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Miscellaneous - 104 MARTIN AVENUE 4/30/2018
N O N � N � gam.. o --� �Z o<` o�'� o r" 890 Date . A/I , ... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that X5,�4/� .`P!�L�,G:k has permission to perform i � h r *! ...KA plumbing in the buildings of ..fit. u.`� :P�--........................ at ........... , No h An�d+over s. Fee3.7! 5' .. Lic. No.. {�. 3. (. ....... �j.•. PLUMBI G INSPECTOR Check # L) MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date: (D Z Permit# Building Location: f!' It v{- j /✓ Owners Name: _y(/1% Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional[] Residential II New: U Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted Yes ❑ No ❑ FIXTURES DEDICATED LU SYSTEMS Z0 4n W Y D H d tY Z f' Y Q V1 F- W O Z LU z Ln Xm tn ~ Z V<—= HXNW C C' W y CQ Ln N IL ~0 LU W W W Q.' al 0 H 0 = z �..,d Qh N 0 '> > 0 0 F- F- 2 W F.V.. 0 LL x Y g g 9o o xa s �. Ln a 0 0 0 3 -SUB BSMT. BASEMENT 1sT FLOOR / 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR F'51.0011 d Check One Only Certificate # Installing Company Name: / ` -.( S `/ �?�/�/, <2c Address: PL' 6VX S A El Corporation City/Town: `V v N �e: ✓r � .Business Tel:- C;' Gr (o �zr� El Partnership ax• E3`rirrn/Company Name of Licensed Plumber: '" �l - � - ��� , URANCE COVERAGE: ve a current liability insurance policy or itssubstantial equivalent which meets the requirements of MGL. Ch.142 Yes goo ❑ F u have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy- Lj/ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's A ent Owner ❑ 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 a Knowledge and that all plumbing work and installations performed under the permit issued for this application wili in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: _ TiUe E?Kkumber Si ature of nsed Plumber City/town E14aster r APPROVED (OFFICE USE ONLY ❑Journeyman License Number: .6 '101-19 k Date.. ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 0 t /44vou.1 This certifies that ................ has permission to perform ............................ ............. 0ee ............................ -.' wiring in the building of JP'Ap. . 4.......61........, ................................. at .1 A1Y...... AIAAh .... . *.V' .................... .V.rth Andover, Mass. .7 ........ ijl Fee../d.l . ........ Lic. ................ Check # 7 6 b 9 Date. .Cn �.?.,fry........ TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that .k . �i .�.... 1,P 1,M.tAa .e ... e4' :: .... /. has permission for gas installation ... S. to .t/. - in the buildings of ..+ t,?" -(:ice ........................ • • • . . at `141- A t2-4. j. - :V.... North Andover ass. Lic. No. ��. ��'j.1�,. .. .. . GAS INSPECTOR Check # 1/_ CIVIr I�cn MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: —),i f.J 7/��.. MA. Date: Permit# Building Location: f 0 V 144 /`kk rV A V (0 Owners Name: 4 Lt vi -5;L Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential E9— New: ❑ Alteration: ❑ Renovation: ❑ Replacement: [J— Plans Submitted: Yes ❑ No ❑ CIVIr I�cn INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes c No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy E90000' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regardinq this application are true and �'W UC'�1 ul Illy nrluwleuge anu trial an plumping worK ana installations performed under the permit issued for this application will be in -x... 11 -- .•. a —1,11 -11L [Jl VVl wn ul ule IYla35acnu5ett5 state dump coae ana chapter 14;�of the General Laws. TT�yp��� of License: By L� Plumber , Title ❑ Gas Fitter Signature of ensed Plumber/Gas Fitter [Master Cit /Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY El LP Installer :L_ W Z WLU LU N Cd m Q 2 0 H = W W z1-- 0 � W V N Womwix 0 0) Q Lu��° Z 0 W w O Q H LU �'co0z�W W 1— W Q W W w Z y w 2 w 0 H LLi it p a, LL Z W W co J 0 z LL. F = W H W W 0 o o L 0 z= g 00 a� W F>>>� 0 SUB BSMT. BASEMENT -f FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 TH FLOOR 6 -FLOOR Tr 7 FLOOR 8 IH FLOOR Installing Company Name: S'� ,�� � �� Check One Only Certificate # (' 13JX �,,.(i ,.,,y ❑ Corporation Add r ss: .;rc Ci /Town tY ••�'j , �-�' �/ �a State: . Business Tel:q 7Y _ 6 k7 0 Fax: ❑ Partnership [Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes c No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy E90000' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 Signature of Owner or Owner's Agent Owner El Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regardinq this application are true and �'W UC'�1 ul Illy nrluwleuge anu trial an plumping worK ana installations performed under the permit issued for this application will be in -x... 11 -- .•. a —1,11 -11L [Jl VVl wn ul ule IYla35acnu5ett5 state dump coae ana chapter 14;�of the General Laws. TT�yp��� of License: By L� Plumber , Title ❑ Gas Fitter Signature of ensed Plumber/Gas Fitter [Master Cit /Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY El LP Installer :L_ Commonwealth Of Massachusetts Official Use only Department of Fire Services FOccuPancy No. BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked 7] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W All work to be performed in accordance with the Massachusetts Electrical Code (MEC),52rIR� 00 WORK (PLEASE PRINT.II�r OR Ty INFORM4TI0 City or Town of: NORTH O'ER A9 Date: By _�� By this application the undersigned gives notice of his or her intention to peTo the rform the el� electrical wector � described below. Location (Street c& Number) /0 �/�� /�"`N �h Cj C p Owner or Tenanty I �V v1 �z' /-- Owner's Address Telephone No. ------------------------ Is this permit in conjunction with a buiiding'permit? yes E�- Purpose of Building S NO ❑ (Check Appropriate Box) cj Utility Authorization No. Existing Service �_� Amps / r(d Volts Overhead E Und d \ New Service ❑ No. of Meters Amps Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Com lelion of the followin table may be waived by the Ins ector of Wires No. of Recessed Luminaires . ! Na. of Ceil: Sus No. of D. (Paddle) Fans Total No. of Luminaire OutletsNo. of Transformers ICDA Hot Tubs Generators RVA No. of Luminaires Swimming Pool Above In-o. o mergency rg g -- No. of Receptacle Outlets Q grnd. nd. � Bette Units No. of Oil Burners FALARt rS No, of Wines ' No. of Switches No. of Gas Burners No. of Detection and No, of Ranges Total Imtiatm Devices . No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers % Heat Pump Number Tons KW No. of Self Contained Totals: `~_.... ...........__..._ _ No. of DishwashersDeteetion/Alertin Devices Space/Area Healing KWLocal ❑ Municipal No. of Dryers Connection Other �' Heating Appliances KW Security Systems:* No. of Water No. of No. of Devices or E uivalent Heaters KW No. of Data Wiring: Si s Ballasts. No. of Dvices or E uivalent No. Hydromassage Bathtubs No. of Mo torsTotal HP Telecommunications Wiring; OTHER: No. of Devices or E uivalent Estimated Value of Electrical Work: tV �. Attach additional detail if desired, or as required by the Inspector of Wires (When required by municipal policy.) Work to Start 6 a _ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee.providesproof of liabili urance including completed peration" enalties o undersigned certifies that such coverageis in force, and as `exhibited proof of same to thee por its ermit substantial equivalent The CHECK ONE: INSURANCE &'BOND ❑ OTHER P issuing office. I certify, under the pains and � (SP�lfy) . r P fperjury, that the information on this application is true and complete- FIRM NAME: Licensee:c��ig7znthe ,a c Si LIC. NO.: %/� i3 applicable, enter exempt ' �— mature LIC. NO.: Address licens� umber line.) U"O,, e ,/� '6 °� Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safe "S" License: Alt. Lica No. OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have the liability required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner coverage owner'sormally ent. Owner/Agent Signature Telephone No. PERMIT FEE: ,�' � ELECTRICAL PERMT NO. ENSPECTZ®NREPORT: ELECTRICAL ITSPECTOR - DOUG SMALL 2. FINAL WSPECTION, ' Passed — ] Failed — Inspectors' comments: 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Inspectors' comments: (Inspectors' Signature - no 4. INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: Passed — [ I Failed — [ ] Inspectors' comments: - no 5. INSPECTION - OTHER: Passed — [ ] Failed — Inspectors' comments: 'Signature - no 00) - NAI M: ection required ($50.00) - Date Date Date Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO DE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts '► Department of Industrial Accidents Office of LnVestigations 600 Washington Street Boston, MA 02111 www muss gov/dia Workers' Compensation Insurance Affidavit: Bu lders/Contractors/Electricians/Plumbers Applicant Information Please Print Ile ibI Name (Business/Organization/Individual): Address: 15- �. City/State/Zip _C,0JA41) l � Phone #:_ Are you an employer. Check the appropriate box: 1. ❑I am employer with 4. ElI am a general contractor and I ployees (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. [No workers' comp. insurance required.] 3. [:11 am a homeowner doing all work myself. [No workers' comp. insurance required.] f workers' comp, insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no 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.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other ;Any applicant that checks box #1 must also fill out the section below sho`•'• Ug :heir workers compensation of ;Any who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby �� under the, i and Penalties of perjury that the information provided above is true and correct Date: �'d— of 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 CIerk 6. Other Contact Person: 4. Electrical Inspector 5. PIumbing Inspector Phone #: r* Date.ZQ...--,5— TOWN OF NORTH ANDOVER PERMIT FOR WIRING C.. -- -.. This certifies that........................................................... has permission to perform,, �':�? . T�.:.'............................... wiringin the building of.................................................................................. at ........................ , North Andover, Mass. F !............ Lic. No l�t�� : �=G- �_ r.�..c ,rt `'r.. ..... ... QQ ELECTRICAL INSPEC R Check # � O� 7099 Date -- TOWN OF NORTH ANDOVER PERMIT FOR WIRING Z, This certifies that: - .... ....... %.................. has permission to perform ..... .................... ... ......... wiring in the building of ....... ....................... .......................... atZeV .................................. North Andover, Mass. Fee Lic. No: ........... ..................... Check # iPEM:AL S CTO r --- L-ummonweattli of Massachusetts l J Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Officiause—onlyl Permit No. Occupancy and Fee Checked/ ,ev. 1/07] n,.. m.,,, APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT flV NK OR TYPE ALL INFORMATION Date: Q 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) J p Owner or Tenant f Telephone No. Owner's Address „ �} j� . Is this permit in conjunction with a building permit? . Yes � NO EJ (Check Appropriate Boa) Purpose of Building �� , i Utility Authorization No. Existing Service �O Amps / Volts Overhead ❑ Undgrd ❑ No. New Service Amps 1 Volts Overhead ❑ of Meters Undgrd ❑ No. Number of Feeders and. Ampacity of Meters Location and Nature of Proposed Electrical Work: No, of Recessed Luminaires , Com letion of the followin table may be waived by the Inspector of Wires. No. Ceii: No• of Susp. (paddle) Fans of Total No. of Luminaire Outlets No. of Hot Tubs Transformers "y A Generators KVA No. of Luminaires Swimming pool Above In - E] 1,51 o, o mergency ig ❑ � -- No. of Receptacle Outlets Qrnd. No. of Oil Burners Batte Units ' No. of Switches No. of Gas Burners , ,� Pr ARU MS No. of Ae ,ones L No. of Detection and No. of Ranges No. of Air Cond. Total Imtiatin Devices Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW Totals: �"""'" ""'w""w' " - _" No. of Self -Contained No. of Dishwashers Space/Area Heating KW Detection/Alerting Devices Local E]Municipal No. of Dryers A Heating Appliances KW Connection El other Security Systems: No. of Water KW No. of No. of"----- or E riivalent Heaters Signs Ballasts Data Wiring: No. Hydromassage Bathtubs . No. of Motors Total HP No. of Devices or E uivalent Telecommunications Wiring: nrrv'rn. No. of Devices or Equivalent 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 Q Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE EP" BOND ❑ OTHER ❑ (Specify:) I certify, under the pains anf penalties ofperjury, that the information on this application is true and complete, FIRM NAME: ! o, Q Licensee: ,iv t LIC. NO.: • �.� a � ' (If applicable, enter " em�PI ,, ' the li ens nrqpumber ine.) 'Signature C LIC. NO.: J� �}'.� j �il 311�9 Address: %�Z C U j'� �l—Y'%<6/'t qty ( �%�, JBus. Tel. No.: *Per IvLG.L c. 147 s. 57 61 security work re D Alt. Tel. No.: ' ty requires q 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 El aQ Owner/Agent -ent. Signature Telephone No. PERMIT FEE. S. w L lY YrV A The Common wealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 NrashingMn Street Boston, MA 02111 j www. nwss.gov/dia Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/plumbers Dplicant Inforniafinn Name (Business/oWizatiort4ndividual): Address: City/.State/Zip• Mr d/7 G IN %G Phone #:. %-0 � � St'/ Are you an employer? Check the appropriate box: L • ❑ I am a employer with 4. ❑ I am a general contractor and I PIoYeM (full and/or part-time).* 2. have fired the sub -contractors al am a.sole proprietor or partner_ ship and have no employees listed on the attached sheet. $ These sub -contractors have working for me .m any capacity. [No workers' comp. insurance workers' comp. insurance. 5. [1 We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGG myself. [No•workers' comp. c,152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] "Any applicant that checks bo)' # l musto fill out the section below showing their workers' compensati tHomeo Type of project (required): 6, ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roof- 13-M Other wnera who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. 4connaotors that check this box must attached an additional sheet showing the name df the sub -contractus and their works , comp. pclic; is �rratian. I ant an employer that is providing:workers' Compensation insurance for information. my employees: Below is the policy and job site Insurance Company Name:) Policy # or Self -ins. Lie. #: scp '�3 9_ %_4 Expiration Date: �0/0 a Job Site Address: r ;n At,, City/State/Zip:� Attach a copy of the_workers'. compensation policy declaration pag Failure to see (showing the policy number and expiration dale) cure eovetage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to $11500.00 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 cerafj nder t , fe,odunus an p asides of perjury that the information provided above is true and correct M Officiat 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/Towu Clerk 4. Electrica b. Other l Inspector 5. Plumbing Inspector G �� Contact Person: Phone # •t. 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,,.assodiation, 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 t mstee 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 woric 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 numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of -the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia 0 r_-- _t commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Utticial Use Only Permit No. 202,7 Permit and Fee Checked Zo [Rev. 9/051 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector' of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building v� 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: Com letion the followingtable ma be waived by the In ector o wire. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans C. o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eatum Totals Number. ons ...... ... o. o e - ontame Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municippi ❑ Other Connection No. of Dryers Heating Appliances KW Securityystems: No, of Devices or Equivalent No. o KW Heaters o. o o• o Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP [Telecommunications firing: No. of Devices or Equivalent OTHER: r G Attach additional detail if desired, or as required by the Inspector of 10res. Estimated Value o�Electr al 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 nless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the gpins and penalties of perjury, that lite information on this application is true and complete. FIRM NAME: �'c"c:2 C LIC. NO.: Licensee: Signatu a LIC. NO.: S✓ -' (/f applicable toyer exempt" in the li.�n'�s,e/number line. Bus. Tel. No.: Address: X33 17�K{4-Shc✓ �/ �3 � Alt. Tel. No.: G7 - *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage n rmally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No.PERMIT FEE: $ c Date. TOWN OF NORTH ANDOVER .o PERMIT FOR PLUMBING This certifies that . ...... . has permission to perform ........ .................... . plumbing in the buildings of ...................... ,North Andover, Mass. Fee! .."` ... Li c. No.. �? ...... ..��.���/ .......... . f / PtUM� G�INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS c Building Location Z 0 A4 4 &f / IV NVwf-e.z Type of Occu anc New Renovation Q Replacement /ice Date Z/LS/d Permit # C Amount Plans Submitted yes No ❑ Installing -Company Name �� / 5 ��d /''.�-j Check one: Certificate Address �� 3 ajC �u ✓L. �_ �yf " ❑ Cote. pr U -?. '2 � .� � l �, � ❑ Partner. Business I elephone Fiim/Co. ame of Licensed Plumber. Insurance CoveraLye: Indicate the type of insurance coverage by checking Lithe ability insurance policy Other type of indem ty appropriate box: El Bond F1 Insurance Vdaiver. I, the undersigned, have been made aware that the lice three insurance nsee of this application does not have any one of the above Signature Owner ❑ a Agent I hereby certify that all of the details and information I have submitted (or enter) above application are true and accurate to the best of my knowledge and that all plumbing wort: �anZ�d*a�tio&ns�perfor.rneda er P 't Issuedcompliance with all pertinent provisions of the Mathis application will be in bing de c1 Chapter _ of the General Law By: J2 a=t Ol LICCRSCQ uim Title Type of Plumbing License City/Town 12) 1 �, icerme ivumoer— Mast F1APPROVED (oFF10E USE. ONLY Joumeyman Date. 6'. - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ......................................... has permission to perform� .................................................................. nC1/YY wiring in the building of ........ ... a ...................................................... at ... 01./ . ..... A.0 ........... V4.742 ....��.. Orth Andover, Mass. ..... ........ Ine Fee-%— .............. Lic. No . ............. ........................... . ... . .............. ELECTRICAL INS E Check # 77833 7199- Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 7 l `nl2 Occupancy and Fee Checked [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME • ), 5Y -CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /O z-/ Owner or Tenant Owner's Address i:✓7fe Telephone Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 16-2.— Utility Authorization No. Existing Service ---"I Amps 12e -,l 2_ ��/(_Volts Overhead � Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity / p Location and Nature of Proposed Electrical Work:zt, Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW No. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Munk'pal ❑ Other Connection No. of Dryers Heating Appliances KW Sectio. oyf Devic s or Equivalent No. of Water Kms, 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 Electr' al Work: "� (When required by municipal policy.) Work to Start: ,A:1-11�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: INSURANCOO BOND ❑ OTHER ❑ (Specify:) 42-z- - I certify, under the papis anYpenalfies of perjury, that the information on this a ication is true and complete. FIRM NAME:�f%�'�F'cr rt.� C LIC. NO.: Licensee: r� �i�p /���°F��,�/ Signer-��A.U, �— LIC. NO.:/��� (If applicabl ntell�. xemj't" in if? c nse number line.) Bus. Tef Q:3—/ ` l,/C% S Address:. ( r/�l/X C7 33 /�` �%l�1`�t✓ /1%,,�/• a 3�/ Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No, PERMIT FEE: $3 I P/ R 9 Date ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ....... ......................... has permission to perform .... ................ ............ wiring in the building of ....5 ..................................................... at ... ......... ............ ,North Andover, Mass. Fee ---b.............. Lic. No.11qw.76L;44i�� ....... ............. ELECTRICAL INSPE&OR .. Check It Pe a 7205 Commonwealth of Massachusetts l t ' r -- - ' Permit No. Department of Fire Services 000u anc\ and Fee Checked u BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9 051 IC;tar hhinkl APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All .\ork to he 1wrt(limcd in ,tccord;ulCC �\ith the \I;i ,achuSClts I ICCu-iC,tl Code 1\It: C). i'-" CAI 12.00 I'LL ISE PRL%T [ INK OR TYPE, ILL I.\ FO)R.1 L I TIO),V, Dater 0h' or Town of: Rnrllg TO rlre-ll�,,I,� ly this ;application the undersigned gives notice of his or her intention to Perform the electrical �\ork described belinv. --cation (Street & Number) by Mqnhn Ax honer or Tenant -9 I /7t�4ef— Telephone No. Dwner's Address 14) MotCA'4 Is this permit in conjunction with a building permit? Yes A�No ❑ (Check Appropriate Box) Purpose of Building els . 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: OA, Corn iclion ul, /Ac /idbm i! s; l(II)IV Inca he V lite L7s ;c..lnr +%/ No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets a No. of HotTubs Generators KVA No, of Luminaires Swimming Pool AboveElIn- ❑ prod. urrld. o. o mergency Lighting Batter U'+lits No. of Receptacle Outlets / No. of Oil Burners I�FIRE ALARMS No. of Tones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Tota No. of Air Cond. 1, ;;No. of Alerting Devices No. of Waste Disposers Heat Pump Number 'funs KW i No. of Self -Contained Totals: Detection/alerting Devices No. of Dishwashers S ice/Area Heating kW p' g Municipal i,Local ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of No. of No. of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of .Motors Total HP Iclecommunications Wiring: No. ul' Devices or E uiE alent OTHER: .I//(Ih,ofdill, -ruti.Icr,nl7l, 1;tcl.„r,I's rr"luu'c+itch,.,l,LLiI,VI fl,: F:,timatvd Value of Electrical Work: AA t k hen required by municipal policy.) \kork to Start: .- Inspections to be requested in accorclance Faith EIEC Rule 10, and upon ContPlctiull. IiNSLRANCE COVERAGE: I- .mess �valve:d by the umicr. no permit for the pertonmulCC OfClectrical tl,ork play i'suC unlC•, the licensee pra�ides hroofOfliahihN insur;utCC includin "_,onlplctrd i,peration" co�era,�e or its ,i.ib�lantial equie,alrnt. a h. r,ndcr::i _ncd cCrtlflc: that ':nch Cokcra'^.,c i:. in 1'nrcc.:111d heti C• IibitCd Arnot ct:,anle to the Permit i:.uin^ office. I11:CK0\1-: iN')I R,\\C'1 ;�.1) �_� ilfll'R pCcily:l Nl der /%1L'�')(!�'1lS,dN(�/?l?lldll.'A(1' )�/)CST/Ah't'. 1'NJ/.!'.IJe.;Iijorot.;1 1,; 11 iv (pp (jelitill I, I,j,! .'°I�L7)1.1f(7�,`/['. n 1101 N;1.1IF:ig91_� Licensee: l���9 %�Or �It;,tnrc _1C. 40.: i,• Address:`1�lIS. Tia. No.:g7�tll,;�.� Vt. Tel. No.:3 ��?��'�, Security Contractor l.icvnsc sluiced to[' this V orl.; it ;lpPlic.ablC. Cntur dhv license number here: OWNER'S INSURANCE NNAIVER: I mil mv,u•e that the I.i+:cn:ec ell,,. ne71 h!n the liability insurtllCc : r :r:t_C n•- rnl:allti acquired by law. %' my si_'nature bcloar. I herchy waiVr this, rrquirenle nt. Owner,'agent m I .. the (check one) ❑ ,.;caner ❑ u«ner' , .r_.:nt. � -- �Y.'.•'ajtury a _��li it t: r'tti , �. F.11.Z/JT f'�' '• Y '�- 3 - Ply) *, The Commonwealth of ,Vassachuselts 11A Department of Industrial. lccidents �3 l Office of Investigations 600 Washington Street f ` Boston AM 02111 y' WWW.1nass.gov1dla Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers �ppli�ant Information Please Print Legibly. Name lliusincssOp1tilli/;IUOIli Intli%idUal): If Address:_ /7 �e7;h�GC-j bf t,zk— State.,Zip: A fo- ®f� Phone it: (16 city; -- I Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and em es (full and'or part-time).* have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet. Ship and have no employees These sub -contractors have working for me in any capacity.workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. El I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 1512, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Pternodeling S. ❑ Demolition 9• ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other \ny applicant that checks box;' I must 3150 fill out the section below showing their workerscompensation policy information. Ifomeuwners 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 :,heet slowing the mune of the sub -contractors and their workers' comp. policy information. I am nn employer !frill is providing ►vorkers' compensation insurance fur my emplgyees. Below is the policy and job site information. Insurance Company Name:. ------ Policy ` or Self -ins. Lic. 'I: 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 25:A of MU c. 153 can lead to the imposition of criminal penalties of a tine up to 51.500.00 and ior one-year imprisonment, as well as civ it penalties in the form of STOP \N NRK ORDER and a tine Of up to $250.00 ;t day against the v iolator. Be adv iced that a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. 1 du hereby ler ' underie pains and penalties of p I that the information provided above is true and correct. '0 tiinnhue: Gate:------ f?.fic•ial w.e naly. 0o r„t tvf ite in this nr gin, h, hc.:,rnrplr►rd h4 . rO „r rotor .!lJic ial. C;ty or Town — lsstring A uthority (circle one): 1. Hoard of Health 2. Building Department 3. City/T,)vvol Clerk I. E'eccrical r>>spector .5. f lumhi,ng Inspector 6. Other (7 e n .r•., a: Phone Date.`. ."9 .`Y,/... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ... !. -? .......... t .;r,,, . .. . has permission to perform - .. .............. plumbing in the buildings of .-<- ..................... f' �f -� .............. . North Andover, Mass. / �[/9(t PLUMBING INSPECTOR Check # C;L 9 7280- MASSACHUSETTS UNIFORM AP%'ICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location jW q M&Akd Owners Name )P� AOJA�A- Permit # � Amount Type of Occupancy New 0 Renovation 0--,- Replacement 0 Plans Submitted Yes No FIXTURES (Print or type) �j / �^ Check one: Certificate Installing Company Name 97Dtt)i640{� T'llVNtbl xliG�S' [I Corp. Address 4 464AW S+ BrAJMASS 1-3 Partner. Business Telephone — �4O'7 Firm/Co. Name of Licensed Plumber. e2l " t 11'B6t u M r4A J Insurance Coverage: Indicate the typ&of insurance coverage by checking the appropriate box Liability insurance policy Other type of indemnity 13 Bond ❑ insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachysettsjSta Plumb ,jng,C-ode and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License License um Master 8— Joumeyman 8— /31116 g.1" Date .r-2 �� f! .7..... . H°RTti 0F4„ao°,'1'O 3� TOWN OF NORTH ANDOVER F ° D ' PERMIT FOR GAS INSTALLATION f 9 i �9S SA �o •• � h SACNUSEt4 This certifies that ... ..`.... . ,.. �.,..`J. ,....... . has permission for gas installation ...�� �....................... in the buildings of ...... 1�... .......................... . at ... �. �! ...2?�!'. f .'� . !:'. ..... , North Andover, Mass. Fee ...3 ... Lic. No..-.).'( ... ...C,.>. .- GAS INSPECTOR Check # 5912 • service, lnstauanon, mepalr VVILLIAWI 0. *1911 In • Gas - Piping MA t.ic. #3762 • Boiler end Furnace Replacement Bradford, MA 01835 • Appliance Installation 978-373-7901 ADVAIUCE® EMER Y 5ERVICEra MECHANICAL CONTRACTING HEATING • AIR CONDITIONING OT HdoniCS A want-mmN b MASSACHUSETTS UNIFORM APPLICATON FOR PERMIlT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 2 ,4 u l + ba 1 A t=( V w TL-ei Owner's Name Date New 11 Renovation D Replacement 0 Plans Submitted 11 emit # �� r LC— Amount $ 3 (Print or type) Check one: Certificate Installing Company Name ADVA#VQ-r0 64%QGV SC -10e,05 Corp. Address 2 c=Gryi u/oo f! Partner. ® Firm/Co. /.V t4W, M.4, Name of Licensed Plumber or Gas Fitter IN 11( /pM T. SAI / rW INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No� If you have checked }_es, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner V Agent i nereny ceruty that all of the details and mtormation I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Slate Gas Code and fh4pter 142 of the General Laws. [APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber G r -?1 (0 ?- Gas Gas Fitter License um er Master ® Journeyman a U U o z H a d w U o a p � H x w z a o a> w C7 F z F z w V p > H w W d w> a px d a d d o o w ,xj o v, x z > x a oo. [`'- O SUB -BASEMENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Check one: Certificate Installing Company Name ADVA#VQ-r0 64%QGV SC -10e,05 Corp. Address 2 c=Gryi u/oo f! Partner. ® Firm/Co. /.V t4W, M.4, Name of Licensed Plumber or Gas Fitter IN 11( /pM T. SAI / rW INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No� If you have checked }_es, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner V Agent i nereny ceruty that all of the details and mtormation I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Slate Gas Code and fh4pter 142 of the General Laws. [APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber G r -?1 (0 ?- Gas Gas Fitter License um er Master ® Journeyman Locationf f �o, 0�� Z2 ,IV -e-- No. Date NORTIy TOWN OF NORTH ANDOVER F Certificate of Occupancy $ E<� Building/Frame Permit Fee $ s�cHus Foundation Permit Fee $; Other Permit Fee $ TOTAL $ Check # r r �� t 19978 Building Inspector Permit NO: - Date Issued: LOCA TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page 1 4h PROPERTY OWNER Print MAP NO.: P ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ❑ Two or more, family No. of units: ❑ Industrial Repair, replacement ❑ IDernol ition ❑ Assessory Bldg ❑Commercial ❑ Movin relocation Other ❑ Others: ❑ Foundation only nFerRrnTiON OF WORK TO BE PREFORMED v 1) Y, . Please Type or Print Clearly) OWNER: Name: AN_,'� G Gr & 50 CONTRACTOR N Address• 0 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: g 689610 Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT.• 512.00 PER S1000.00 OF THE TOTAL ESTIMATED OST BASED ON f 125.00 PER S F. T_ Project Cost :$cf. 00 d FEE:$0 C Check No.: _A4 Receipt No.: Page [of 4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work Addition Or Decks o Building Permit Application a Surveyed Plot Plan a Workers Comp Affidavit a Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) a Building Permit Application a Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks oMce must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Dec: INSPECTIONAL SERVICES DEPARTMENTMFORMOS page 4 of 4 _i Date 0. 5�-`" e%. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..�--rr!�'',r`f`...;� ....... f � } has permission to perform —7`'. plumbing in the buildings of ... .................. at ..1,6 `.........''��,-.. , North Andover, Mass. Fee . , ° .... Lic. No.. �.�.. ....... . PLUMBJNG I SPECTOR Check 0 7220 1■ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) j r� l�► Mass. Date1 i✓i l-162-0 Permit # Building Location nqAV2M` ,f ALV--Owner`s Name " Type of Occupancy New ❑ Renovation ❑ B.P. # Replacement5�� SFWpR Jt FIXTURES Plans Submitted: Yes ❑ No 0 Installing Company Name �1--`�,{,, d,.Y�, r ✓� BuisinessTelephone_( A-1Qj1 Nome of Licensed Plumber or Gas Fitter Check one: Certificate D -Corporation Z(ob(o ❑ Partnership 0 Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes 0 No 0 If you have checked Ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 0 Other type of indemnity 0 Bond ❑ OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted Ior entg boapplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed uj10;:t th�:'n ed for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chap eral Laws. By Title Signature omber Clty.?Owe APPPOVED(OFFICEUSEONLI7 Type of License: i Master ❑Journeyman -- - I jV-r if Z Z tN� Y Z ¢ � } Ov zM W '-' w = V)E- U W to N LL Z . CL z of 0- rx w O. w Q� Q w Z nin Z n 0LL LU Q 2 V> H_ I<-- �! O p a. Ln o D z Q~ Z3 Z Ln'he. O O 17- W Q Z 2 Z a • 0 � Q' 0 w m to U 0 0 ° Q -j � Zi u_ Q U Wa 2 o W Q�° Q u U m o= .o 0 SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TH FLOOR TH FLOOR L , Installing Company Name �1--`�,{,, d,.Y�, r ✓� BuisinessTelephone_( A-1Qj1 Nome of Licensed Plumber or Gas Fitter Check one: Certificate D -Corporation Z(ob(o ❑ Partnership 0 Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes 0 No 0 If you have checked Ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 0 Other type of indemnity 0 Bond ❑ OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted Ior entg boapplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed uj10;:t th�:'n ed for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chap eral Laws. By Title Signature omber Clty.?Owe APPPOVED(OFFICEUSEONLI7 Type of License: i Master ❑Journeyman I: TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .........� %.!t-c°c,.................................... has permission to perform.....(.%/ ...............`!` !3 *:<<r1...................... wiring in the building of ............ �4J ............................................................... at A .................. , North Andover, Mass. Fee..k............ Lic. NdT� ; � �% % � ELECTRICAL INSPE,^C7�R Check # 7090 Ip -� t ommonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 11'/D 50 Occupancy and Fee Checked [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: (2 e/ o MI City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjuncti n with a building permit? Yes ❑ Purpose of Building /--- Existing Service Amps / Volts New Service �� Amps / Volts Number of Feeders and Ampacity Location and Na ure of /Proposed 9Electrical Work: 97 Telephone No. Via - ex, 7P, No El (Check Appropriate Box) Utility Authorization No. Overhead Undgrd ❑ Overhead Undgrd ❑ No. of Meters No. of Meters / 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: elo� 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 C_ BOND ❑ OTHER ❑ (Specify:) I certify, under th pains and penalties of perju that the information on this application is true and complete. FIRM NAME: /SGT moi« LIC. NO.:/ Licensee: f <zi �� `� Signatu - –T- LIC. (If applicable tW exem " in the license ber li ) Bus. Tel. No.: o Address:~ X-`3 �Jlj'a� i�iii�to�,J'- D3/ Alt. Tel. No.:, �� S�Dti S— *Security System ontractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ie may ae waivea Dy the ins ector oy Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans o. of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑o. of Lmergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of RangesTotal No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat ump Totals: um er ons o. o e - ontalne Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security ystems: No. Devices No. o Heaters KW ater°� ° f N °' ° of or Equivalent Data Wiring: Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: 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: elo� 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 C_ BOND ❑ OTHER ❑ (Specify:) I certify, under th pains and penalties of perju that the information on this application is true and complete. FIRM NAME: /SGT moi« LIC. NO.:/ Licensee: f <zi �� `� Signatu - –T- LIC. (If applicable tW exem " in the license ber li ) Bus. Tel. No.: o Address:~ X-`3 �Jlj'a� i�iii�to�,J'- D3/ Alt. Tel. No.:, �� S�Dti S— *Security System ontractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ TOTAL °i3L55 $ Building Inspector Div. Public Works XA R l 14) A U�- Location .f� 7 No. z © Date01 / S �c/ MORTol TOWN OF NORTH ANDOVER c1f . p Certificate of Occupancy $ $ aJ * : , BuildinglFrame Permit Fee $ 'Ss+CHUSE` Foundation Permit Fee $ Other Permit Fee $ P1 Sewer Connection Fee $ o Water Connection Fee $ CM Q, rn TOTAL °i3L55 $ Building Inspector Div. 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