 805-0069 CML STRUCTURAL DYNAMICS November 20, 2003 Mr. Andy Schwab Curran Construction 8 Stone Post Road Salem, NH 03079 Dear Mr Schwab: I am writing in regards to the proposed addition of a Sunroom at the Brieland Residence on 103 Johnnycake RD in No Andover, MA. I have reviewed your plans of the layout of the room and I am providing you with the framing details of the roof structure and supporting columns and beams. They are presented on the attached Engineering Design sketch, Sheet 1. I have allowed for some snow buildup due to drifting on this roof. If you have any questions concerning this matter, please do not hesitate to call this office. Sincerely, COLLOPY ENGINEERING CONSULTANTS Francis H. Collopy, P.B. Structural Engineer Enclosure; Sheet 1 11/21/2003 08:42 978-6858069 r COLLOPY ENGINEERING CONSULTANTS 65 Ayer Street METHUEN, MASSACHUSETTS 01844 TEL/FAX (978) 685-8069 COLLOPY ENGINEERING PAGE 02-, roe Y.R/Z'1-/1' A.1D �0,r.g / D f—AJ C ,E SHEET NO, D I OF / CALCULATED SY �H C PATE CHECKED By DATE r:ru r l