HomeMy WebLinkAboutMiscellaneous - 1044 SALEM STREET 4/30/2018 (2)3
4. 19".3
Date...! �': .,• 1�
NvR�ry
�'<•��° •��c -TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACHUS�
This certifies that ...t`: � :� ....' .............. .
has permission to pe rf� .... e ! .. .' :F...�...... ' ....... .
`VV ( .k
f
plumbing in the buildings of ........`... ........ .
at ...{....... .,, .1 ..:................... . North Andover, Mass.
Fee.. .---Lic. No.,, •. ...... 1:o -.t .............
f PLUMBING INSACTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .GOLD: File
I
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
�—\ (Print or Type)
0
NORTH ANDOVER, , Matt. Date
Building PermN #' v
Location S, /,em S
Owner's
Name% 64 X e 7a ata u,,; �—
New a Renovation p Replacement p Plans Submitted: Yes ❑ No (I—
FIXTURES
Installing Company Name
Address
Business Telephone S—elp
Name of Licensed Plumber /! c
Check one:
p corp.
p Partnership
[3i-1rm/Co.
INSURANCE COVERAGE:ec ong
I have a current liability Insurance policy or No substantial equivalent. Yet COY No C3
If you have checked y", please Indicate the type coverage by checking the appropriate box
A Ilablilly insurance policy ❑ Other type of Indemnity O Bond ❑
I.
Cerimcale
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:
Ninp
s ure of Owner or Owner's Acent
Owner p Agent
I hereby cwflty that all of the delalis and Inhmmallon I have submitted for entered) In above application are true and &osmate to the bait of my
knowledge and that all plumbing work and Installations performed under thepemrit Issued for thls application will be In compliance with all
pertinent provisions of the Massachusetts State Plumbkv Code end Chapter t42 of tM laws. �q
u �C
nuto of Ucensed Plumber
Ucense Number
By
Title
Ctty/Town
APt I'MED (OFFICE USE ONLY)
Type of Plumbing license: Master ❑
Journeyman [9 --
��.����■11111111■111111/������;
Installing Company Name
Address
Business Telephone S—elp
Name of Licensed Plumber /! c
Check one:
p corp.
p Partnership
[3i-1rm/Co.
INSURANCE COVERAGE:ec ong
I have a current liability Insurance policy or No substantial equivalent. Yet COY No C3
If you have checked y", please Indicate the type coverage by checking the appropriate box
A Ilablilly insurance policy ❑ Other type of Indemnity O Bond ❑
I.
Cerimcale
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:
Ninp
s ure of Owner or Owner's Acent
Owner p Agent
I hereby cwflty that all of the delalis and Inhmmallon I have submitted for entered) In above application are true and &osmate to the bait of my
knowledge and that all plumbing work and Installations performed under thepemrit Issued for thls application will be In compliance with all
pertinent provisions of the Massachusetts State Plumbkv Code end Chapter t42 of tM laws. �q
u �C
nuto of Ucensed Plumber
Ucense Number
By
Title
Ctty/Town
APt I'MED (OFFICE USE ONLY)
Type of Plumbing license: Master ❑
Journeyman [9 --
Date....."./.16 1 ..
N21 910..... ......
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that ............... ..........................
has permission to perform ..... V� .....
........................... i
f ' ... n 1,�1.)
wiring in the building of ..................................................
............... North Andov;rj Mass.
at ......... ......
Fee....L( /;
Lic. No/5.- 2.v .......... .............
91 o�j K19 9 12:20 /
ELECTRICAL
3
15.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
77EC0W0A E4LTHOFM9SSACHVSETIS Office. Use only
DEPARTMFNTOFPUBLIMFETY Permit No. _ I.
BOARD 0FFIREPREVEN7I0NREGUL9TT0NS 527CMR 12.00
Occupancy &Fees Checked
APPUCATIONFOR PERMIT TO PERFORMaE�CAL WO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, S27 CMR 12:00 g
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat 26 CP l
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street 6
Owner or Tenant
Owner's Address .fG��—
Is this permit in conjunction with a building permit: Yes � ~J No (Check Appropriate Box)
Purpose of Building
Utility Authorization No.
Existing Service I � Amps Za 226 Volts Overhead �/ Underground ID No. of Meters
New Service �_ Amps / Volts Overhead Underground No. of Meters.,,,
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work r5 -rte
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
f
ground
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
j
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
El
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
,go. Hydro Massage Tubs
No. of Motors
Total HP
O R -
hNrdrKeCoverage Ptasuantiottlererp mnat;oavbmdxB&C xdLaws .
Ihme act=tIJabkRMmrxePdxyMAxk9CWO* CotWearts 933sorfil egivatartQ
YES- NO
IhmeW"&dvalidptodbf'same1otte0ffi= YFS�hmdra��Pkm��ofmcaWbY�g�
box. �--+
INSLRAMCE M' BOND OVER (t' mSpe fy)
E edVakxcfl3x calWC1k$
WOkIDSta;t 116 f h�pamanD�eRe d Rauh Final
Sigrtecitax5XMPd1Wlies ? %
FIRMNAME
Lioel>sae �T— h" / Signattae
OWNER'.SiNSURANCEWAIVE ;IamamdrttheLimwdmmtin
a �anTysatlispmntapphxbmwa'pAsdftsmW'wriat
(Please check one) Owner Q Agent o
13wi oTd.Na y'% %�°
r A�1' Gid
AILTe1Na
eu>Suratoeo�a�aits�diaieastecgmadlryMass�as�CLaws
Telephone No. PERMIT FEE $ /v
Location
No. _ Z Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
Il
Building Inspector
��= ,g 0 �9 52.00 PAID
Div. Public Works
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Restricted To: 00 48798 S
DEPARTMENT OF PUBLIC SAFETY J
CONSTRUCTION SUPERVISOR LICENSE 00 - None
Number: Expires: Birthdate: 1A - Masonry only
tCS 020519 04/24/1998 04/24/1939 1G - 1 & 2 Family Homes
& SWestricted To; 00 Failure to possess a current edition of the
Massachusetts State Buiilding Code
RICHARD A PEAKS is cause for revocation of this license.
59 LILLIAN .
WOBURN, MA 01801
,
-.: OFFICES OF: _ _� _,--TOwxl Of20ma;riscre t✓
APPEAtS NORTH ANDOVER - - -- - ~"- North Andover.
�.y.
BUILDING .t,e - Massachusetts o 18-25
CONSERVATION DMISiON OF IM
HEALTH
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KriRE.` HP. `ELLSO\\ DIRECTOR
-"
In-ac:rrt ince wick: the pm—vsic:rs .. aG S
cordit:cn of Building pear_ ..c
i`+urtee:ist fat -
is resaiting fret^ this work shall be
orcne: 1 by %IG __.._-- - _.,__ ._.
.
_5CA-
The debris -ill be disoose;t cf in_
A A `h' 1
nate
NOT=: Demolition permit fr= the Town of :forth Andover must be obtained for
this project through the Office of the Building Inspector.
NpRTM TOWN,g F NORTH ANDOVER
pF 41.ao ,°,ti0
PFAAI� FOR GAS INSTALLATION
This certifies that ... s.: f r r�„% ....................
has permission for gas installation .........'. - ........
in the buildings of ......:....... .`: .A..rr...................... .
at ..... ! ....: ! !' .`:......: t ...... , North Andover, Mass.
Fee.. 4 ..:. Lic. ......................
s GAS INSPECTOR
WHITE: Applicant I CANARY: Building Dept. PINK: Treasurer GOLD: File
rMASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING �!
(Print or Type)
f NORTH ANDOVER ,Mass. Date 9 3
l4uilding Location /0 c y5n 1'ea4 U ' Permit #
.� Owners Name 'T'l S
• - New 'y Renovation D Replacement T-1 Plans Submitted 11
FIXTUP=c
(Print or Type) Check one: Certificate
Installing Company Namezx- GL( ��a�ti.� he Q Corp.
Address SS Partner.
Lunn fir— a SS [—rFirm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverage_. Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Ei�other type of indemnity Q Bond Q
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 coverages.
Signature of owner/agent of property Owner Q Agent Q
1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of mY
knowledge and tint all plumbing worst and lnstaUations performed under Permit isseed lo: this application wiU-be to eomplia'hce with all pertinent
provisions of tho Massachusetts State Cas Code and chapter 142 of tho General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: w- (/(/1
Plumber 4qj1'ej'
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman V �- -� ( 7'y
License Number
Y
Y
•
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(Print or Type) Check one: Certificate
Installing Company Namezx- GL( ��a�ti.� he Q Corp.
Address SS Partner.
Lunn fir— a SS [—rFirm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverage_. Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Ei�other type of indemnity Q Bond Q
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 coverages.
Signature of owner/agent of property Owner Q Agent Q
1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of mY
knowledge and tint all plumbing worst and lnstaUations performed under Permit isseed lo: this application wiU-be to eomplia'hce with all pertinent
provisions of tho Massachusetts State Cas Code and chapter 142 of tho General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: w- (/(/1
Plumber 4qj1'ej'
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman V �- -� ( 7'y
License Number
__„--' .ext.-_-r''ai,:'aT'--.'_S-x:--T;s..:.--. .._...,✓. ,.. `._
COMMONWEALTH OF MASSACHUSETTS
ti.DIVISION OF REGISTRA'TION
IN PLUMBERS -AND GASFITTERS
_ICENSED AS A -<JOURNEYMAN PLUMBE
WOE $ TRS-1IGENSE TO
RICHARD MATHEWS.: m m
55 BROOK i DRIV.�.`'
LYNNFIELD ot 940-000
23678 05/01/94 350214-4,
LICENSE NO.
EXPIRATION DATE SERIAL WO
4. It 'L• t 5 .\:'\ tj. '�` 4 ... ..
3269
Date./!�� ....��
_a
NpRTp . TOWN OF NORTH ANDOVER &C
py aao ,e;tipL
p PERMIT FOR GAS INSTALLATION o
w
1
This certifies that .. � ... �. ......... �
has permission for gas installation ... (?............o
w
in the buildings of .....................
at E: -It .......... North Andover, Mass.
Fee ;/. tQ ..... Lic. No..1e.?L'1* . ...... . .........
%GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MAP -(O
SETTS UNI FORM APPL]
PARCEL (jam
or print)
iwnlH ANDOVER, MASSAk-rM
TON FOR PERMIT TO DO GAS FITTING
Date 9/77
Building Locations l ��t`�i1 S�L .� Permit # 3Q G /
Amount S '
Owner's Name q4? f/ P&-,�?
New ❑ Renovation ❑ Replacement Plans Submitted ❑ .
(Print or typ; ,' ^Y �L4 / J� T heckF-1. Cor
Name C: -%p.
IA- )9 y x/44
Certificate Installing Company
Address .t_C r�t__Sa ❑ Partner.
Business Telephone eo U3 3 9 2 "7115- Z ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check e:
I have a current liability Insurance policy or it's substantial equivalent. Yes EV Non
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one: ED
of Owner or Owner's Agent Owner F-1Agent
( hereby certify that all of the details and intormation I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work andi tallations pertormed der Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach setts State C' s a Ch er I f the General Laws.
By:
Title
City/Town
:APPROVED (oF1--ici, USE ONLY)
Signature of Licensed Plumber Or Gas Ritter
Plumber /0 %z 5
Gas Fitter License Numb
lournevman
Date
N2 MS
r
NOtD RT" TOWN OF NORTH ANDOVER
3r �. OL
° PERMIT FOR PLUMBING
,SSAGMUS� /
This certifies that ........................ .
has permission to perform ....13Q?.4.� /'......................
plumbing in the buildings of ...(. e -p S / L i(c)
at. .S7 ... ...... _ o
...rth Andover, Mass.
Fee ../ S ..... Lie. No../. O Z. ...... .... G !k :....... .
PLUMBING INS ECTOR
10/06/99 16:22 15.00 RAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PE IT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS U_ t
n Date
Building Location (� �{ / Sl�LE M � Owners Name V _ P r X Ao y,(04 / 110 Permit #
Amount /'3 , --
Type of Occupancy
New Renovation Replacement 0— Plans Submitted Yes ❑ No
TN TYT1IT 1D F C
(Print or type) Check one: Certificate
Installing Company Name�Cl /' S % �G e!� �' Corp.
Address t 1vtFC Partner.
Business Telephone 2 C( -2- 0 Firm/Co.
Name of Licensed Plumber:�� �Zw S
Insurance Covera e: Indicate a type of insurance coverage by checking the appropriate box:
Liability insurance policy ey Other type of indemnity Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner
I hereby certify that all of the details and information I have submitted (or
best of my knowledge and that all plumbing work and in llations perfon
compliance with all pertinent provisions of the Massachu etts State Pl
IBy:
'.D (OFFICE USE ONLY
Agent
e d) in above application are true and accurate to the
er P rt Issued for this application will be in
pd d apter 142 of the General Laws.
i
e of
Plumbing License
�tn
knsumer
Master �--
Journeyman 11
•
.J
(Print or type) Check one: Certificate
Installing Company Name�Cl /' S % �G e!� �' Corp.
Address t 1vtFC Partner.
Business Telephone 2 C( -2- 0 Firm/Co.
Name of Licensed Plumber:�� �Zw S
Insurance Covera e: Indicate a type of insurance coverage by checking the appropriate box:
Liability insurance policy ey Other type of indemnity Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner
I hereby certify that all of the details and information I have submitted (or
best of my knowledge and that all plumbing work and in llations perfon
compliance with all pertinent provisions of the Massachu etts State Pl
IBy:
'.D (OFFICE USE ONLY
Agent
e d) in above application are true and accurate to the
er P rt Issued for this application will be in
pd d apter 142 of the General Laws.
i
e of
Plumbing License
�tn
knsumer
Master �--
Journeyman 11
:ti'[.3i�.('-"^^'W`�r'dw�'�"�ti `'.�„"e�"`„^i!r+.._..
..--•EY•w,9�j�+�.v.�K� �'�F-yM,�`,�;�,fC.y�'�i'Y�+is]Ilrr'.` ...�F. ...- ,. _....- . .. -....
N, TO253
Date.Xm� ./� I�r9r,6
s .—
,,,pRTH
TOWN OF N—/O,�RpTH ANDOVER
ICAL
PERMIT FOR 1Q3 INSTALLATION
9
�9SSAcewU5ES4 �
,
r
This certifies that J � . cT .. T 1......... .. Z.
ILII Yt ma
has permission for installation T.e........ � �>�'us7.v 1 h�P7��
in the buildings of .:3C71. Sl' C -N o w rC 7..... . .
at .f.(?. Sr4�aC�7?-1..�� .... , North Andover, Mass.
FeA/!' r Lic. No�aS7C. ........... ....... .
T-';-;L,,'i) -1= KK,. FL -4 LL��""'' 3M INSPECTOR
WHITEi pPI%A?etr1C��71NARY: Buiidid5.9*t. PAID PINK: Treasurer GOLD: File
(� Office Use Only
044 Lfammunwailth If ffflusar� dts Permit No. a`�3
13C#futmirit Of Vublit Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:000 peeve blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 1200
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ��lp/��
Q)R or Town of NORTH ANDOVER To the inspector of Wires:
The udersigned applies for a permit to pperfor�m,, the electrical work described below.
!(2�Location (Street & Number) !
Owner or Tenant
Owner's Address
Is this permit in ccnju tion with a building permit: Yes �l(Check Appropriate Box)
Purpose of Buildina�',.- �+� / H Utility Authorization No.
Existing Service Amos 410Welts Overhead L-! Undgrnd r No. of Meters
r-
New Service Amps - Voits Overhead Uncgrno No. of Meters
Number of Feeders and Amcacity
Location and Nature of Prcoosed Electricai Wcrk
No. of Lghtlng Outlets i No. of Hct -.:bs No. of Transformers KVA
j r
No. of Lighting FACcve.— In- ixtures I Swimming Poot grna. — gma. _ I Generators KVA
No. of Emergency Lighting
No. of Receetacte Cutlets I No. of Oil turners I Battery Units
No.
of Switch Outlets I
No. of Gas Surners I
FIRE ALARMS No. of Zones
No. of Detection and
No. Ranges
Total
I No. of Air Corc.
of g
tons
Initiating Devices
No. of Sounding Devices
No. of Sad Contained
No. of Disposals I No.of treat Total Total
Pur^cs Tors KW
No.
of Dishwasners
! ScaceiArea Heating KW
Detect:oniSounetng Devices
Muntcioai
Local _ Connecnon _Other
No. of Dryers Heating Devices KW
No. of No. of
Low Voltage
No.
of Water Heaters KW
Signs Ballasts
Wiring
No.
Hydro Massage Tubs
No. of Motors Tctai HP
OTHER:
INSURANCE CCVERAGE: Pursuant t0 the requirements --f Massac.nusens general Laws
I have a current Liaoiiity Insurance Policy inctucing Comc:erec Ocerat+ons Coverage or its suostantial eduivaient. YES = NO = !
have suomtttea valid proof of same to the Office. YES = NO = If you have checxed YES. -lease indicate the type of coverage cy
checxtng the appropriate pox.
INSURANCE — BOND — OTHER = (Please Scec:!y)
— — � (Expiration Datet
Estimated value of !e tncal �K S _
WorK to Start
Signed under the Penalties of perjury:
FIRM NAME�_
Licensee [1i4G1 �r"�1
Address ._
OWNER'S I
qurrea by N
tP!ease c
Inscectton Date Recuestec: Rough
k
Signa ..re
I am aware that the Lxent" cc
L�vs, and -,net my Si nature an
of Owner or
Finai
LIC. NO.
LIC. NO.
L Bu No.
AI i. No.
nave the insurance coverage or its suostanttal eewvaient as re-
s cermtt aopttcatton waives this requirement. Owner Agent
'eteonone No. PERMIT FEE S �^
s-6�n�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: o/ — JL5 Date Received
Date Issuel.
IMPORTANT: Applicant must complete all items on this page
d4LOCATIONi --
_ _ _ _.. � t
P-1
PROPERTY,xOWfV-ERCC 1 C!Q�/`'/�Q
Print 1 -6';Y arOld"Structure yes; o:
MAP''NO?' PARGEL ZONING DISTRICT:__ Historic.District y,es no
Machine Shop Village: yes, no>
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
- No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic+ .❑ Welly
ELFloodplaln? [IWdtlands,
p Watershed3Disfricta
q Water/Sewer;
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
A�rlrace•
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ ��
Check No.: ��� Receipt No.:C"�%�'
NOTE: Persons contrach wit unregistered contractors do not have access to the guarantyfund
Si natute�of A etit/Owner)gnature,of
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans
ki
a'j
E
2
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
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office 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 subm;4ted with the building application
Doc: Doc.Building Permit Revised 2012
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:_
Planning Board Decision:
Comments
Conservation Decision: Commen
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow; ]Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at'124 MainStreet _
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector . Yes No
DANGER ZONE LITERATURE: Yes No,
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and ®ATA — (For department use
®. Notified for pickup - Date
Doe.Building Permit Revised 2010
Location
No. Dat
Check QM
26202
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ a
67-�
Building Inspector
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The Commonwealth of Massachusetts
- Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect lease Print Le ibl�
A --I. -.„+ Tnfnrmn+inn .,
/Name (Business/Organization/Individual): C,
Address: ^/ O Z S
City/State/Zip: P.
a &A Mal
hone #:
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have Hired the sub -contractors
listed on the attached sheet.
2. El I am a sole proprietor or partner-
These sub -contractors have
ship and'have no employees-
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
officers have exercised their
required.]
3.A I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
t
c. 152, § 1(4), and we have no
employees. [No workers'
insurance required.]
comp. insurance required.]
Type of project (required):
6. E]New construction
7. [] Remodeling
8. ❑ Demolition
9. [] Building addition
lo. E] Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Any applicant that checks box A must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they aie 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 Nan
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: ICity/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.
Ido Zzere�y cer' a der t1 a pains andpenalties
of perjury that lie information provided above is true and correct.
I-, - x -
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Informati®n and Instruction's -
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 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 chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'the affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth ofMassaclhvsetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston} MA, 02111
Tel, # 617-727-4900 ext 406 or 1-877rMASS.A.FF
Revised 5-26-05 Fax # 617-727-7749
www.mass.govldia
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, -Suite 2-36
• North Andover, Massachusetts 01845
Gerald A. Brown Telephone (97$) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER -LICENSE EXEMPTION
BLUDING PERMIT APPLICATION
Please print
DATE:_ 3 3
JOB LOCATION: /0 S R'lPrp Sf _ n U7°fD d��r'�—
Number STreet Address MapiLot
oMEOWNER ) r�-7 63.
Name Home Phone WorkPhone
PRESENT MAILING ADDRESS S Q '71 d 112
i
City Toil
+` + Zip Code
The current exemption for "homeowners" was extended to inchide owner -occupied dwellings to two units -or less and
to allow sui;b homeov"'ners to engage an h�dividual-for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 1.08.3.5.1)
DEFINITION OF HOMEOWNER
Persons) who awns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who constructs more thatone home in a two-yearperiod shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of Forth Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with,said procedures and
requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541
FFICIAL
CONSERVATION 688-9530 HEALTH 688-9540
PLANNING 688-9535