Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 105 FOXHILL ROAD 4/30/2018 (2)
I Date ......3.-...12 - /-f-- ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......................................................... has permission to perform .............. winng in the building of ........ 2:-7.7- ...... ...... �.�- ............. .at LC..:.................................. rth Andover, Mass. I Fee ..... Lic. No. . ................... hLEAICAL INSPECTOR Check# 13151 The Commonwealth of Massachusetts Office Use Only Department of Fire Services Permit# ` BOARD OF FIRE PREVENTION REGULATIONS Occupancy & Fee Checked Rev. 1/07 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with Massachusetts Electrical Code (MEC), 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: March 12, 2015 City or Town of No. Andover, MA 01845-2937 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) 105 Fox Hill Road Owner or Tenant Hedi Gladstone Tel. No. Owner's Address Some Is this permit in conjunction with a building permit: Yes FTI No F-1 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead Undgrd No. of Meters New Service Amps Volts Overhead Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Basement Remodel Completion of the following table may be waived by the Inspector of Wires. No. of Lighting Outlets No. of Hot Tubs No. of Transformers No. of Lighting Fixtures 9 recessed fixtures Swimming Pool Generators No. of Receptacle Outlets 3 No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switches remove/ replace 3 dimmers No. of Gas Burners ALARMS # of Zones No. of Ranges No. of Air Cond. Tons No. of Detection No. of Disposals No. of Heat Pumps kw No. of Alerting No. of Dishwashers Space/ Area Heating kw No. of Self Contained No. of Dryers Heating Devices kw Local Municipal �j0ther F No. of Water Heaters No. of Signs Data Devices No. of Hydro Massage Tubs I No. of Motors (Telephone Devices Other: Remove / replace 9 recessed trim, remove / replace 5 surface lights, remove / replace 3 dimmers Remove / replace 1 exhaust fan -light, Install 2 Refridgerator outlets, Add switch for Mech room & closet light Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $3,240.00 (When required by municipal policy.) Work to start: March 12, 2015 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 the exhibited proof of the same to the permit issuing office. CHECK ONE: INSURANCE rX I BOND r OTHER j (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true & complete. FIRM NAME Dumais Electric LIC. NO. Licensee Mark A. Dumais SignatureLIC. NO. (If applicable, enter "exempt" in the license number line.) Address 8 Newport Street Bus. Tel. No. 978-683-9438 Methuen, MA 01844 Alt. Tel No. 978-685-4553 12170A 26665E * 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 insurance covers a normally required by law. By my signature below, I herby waive this requirement. I am the (check one) I towner coverage agent Owner / Agent Signature Telephone No. [PERMITFEE: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Dumais Electric Inc. Address: 8 Newport Street City/State/Zip: Methuen, MA 01844 Phone #: 978-683-9438 Are you an employer? Check the appropriate box: 1. ® I am a employer with 9 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 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.® Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Travelers Insurance Company Policy # or Self -ins. Lic. #: UB7C833078 Expiration Date: 2/2/16 Job Site Address: 105 Fox Hill Rd City/State/Zip: N Andover—MA 01845 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 0. Date: 3/12/15 Phone #: 978-683-9438 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts. Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/da iPlease visit our web site .at http://www.mass,.gov%dpi/boards/EL DUMAIS ELECTRIC INC MARK A OUMAIS (EL) 8 NEWPORT ST METHUEN MA 01844-3425 C 7Please.visit our web site at http://.www.mass.gov/dpl/b.oards/EL MARK A DUMAIS {E L) 8 NEWPORT ST METHUEN MA 01844-3425 ' Fold, Then Detach Along All Perforations 11083 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that. ........................................................................................... I ........................... has permission to perform ...... )�� ........ plumbing in the buildings ......................................... at ........... b ....................... North Andover, Mass. .......................................................... Fee �0 .... . ........ Lic. No. M.0 .... ...................................................................... .......... ' . . PLUMBING INSPECTOR Check # '�� t> 2-1 -V -A�\\ffv MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY /V 14 1 �� MA. DATE PERMIT # �� f�w- JOBSITE ADDRESS /. 05L l' X 1 /Cl� Gil c( OWNER'S NAME CZ& POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CL INT NEW: El RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES ❑ NO El FIXTURES 7 FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GASIOlUSAND'SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTF ER INSURANCE COVERAGE: 1 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 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I 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 and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. provision PLUMBER NAME it'_ 62.SIGNATURE LIC # iL`%% MP K JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC [0'4 COMPANY NAME /'vt 6 7"A7l LLL' . ADDRESS: 4'O CITY VO STATE i' C ZIP 0/, : ? EMAIL 7Lc�/4 TEL CELL P %. — i g.. ��? y`` FAX R75 -V -A�\\ffv I Date 4.�rj.1.45 .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ........................................ .. .............. ............ has permission for gas installation .. ..... il� .............................................. in the b 'Idings of ......... ��.L:5w.Ajn.................................................................... at ............................... .............................. I North Andover, Mass. s Ti'xEOR PR N;T CLEARLY GP�ILLE TEST MASSACHUSMS UNIFORM APPLICATION FC R A PERMIT TO PERFORM GAS FITTING WORK �`' �` tic t9.�� MA DATE i �� PERMIT JOB5r7E ADDRESS:_._f_p 5 �� SC �t t �� �� Mffi 'S NAME OWNERADDRESS: TEL OCCUPANCY TYPE COMMERCIAL ❑ EDUCA nONAL ❑ Nom: ❑ RENOVATION. - D REPLACEMENT -gg- 0.-- BURNER. AIRUNIT BSS2 3 A ZZi�#7{$ FA RESIDEN i iAL-Q— PLANS SUBM 1 RID: YES -(l' NO[ 0 1 11 ( 12 f 13 vv .. uanu�, / I have 2 current liabiti insurance poircy or its substantial equnralentwhich meets the requirements of MGL ch. 142 VES K NO ❑ Ifyou have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILrfY INSURANCE POLICY OTHER TYPE IMDEllVI7Y ❑ BOND ❑ , OWMER'S INSURANCE WAIVER: I am aware thatthe 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 SIGNATURE OF OMER OR CHECK ONE ONLY: OWNER ❑ AGEffT ❑ IIIeraby ceriity that all of the details and informaion i have subm ed (or entered) n?garaling ihis appication are true and accurate to the besL of my Knamrledge and that aff plumbing work and inslallallons performed undsrthe permkissued for ibis appkafron Jwo be in_compGance w4h all Perdneni provision of the Massachuseds Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITi ERNAM E: : r ra SIGNATURE / COMPAW NAME r_ " :0 - • - -)AZ -r ADDRESS: !''/" P"it Y 1 STATE sL cG,- ZIp: _ FAX: LEL- CELL �7!r-rte 4 = 7 S EMAIL-�C;; MASTFREf JOURNEYMAN ❑ LP INSTALLER ❑ CORPORA71ON ❑ g PARTNERSHIP ❑ 4 LLC ❑. The: Commonwealth of Massachusetts Department of IndustrialAccidents = I Congress Street, Suite 100 Boston, MM 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Orgmization/Individual): Address: /'p 80)T- 7 5` 'X City/State/Zip: Etre you an employer? Check the appropriate box: #: 2 15'/5— 'ZZ� �4& 1.F'I am a employer with • ').. employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have, employees and have workers' comp, insurance.$ 6. 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.] , eje Type of project (required): 7. Q New construction 8. E] Remodeling 9. ❑ Demolition 10 0 Building addition l l.❑ Electrical repairs or additions 12. E] Plumbing repairs or additions 13. [] Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-coritraciors have employees, they must provide their workers' comp. policy number. ]:am- an employef' that is providiizg workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: k V f—L.6t (i7 E Policy # or Self -ins. Lie. C i4-7 ®� / 12 Expiration Date: Job Site Address: /G 5� % � j_ �i i/! �'l City/State/Zip: /1%. � tri jL(�_ o i b- yr_5_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ynder thep*s an�alties ofperjury that the information provided above is true and correct. Phone #: 9 7 e- az5 — 5,� `/ s -- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation 'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I �`.OMMONW LTH fOF Ma SAOHIS TCS: • ` ! �oa��w aC PLUMBERS: GASFITTE, ISSUES THE F0 LOWII�IGr�LICE.NSE �1 L I CEI+TSEU AS A MASTER PLUMBER {§ 1 ij MICHAEL MARCOUX y b w 108 LA((1~,S#ORE gRACU NSA 01826 1008 ,i i 1og17 0/01/16 ' 199204 Date ... 5 .=.2.-.. i. _71 4 ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....................................171.-'.;/!'t&z ................. has perrmssion to perfomi ...... .................................... .... ......................... wiring in- the buildin of. . ........................................... .9 at ... /PS ........... ��.X ... W6.�-4 ........%... ........ .. ...... . North Andover Mass. ...... ..... ........ ... .. ....... Lic. No.2.� ............... ELECTRICALNSPEW; Check # 11.77-8 <L11\ Commonwealth of Massachusetts Offic* 1 Use Only R 0 Department of Fire Services Permit No. c It Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT -TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MECO 527 CM 12.00 (PLEASE PRINT ININK OR YTPE ALL MFORMATION) Date: (T 9—/l City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pp4orm the electrical work described below. Location (Street &.Number) /0-5— / d f ZZ 16W Owner or Tenant Kl?tA t Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service. Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: 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- o, o mergency ig ting rnd. rnd. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches Yi No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number * * "' Tons """". KW "........"'..........Detection/Alerting No. of Self -Contained Totals:..... Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances . KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. stimated Value of Electrical Work: (When required by municipal policy.) Work to Start: T-91— Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) 1 certify, tinder th di�n/s�nd pe hies of perjury, that the information _on this application is true and complete. FIRM NAME: G� 6 00,LIC. NO.: Licensee: Signature46g;FY_ LTC. NO.: ,3e (If applicable, enter "e mpt" in the icense number line.) Bus. Tel. No. • - 7 Address: IV / ele, 19 ®3 Alt. Tel. No.• N--TR5�— 2YY *Per M.G.L c. 147, s. 57-61, set6rity work requires Department of Pu is Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. 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 R — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: ozz Inspectors Signature: ate: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: d Pass 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: 6 Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass ❑' Failed 0 _ ' Re- Inspection Required'($.) ❑ Inspectors Commenty.—\ Inspectors Signat re: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 1K d'%0. City/State/ZiARe,Pv' WI?4 03t Phone#: / % -7 3,7 Are y m an employer? Check the appropriate box: 1. U11 am a employer with4. ❑ I am a general contractor and I employees (full and/or pa -time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. 9; Expiration Date; Job Site Address: j � Jsdz g 0 City/State/Zip: A2 1104A,^ 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 fide 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 Inv` stigations of the DIA for insurance coverage verification. Ido hereby certp under lthe pins a and pe7ldes of p jury that the information provided above is true and correct. Phone #: Official use only. Do''not write in this area, to be completed by city or town official. City or Town: Permit/License # ..— —7 �— Issuing Authority (circle one): 1. Board of Health Z Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: ,r Informati®n 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 ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152; §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152; §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigation$ 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877.7MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.rnass,gov/dia ClAumbla Gas - of Massachusetts A NiSource Company 995 Belmont Street Brockton, MA 02301 June 26, 2013 Mr. Karl Gladstone 105 Fox Hill Road North Andover, MA 01845 Dear Mr. Gladstone: During a recent visit, our service technician detected a safety problem with your gas heating system located at 105 Fox Hill Rd., North Andover, MA 01845 — plugged chimney. Accordingly, we have issued a Warning Tag because of this situation. Under the circumstances, we strongly urge you to correct the code violation. In addition, the Massachusetts code pertaining to the installation of gas appliances and gas piping, established under Chapter 737, Acts of 1960, requires that the condition be remedied. If you have any question, please call our Service Department at 1-800-677-5052 and ask to speak with the Service Supervisor. Please disregard this notice if the condition has been corrected. Sincerely, Customer Service Department Columbia Gas of Massachusetts TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.........R.................................................. :........ r has permission to perform .... .....�- T 7�d wiring in the building of ... ........A,,/. ....f 1� °+............... r�' i at ..... 1�1�. e ..............................:................. .North ydovr, Mass Fee.............. Lic.No. ..... .K... .............. LECTRICALINSP Check # 10868 L Conwwnwea[Ui olec1/laayaelutialb Apart.-- a/,tire �eruiced BOARD OF FIRE PREVENTION REGULATIONS official Use Only Permit No.v Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICALWORK All work to be performed in accord " Z (PLEASE PRINT IN INK OR TYPE ;l INF '1�1TION) Date: 7 City or Town of: , a Uel To the Irlspe for f Wires: By this application the undersigned gives notice of his or her ' niio to orm the electrical work described below. Location (Street & Number) �J © t Telephone No. Owner or Tenant Owner's Address Is this permit in conjunction with a building p rmit? Yes ❑ No � (Check Appropriate Box) Purpose of Building S !Yl Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters � New Amps / Volts Overhead ❑ Undgrd ❑ No. or Meters Service Number of Feeders and Ampacity �� Location and Nature of Proposed Electrical Work �� No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires F eptacle Outletstchesngesste Disposershwashersersater eaters No, of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Above In - Swimming Pool grnd. ❑ � No. of Oil Burners No. of Gas Burners Tota No. of Air Cond. Tons 0 !able ma be lvaived b the Ins ech (o. of Tota Transformers KVA KVA o. a ALARMS INo. of Zones of Alerting Devices Space/Area Heating KW Local❑ Security Heating Appliances KW No. a o. of No. of Data Wi KW Ballasts No. a No. Hydromassage Bathtubs INo. of Motors Total HP tion or or Equivalent OTHER: Attach additional derail if desired, or as required by the Inspector of (Fire Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. may issue unIeE INSURANCE COVERAGE: Unless waived b including own r, no"completedermit for the ion"rcoveage or'�ts substantialce of electrical fequivalent The the licensee provides proof of li ability, undersigned certifies that suche is inforce, and has exhibited proof oAusapplicaU62 to theit issuing o . ce.OTHER ❑ (Specify:)IZ`�CHECK ONE: INSURANCE OND ❑ I certify, ttnrier the airs aidpen i' of e Ctry: t/ t the in rination ontrue C oN0 et FIRM NAME: v � ��� �,J Signature -c LIC. NO.: Licensee: ��� h Bus. Tel. No.• (Ifapplicable, ent "exem !" in the license number li �. / �t7 Alt. Tel. No.: Address: ' 2 (J *Per M.G.L. c. 147, s. 57-61, securityRw 1 awtare that the Licensee does not has Dep 'ent of Public Safety ve the liability insurance coverage normally OWNER'S INSURANCE WAIVE ❑ owner's age required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑owner Owner/Agent Telephone No. PERMIT FEE $$ Signature -Ttwi 6? -c �- L 7- o, P, 9 _ 2 5 ILI, Date.7// /Z........ .. � .. . ,eye O TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,,�'�.,.,, .•''nth SsACHuse This certifies that ..-'�^...... ...�..//........ has permission for gas installation //.SIRS �?.?�" f'i.� ....... in.the buildings of . 1hdS1v/ :e,.. ...................... at ....16 J"7..X �GG%' �% �°d • ....... , Nort An s Fee�l.�. _0.. Lic. NoN-?Y ..... 14,� . GAS INSPECTOR Check # 8245 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY -_ / O(/LL MA DATE L7(/JT -'A PERMIT # JOBSITE ADDRESS 1OWNER'S NAMES GOWNER _ ADDRESS i' /Cd x`�7L(� TEL__�FAx TYPE O PRINCLEARLY OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL D RESIDENTIAL21 NEW: A- RENOVATION: REPLACEMENT: Fj PLANS SUBMITTED: YESCj__I NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER) COOK STOVE DIRECT VENT HEATERS DRYER FIREPLACE �.— --� -�a .. IF I J FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS (_� I (�-��� - _r. {_�-_J _1.I__ . I _ ��-1 _ I _-%� I l MAKEUP AIR UNIT OVEN POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT TEST UNIT HEATER �J UNVENTED ROOM HEATER WATER HEATER-- OTHER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES J;afl0 E] 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L_�fJ__ �� OTHER TYPE INDEMNITY [-D( BOND I__( 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 DI AGENT 0 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 kn Fledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with n ro 'si he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME �r"ZLJ LICENSE # ..Y�I SIGNATURE MP 0 MGF 01 JP [ JGF LPGI] CORPORATION PARTNERSHIP D#= LLCf # COMPANY NAME:�l��v_ ADDRESS __._.__._ �`f�y f�°4_. `- CITY STATE 25NZIP ®` / TEL F�0` FAX __ �L % CELLEMAIL---- S The Commonwealth of Massachusetts .Department ofIndustria[Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): % /�cL �'./%�–/ Address: 'S 7 /'A City/State/Zip: Phone #: T ? ? 75— 3 �2 Are you an employer? Check th�propriate box: 1. [th am a employer with 4. ❑ I am a general contractor and I _ employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I LP4PIumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ire 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 thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: ����� Expiration Date: (::�77/o Job Site Address:l'Qi��/(, ( �/ ,G 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 DTA for insurance coverage verification. I do hereby certify under the pis and the information provided above is true and correct. Date' 712—,12— Official 1Z'12— 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 f s 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 ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who firesides 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 confnmation 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 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 Ma ssaCJIUSettS Department of industrial Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 446 or 1-877rMASSAFF, Revised 5-26-05 Fax # 617-727-7749 wwW=ass,govfdla Location No. !? y Date 2 dY TOWN OF NORTH ANDOVER M 9 i Certificate Occupancy $ of "••e°' EZ<' s►cNus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 /� Check # .3 2 17222 A�/M Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: y a LC) Z, Y SIGNATURE:/a.f a O Buildin Commi;sioner/12UEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 169 FOXX II X7 C o a Map Number Parce Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT istoric District: Yes No 2.1 Owner of Record kwrt I /v 4,ff 2 0 Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: % Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0&01 License Number <d/ r `( �- / Address at 6 �/ / S-1.7 ExpirationDate Signature rTelephone 3.2 Registered Home Improvement Contractors Not Applicable ❑ s�7 q�Li S�d✓r' e / % 10— Y / 2 Company Name IiLc CI 4 lrz 64 ��/ S � Registration Number oy Address -,g Expiration Date Signature I elephone b SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 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 ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description ofProposed Work: /� •W� 'i D ` _ .r. +�3& SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost Dollar to be (Dollar) Completed b rmit a licant #' " 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction oow 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection _6 Total 1+2+3+4+5 Check Number �3 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> as Owner/Authorized Agent of subject property Hereby authorize to act on in all matt relative to work authorized by this building permit application.G A 4e Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date �..' NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS in 2 ND 3RD SPAN DRVIENSIONS OF SILLS DIN ENSIONS OF POSTS 1324ENSIONS 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 Vropozat Page of Free Estimates 105 Haverhill Street Fully Insured Methuen, MA 01844 THOMPSON'S ROOFING (978) 691-1355 Shingles — Slate — Rubber Roof Single Ply — Copper Work PROPOSAL SUBMITTED TO PHONE pA� Heidi ["lads torte A rii 5 2004 STREET 105 FoxHili Road JOB NAME CITY, STATE AND ZIP CODE JOB LOCATION North Andover, MA ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and. estimates for: Strip off all root shingles on.house Ranail all loose boards, if any need replacement it will cost $5.00 a foo Install aluminum drip edge around roof line Apply ice and water shield u ft. up all along edge, and in valleys Apply 15 lb. felt paper on rest of roof area Reshingle with a 30 year Architect shingle (Match color o.f shingles l Install new flange around soil pipe to new addition ) Waterproof chimney flashing Cut in a ridge vent Remove all work related dehris 30 year warranty on materials 5 year vuarantee on labor c Construction license #, 060112 Improvement license # 128612 You are responsible to cover all things in the attic We pull permits k. Tnis contract is valid ::or 60 days.(sixty days) P Vropo t hereby to furnish material and labor — complete in accordance with above specifications, Thirteen Thousand Nine Hundred Seventy Five Dollars for the sum of: Payment to be made as follows: dollars ($ 13,975.00_). $4,000 down balance upon completion Ail material is guaranteed to be as specked. All work to be completed in a workmanlike manner . according to standard practices. Any alteration or 'deviation from above specifications involving Authorized extra costs will be executed only upon written orders, and will become an extra charge over and Signature above the estimate. All agreements contingent upon strikes, accidents or delays beyond our. control. Owner to carry fire, tomado and other necessary insurance. Our workers are fully Note: Thisproposal may ,...A�... UL. . �_ withdrawn by us if not accepted within days. Xtteptatire of i9ropogor = 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. Date of Acceptance: Signature 01 CERTI f I C A T E OF PRODUCER PELHAM INSURANCE SERVICES INC 122 BRIDGE STREET 122 BRIDGE STREET PELHAM LIABILITY INSURANCE NH 03076. INSURED Thomas Doyle DBA Thompson's Contruction & Roofing 8 West St. Salem NH 03079 DATE 7/10/03 (MM/DD/YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER A: Western World INSURER B: Liberty Mutual INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO THE TERMS, THIS ALL EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY [X) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 [ ] [ ] CLAIMS MADE [X] OCCUR NPP770609 04-17-04 04-17.05 FIRE DAMAGE (Any one fire) MED EXP (Any one person) 5 $ 50,000 [[[ PERSONAL & ADV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER [X]POLICY [ ]PROJECT [ ]LOC GENERAL AGGREGATE PRODUCTS COMP/OP AGG $2.000,000 $2.000,000 AUTOMOBILE LIABILITY [ ] ANY AUTO COMBINED SINGLE LIMIT [ ALL OWNED AUTOS (Each accident) $ [ SCHEDULED AUTOS BODILY INJURY ( HIRED AUTOS (Per person) 5 ] NON -OWNED AUTOS BODILY INJURY (Per accident) $ [ ] PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY [ ANY AUTO AUTO ONLY - EA ACCIDENT $ [ ] OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY [ ] OCCUR [ ] CLAIMS MADE EACH OCCURRENCE $ 8 AGGREGATE [ ) DEDUCTIBLE $ [ ] RETENTION 5 $ 8 B WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY [X] WC STATUTORY [)OTHER WC2.31S.314995.013 04.21.0 4 04.21.0 5 E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE $100,000 $100,000 E.L. DISEASE -POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Various for Kevin Murphy Construction. CERTIFICATE HOLDER [X]ADDITIONAL INSURED: INSURED LETTER: CANCELLATION Kevin Murphy Construction SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF; THE ISSUING INSURER WILL ENDEAVOR 169 Boxford Rd. TO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED N Andover OR LIABILITY BUT ANY ILKINDTODO UPONSOTHE�INSURER. ITS SE NO OAGENTSIOR MA 01845 REPRESENTATIVEt. AUT RIZED R RESENTATIVE/) n t//9/) )OS P g e l of 2 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: ri.-Y. Location: City //1 �o d-� Phone am a homeowner performing all work myself. FI am a sole proprietor and have no one working in any capacity I am an employer providing. workers' compensation for my employees working on this job. r.mmnanv name- Address City: W `4 Phone #: Company name: City: Phone #: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the. Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. b L(- 2G—dy Print name TH v VV, u o W 0 Phone # G 9/-13s s - Official use only do not write in this area to be completed by city or town official' Building Dept E] Check if immediate response is required Building Dept p Licensing Board p Selectman's Office Contact person: Phone #: Health Department El Other FORM WORKMAN'S COMPENSATION Official Use Only Permit No. D0av--a 4 paeka 5410 Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number Owner or Owner's Address Date TO the Inspector of LVVir es: Is this permit in conjunction with a building permit Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgmd 0 No. of Meters New Service Amps Volts Overhead 0 Undgmd 0 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a currentLiability Insurance Policy including Completed Operations Coverage or its substantial equivalent' YES = NO - have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC. NO. Licensee Signature LIC. NO. Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 No. of Lighting Fodures Swimminq Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Bumers FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Inflating Devices Heat Total TSI No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishwashers Space/Area, Heating KW Detection/Sounding Devices 0 Municipal 0 Other No. of Dryers Heating Devices, KW Local . . Connection No. of No. of Low Votlage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a currentLiability Insurance Policy including Completed Operations Coverage or its substantial equivalent' YES = NO - have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC. NO. Licensee Signature LIC. NO. Bus. Tel No. Address Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) 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 P disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: s Ldy,-e-& s� (mow & (Location of 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 b Cl z w o PQ u a O w z a o °�° v tsO ® w °�° io OG a w W °�° c H _O C :cm oZW a °�° in a w w ro z cn v Q O cn •A � M-16. E z y O y E CDCL O C.3 _O M C* O .ca CIO O cc c _cc is i O Q� h C O CM cl ccco �S® �m • c := o tsO c H _O C :cm O C.2 •dam i c aC ev o :t o r o m CD 0 :ACL (/J �o m yQ ®e�� a m 0.3 ce c y p 0O+ . y m tV S cmw ago 9wo 4D V O +r w C O C! C a®3 o d Ui O ®w0.. D .p :s 'fl .0 06Z O fy W .� C .tn O 0 o c' COD O ®� 0:6 g E 44 mL'3 F- .c S a -095- m9 zip •A � M-16. E z y O y E CDCL O C.3 _O M C* O .ca CIO O cc c _cc is i O Q� h C O CM cl ccco -P 4,090 Date...'. 711 71e 0, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... h -f ..... ....................... 61,1 has permission to perform ..... . .. q.,Il . .................................................... wiring in the building of ........... ................................... -I" 1A 1. At -�7 ..... ..................North Andover M Fie .9 ... v Lic. No. .......... ELECTRICAL INSPECTOR Check # THECOMMONWEALTHOFMASSACHUSEM Of use pm DEPARTMW0FPUBIJCSAFNY Llqnly BOARDOFFIREPREVENrION Permit No. V �ONS527CW 12 00 Occupancy & Fees Checked APPLICATTONFOR PERMIT TO PERFORMELECTRICAL, WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 1✓ PT 1-1 A as Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant A Owner's Address 1015 P'uxµt L -L 2.01 Is this permit in conjunction with a building permit: Purpose of Building Yes © No 0 (Check Appropriate Box) To the Inspector of Wires: g Utility Authorization No. Existing Service �� Amps —Volts Overhead � Underground ED No. of Meters New Service Amps / Volts Overhead Under found o� g No. of Meters Number of Feeders and Ampacity — Location and Nature of Proposed Electrical Work IAA 64 JCS 2 'iZ C No. of Lighting Outlets No. of Hot Tubs No. of Lighting Fixtures Swimming Pool Above No. of Recep 1 cle OutletsIc No. of Oil Burners round No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total No. of Disposals No. of Heat Tons Total No. of Dishwashers Pum s Space Area Heating Tons No. of Dryers Heating Devices No. of Water Heaters KW No. of No. of No. Hydro Massage Tubs Signs Bailasis No. of Motors Total HP No. of Transformers Below Generators ,round No. of Emergency Lighting Battery Units FIRE ALARMS Total No. of Detection and KW Initiating Devices KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW LocalMunicipal 0 Connections Total KVA KVA No. of Zones Other knZance,CO Rirsuantl0the mVitecrt�tsofMassXhusettsGatelalIam [haw acurrent Li*htyhist=o Rky'Wk&g C0ffP1CfP-"0XM0nS COWMWcritsstftarlialegtuvalent [havesubrn&dvandptoofofsametotheOlfiM YES NO gthe box [a gyouhavechecl®dZlemindi�ethetypeofmvrrageby NSURANC'E BOND OU -ER ( Specfy) LLL..���111 E>t1I�te VotktoStatt b onDa�Ret etl Esbn�&dVahjeofF�riCalWo& $ ignedunder�rRmkiesof Rc* Final IIZMNAME _ � 9 foe 1 (� U L1 D Signature IiomseNo BusumTel No. At Tel No. WNFRSIlVSURANCEWAIVE[t,IamawatethattheLi�edoesnothavetheinstuan�oov��eoritssubstantial valentas �lthatmysgnattueonthispamitapp?icntiorlwaivesthistegititeirmt OdbY hLaws ".'lease check one) Owner 1 Agent Telephone No. PERMIT FEE d Igna ure o . caner or gen S 4075 Date..!F-/,'P .10......1 ............?-........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING v? 11 0 This certifies that ... ��f .-I/ ......... ........... ................................ 4; - 'has permission to perform ....... ..................... Aviring in the building of ... 1Z, I'a'L - .... ...................................... atZ12A-..A/ ... &4-4-t ... / .......................... . North Andover, Mass. Fee QNS ..... . ..... Lic. No. ..... ELECTRICALINSPECTOR Check # IN 13 C..arnmo,rwaa[lh ojcc�%a�eac�rwalE� 1JaparEntariE o�.}ira �araicae BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Pemti t No. 7 Occupancy and Fee Ch\/d Ste_... Rev- 11/99] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Cleetrical Code (AiCC , 527 gm 13.00 (PLEASE PRItVT Oil TYPE :ILL IWORAL-17701V) Date: i"I. City o , Town v : I� Q�a�- To [he Inspector By this application t ersigned gives notice orltis or cr intention to perform the electrical work described below. Location (Street & Number) �p Owner or Tenant _ _67 fA-t J 5TV �l-Q• Telephone No. Owner's Address Is this permit in conjunction' with a building permit'_' Yes ❑ No Purpose of Building ® yn -e— Utility Existing Service Amps 1 Volts Overhead ❑ . New Service Amps 1 Volts Overhead Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: security (Checic Appropriate Box) rdthorizntion No. Undgrd ❑ No, of Meters . Undgrd CJ No. of Meters. 0 Canraletiarn Offlre (ollnwine rnhie nrav h,..,.. f...,.1 r... a.- r.._i.-_.__ _r,rrc_.__ No. or Recessed Fixtures No. oC Ccil: Susp. (!'addle) Falls ........0 �r..aa uw caw. vl ••ui'S. °• °l Total fransforiners KVA. No. of Lighting Outlets No. of Mut Tubs Generators K1'A No. or Lighting Fixtures Swimming Poul Above in- rnd. rnd. o. o mergency ig Ming Batteryunits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zolies No. of Switches No. of Gas Burners No. of Detection an 1 Initiating Devices 1 No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices \'o. of Waste Disposers 1•lcat Pump Totals: Number — Tons _ w-� KW ��" No. of Self -Con tained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [] 1Vlunrci do Other Connection No. of Dryers Heating Appliances IM Security ystems: No. of Devices or Equivalent No. o. of Water KW Heaters No. of ' ala Signs Ballasts Data Or,iring• No. of Devices or Equivalent No. Hvdroinassage Bathtubs No. of Motors Total hIP 1 elecommumcatlow Tiring: No. of Devicis or E uivalent OTHER: Attach additional detail if desired, or as required br the hrspector of !Vires. INSURANCE COVEILiGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof or 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 ❑ 91TIER ❑ (Specify:) O'� (Expiration Date) Estimated Value of Elec rical 1Vork: y D ^ '(When required by municipal policy.) Work to Start: .7 ® %Inspections to be requested in accordance with iv!EC Rule 10, and upon completion. f certify, under the pants and penalties of perjury, that Me infornrat' n ort t lis it 1' ari it is trite and complete FI 10 l NAiIE: Alarm Technology & Surveillance Systems. Inc LIC.NO.: 1203-0 Licensee: William J.Raimondi 6ngnature L]C.it0. 948_p - - (1f alrplicable, en rer--err,npi - in the license number line.) Bus. Tel. N 0.:_(617) 783-1771 _ Address: 415 Shirley Street. Winthrop MA 02152 Alt. Tel. \o.• 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 requircnzcut: 1 am the (cheek onc) ❑ o.,rnrr ❑owner's agent. Owncr/Agent (� ou Sibnature 'Telephone No. I Pi'RiIIIT FEE: S3(5 Date. 9..Gl. 6) L...... ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .t'04. ` 1 re- ... j`j c k1, /', has permission for gas installation .... .f ? -< /Y., .............. in the buildings of .. �1:9.4.Z;/Q r. -n ....................... at .,/.v.1 �..F. vx. , `{ 1, , ,/ .�, . , .. `[ , North Andover, Mass. Fee. ? ..... Lic. No.�......... . GAS INSPECTOR Check # 4121 MASSACHUSETTS UND ORM APPLICATON FOR PE2M1T TO DO GAS FITTING (Type or pmt) Date: N ORTH ANDOVER, MSA—'SSAC 1H'US`E(TTS � Building Locations �% 1'O�F 1�C y 1 l lzC l Permit # �11 Owner's Name Amount $ �L8 S �h�r, New Renovation Replacement Plans Submitted (Print or one: Certificate Installing Company Corp. Address-- a� G r I +rv�\ Partner. Business Telephone t 31a 4RV43 �Firm/Co. Name of Licensed. Plumber or Gas Fitter INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes Noo Ifyou:have decked mss, .please ' tate the type coverage by decking 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: Signature of.Owner or Owner's Agent Owner Q Agent Q i nereoy testy tnat an of the amus and miarmation 1 nave sutamttea (or entered) in above apphcabon 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,Massach" State Gas and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature ofLicensed Plumber Or Gas Fitter [1 Plumber �,]aq Gas Fitter License Number 0 Master ® Journeyman tt t t (Print or one: Certificate Installing Company Corp. Address-- a� G r I +rv�\ Partner. Business Telephone t 31a 4RV43 �Firm/Co. Name of Licensed. Plumber or Gas Fitter INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes Noo Ifyou:have decked mss, .please ' tate the type coverage by decking 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: Signature of.Owner or Owner's Agent Owner Q Agent Q i nereoy testy tnat an of the amus and miarmation 1 nave sutamttea (or entered) in above apphcabon 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,Massach" State Gas and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature ofLicensed Plumber Or Gas Fitter [1 Plumber �,]aq Gas Fitter License Number 0 Master ® Journeyman Location �t%5 b Y -A ` l DIP - Location No. Date NORTH TOWN OF NORTH ANDOVER > ; ; Certificate of Occupancy $ s', Building/Frame'Nrmit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL m $ Check # 809, 15861 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING j s Seeflon for Official Use Ont BUILDING PERMIT NUMBER:DATE ISSUED: /6�0/-J/) /U SIGNATURE: Buildim, Commissioner/ or Of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0 C ParcelNumber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Fronts (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Ra*ed Provided Re red Provided 1.7 Water Supply M.G.L.C.40.% 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 zone — Outside Flood Zone 0 Municipal On Site Disposal System 0 IMN, 2.1 Owner of Record L1--1 I 4-V &-A(CL '15; plc' I C5 r72, V Z) Name (Print) Address for Seivic—e` S* tur Telephone 7V76 , 2.2 Authorized Agent Name Print Address for Service: 6?64,-j�t7 ,i _ Signature Telephone 3.1 Licensed Construction Supervisor Not Applicable 0 Address License Number Li Cocho S cc c ' Musor: av Expiration Date TA Z Z Signature ffeIephone 3.2 Registered Home Improvement Contractor Not Applicable f] mpany-Name Registration Number Address Expiration Date Signature Telephone M 0 4 X M Z 0 Z M Name: Address Signature Telephone t 5.2 Fegisf�ered Profess�e�a� �ees�� � , fl� Name: Area of Responsibility Registration Number Address: Expiration Date- - - Signature Total _ Not applicable ❑ Name: Registration Number Signature YLGitlYiaiiYYW{'Yy. Company Name: Responsible in Charge of Construction Telephone Expiration Date Area of Responsibility — Registration Number Telephone Expiration Date Area of Responsibility Registration Number Telephone Expiration Date Not Applicable ❑ New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify , Brief Description of Proposed Work: IA 113 ❑ ❑ B Business ❑ 2A 2B 2C I, as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly -❑ A-1 0 A-2 ❑ A-3 ❑ Alt ❑ A-5 ❑ IA 113 ❑ ❑ B Business ❑ 2A 2B 2C ❑ ❑ 0 C Educational ❑. F Factory " ❑ ' .' F-1 ❑ F-2 ❑ H High Hazard ❑ 3A 3B ❑ 0 I Institutional - + _ -0 1-1 ❑ I-2 0 1-3 ❑ M Mercantile ❑ , 4 ❑ R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 5B ❑ ❑ S Storage ❑ S-1 ❑ S-2 ❑ U Utility ❑ M Mixed Use ❑ S Special Use ❑ Specify: Specify: Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: Proposed Use Group: Proposed Hazard Index 780 CMR 34: r `.7 E"Mgm M BUILDING AREA M EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area s Total Height ft Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date I, as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Signed under the pains and penalties of perjury Print Name Signature of Owner/Agent Date Item Estimated Cost (Dollars) to beN Completed by permit applicantME 'MEN, 1. Building „r (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of rj Construction from (6) 3 Plumbing Building Permit 4 Mechanical (HVAC) 5 Fire Protection 6 Total) (1+2+3+4+5) Check Number ,yy - ...l..�d�l :�`', �{2� ',..}�1'� v�vYef'r �... !s,`:, Sja {,+';� sl'? Wu tx s s� 1i; . 6 � 2r �'� 7t ,#.�. ,+� s twat. ,1t n a. �' 7r3 +�•z,.�� .�.. ts'. -r .•.m'7�. m t�'Sx r7 F:- x#'U`44 R`{ iw ; x -s rll , <..��: aSX s£,+aY' ��}.., �..;i.�,r,* ('a� .0 �. :.:fi{,tf' �3)1,� .j,R'.?..y �{ 1. S, if �fi, f 1✓rY q1:� ?1 �� 1'. �1 M'�J'.4 G'a ,Yf� l fr' U�a ti 1 � 1.^:. { J. hi `,� % W { �i �i"5 �" Tt'a'�.'i> ,r :1 ,�--.� .t1r.�a„a, afi'�{�✓♦ti fk.:: `rr:�,.=5 ya71S1', �,'�. � ��' t T,y..HLk t�X,�,11, � �Y� � Si ni '� (�,� ��� �¢,. ss �§�s\.-Y: ��4�il�i'�i�l: ;� t t �� h S'{ ��.�'w�., �N.4�ti��+'A �` 4i7t J. � ���;r.,`!'�� ij5'i,,,: 14. .,, ,�! y �, q'. NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2ND 3 RD SPAN DEMENSIONS OF SILLS DEMENSIONS 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 ,$ � •4`; F � `'�'i�-.� � � y 1 " y+ �i•T,f-§Y ��;X'h,$ ,_ Fy t "'` �8 �`4i � � ��'�"� r�1� � y� E �5�, i': 1 1 y#� .' � 0 z x w O; CQ o w A V)w UW a z o cL v U ro G w a p w MW C w a w 24 za 0.4 w, °�° p r� chi ro G iw w z � °�° p r� m C w w w Q 7 CO z V) D o cn c CD go ;ti o c v .: oo N:oy mgill, oa� o"�:moo m ` a O zyvL c � c � :02_m� o A .O y • y � O `•: ® o c CLU m y m ; Q Of �:�_ =.5�O c ACY ®or m Q : y C! = C _ y cc), - p N � y C0.2 ~ CD y C l0 = co W O fl C y=. •«� LU � m y QO U m 0-0 COD a' O O 32 Z eyv y O ►- �m a Z O U ., m O O CD 0 z O D w CDH .E O L CL CO O co V CL CO) 0 O V w C O C..) K%--1 0 CD ivy 3 � �CD 0 0 o a - C. cmQ C c OO Z � CL y C w Lli Cn w w W Lij U) 0 + i BOARD OF BUILDING REGULATIONS i License: CONSTRUCTION SUPERVISOR # N� i Number: CS 022476 Iy Birthdate: 11/11/1955 IExpires: 11/11/2003 Tr. no: 9642 - _ I Restricted: 00 ROBERT R TIMMONSs/ 2 HAMPSHIRE LN/PO BOX 416 (� { LbNDONDERRY, NH 03053 Administrator , r -�. _ .. ` -' _.. i ;�-s-ar.4r, ,.-t° .mow'-.. ,.--- -- - _ •._ ..- - - --y ;/lze•�amrniza�uac�� o�✓���d�c�r�ue . Board alGuilding Regulations and Sta;,dard= HOME-OvIpROVEMENT CONTRACTOR Re jis#cation:.117426, Ex'p' i t'son: 10/03!2002 �ww Type: DBA TIMMONS CONT ROBERT TIMMONS 2 HAMSHIRE LN LONDONDERRY, NH 03053 ,ldministr�iter North Andover Building Department Tel: 978-688-9545 t, 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 c111S150A. The debris will be disposed of in: Qrn E-,; +e g Oe Po I (Location of 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name Ljeinnr✓ 0/1S runs°&((-tf a/ Location City N- 0 &l ;0� tZ ✓►A 6 S� Phone �i�S)696 -7-17-1 1 am homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance Co. Policv # Comr)anv name: Address City Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' impdsonment_as welLas_civil..penaltiesin.lheiamd-a STOP WORKORDFR.and_a.fine. of_($1110.00)-arlay.againstme I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage ver cation. 1 do hereby cert"deptpib pains and periges of perjury that the information provided above is true and correct. --17 — G2 Print name �(1 OOT 0� `"C � �©"`- Phone# 60 " V?V�, Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept []Check d immediate response is required l] Licensing Board p Selectman's Office Contact person: Phone #.• Health Department Other Location a No. Date 512 c2s M�RTk TOWN OF NORTH ANDOVER . 9 Certificate of Occupancy $ }° Building/Frame Permit Fee $ sAC 14 Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ + '�4//lit/— a inspector r{Building 1 8 �j 25/9a 09:06 25.E PAS G Div. Public Works Lpcation No. `> r ,5 x49/25/98 09:06 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 $ f 25.00 PAID Building Inspector Div. Public Works rn I mum z 9 LU z L z u a U w N z C a� � CA N . LL) T z � T a, .J LU z r z _ C � Y���77►�. 1 L N_^ V Z y z W 3 w �+ J � ^ .� w 3 < z � o ~ _ L Z m LJ '" Y2 z G y LU J.1 LLJ n :1J uj C ►+ _ Q ✓n r J — �` Q Z z z — U O z C Z z O U Z U Z zz C U 'y z —•. z C z z G N W H N h rl - I..q N C � Z Y) Q C3 5 Q Z z d N z � "�j z r - z - W C LL z F L _ "• ZZ N L z �( z= '/1 J ^ 3 ' _ Q z i11 W Z z C H < z z r y z CILU d Z z C y Q Z zr- r� 0 z Q J ;) z 2 V U z 6 _� _Z Q Z ' ? z m N N Jn 5 �. mum z 9 LU z L z u a U w N z C a� � T � T a, .J LU z r z _ a 1 ✓tie 'C�ogivpw�uue� o��ac�iuoella OEPAR�EHT OF :PUBLIC SAFETY' ' UiO\f CONSTRSUPERVISOR LICENSE • - Xpires: Birthdate: 14,1 Y t j { ` B ;if/11/1999 11]11 1955 p a �•�v'�l RO�� ��jN,BNS . :' e r •� 2 HA IN POBX- 416 LONDONDERRY, NH 03053 r. h''WE IMPROVEMENT CONTRACTOR Registration 1'11426 ..: TYPe DBA E ExPiration • CONT ��� r, ,F, ,ONS r� RL.R '. TIMMONS n�MiNs7RnTon ,.HAMSHIRE LN LONDONDERRY NH 03053 O T 'mss_ ANIN "`k4o� \` O z COD WLAJ L W C3 CLy H c c c� o � c ` o� 'ate a= ev o y C N � • Ea m C r.+ O m ts rt+ yam+ d I�♦ E c o O C CD c CL:~ N � � m y C3 � O c c � 'O N A ;•E N CD ao Ocj N m C�D,, O 7�oQ N d C L co c � o 0 CL O H o C O CL r O w N m yO.H G w L .E cao�� L- CD o� o: wa 0 y 7 r a� m 0 a z O U Q i lo CD 0 CDL O s z °' CL O CO) 0 C w+ � W cm i O -0 O G CO2 O O m m CD O = C. �' ♦... = R� CD O C i O O a M: rmac go CID V = O zyCD ca CD CL V CO) O C C h D a 0 a a x O u a A C x a � w W �� no' w w � w W C w7 z cn '� '� cn O T 'mss_ ANIN "`k4o� \` O z COD WLAJ L W C3 CLy H c c c� o � c ` o� 'ate a= ev o y C N � • Ea m C r.+ O m ts rt+ yam+ d I�♦ E c o O C CD c CL:~ N � � m y C3 � O c c � 'O N A ;•E N CD ao Ocj N m C�D,, O 7�oQ N d C L co c � o 0 CL O H o C O CL r O w N m yO.H G w L .E cao�� L- CD o� o: wa 0 y 7 r a� m 0 a z O U Q i lo CD 0 CDL O s z °' CL O CO) 0 C w+ � W cm i O -0 O G CO2 O O m m CD O = C. �' ♦... = R� CD O C i O O a M: rmac go CID V = O zyCD ca CD CL V CO) O C C h D Town of North Andover MORTN OFFICE OF 3�°�, `�' 6.,ti0 COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street North Andover, Massachusetts 01845 s�, ":•�sy WII,I,IAM J. SCOTT SS-AcHust Director In accordance with the provisions 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 c l 11, S 150A. The dcbris will be disposed of in: L0,c4i rW--,A (Location of Facility) G¢� Signature of Permit Applicant Date NOTE- Demolition permit from the Town of North Andover must be obtained for tills project through the Office of the Building Inspector. rJ v n � 9530 HEALTH 688-9340 PLANNING 688-9335 s HOARD OF APPEALS688-9541 BUILD�ING 688-9545 CONSERVATION 689 Il •*'..^„"��--�,-.,,!-r,�.a.."-,"rr- .:...,.,:.i•-"6""'++.<; ,�,'�i^'79!`.� «ice, . -+,,, �. Location d S 'No - Date I TOWN OF NORTH ANDOVER NORTH r F p Certificate of Occupancy $ �" + Building/Frame Permit Fee $ eMusEt : ,, Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ uilding Inspector a/E4/96 n110. 25. pp >, .{� ID tJ Div. Public Works < 0 N - W N_ H z � � N W \ Qf W z ^ c 0 0 � z ~ C J C l Yi' s x 3 0 N z Z p C 0 z 0 L U 3 � a D _ ° IL F Z W 0 i N z W ¢ < 0 M 70 O J H z m d t7 Z Q 01 z O W m_ N W m W ` u O _ 7 a W W 0 0 o D m p O y, J W Ur a < 0 a I J_ J� p W 7 p m O W ® U. W H m W N G 0 W < 0 O a0 E 4-. O z W 1-.` _ 13 . C w W N Z < W E / U' N L 7 2 m m y0 p I C a W K W a, z 0 m IL W O 0 u 4 0 m Z W I W m Z1CC O 0 < Z K O W U r J (7 < z u a Z_ J O 7 J m 7 m J " 13 Z 0 H < 0 'ZI U. O z p rK) I W ,p 0 U L p O U m A < W 'iii• Q p W J_ W 1 W4 P- 14 0 Qf W z c 0 0 � ~ C J C l Yi' s x 0 N z Z p C 0 10 L U 3 � a D _ IL O F Z W 0 O a 1 C N z W O Z r M 70 O ( W o z z O 2a u N O 01 z O W m_ a m W W F W W W 7 7 W p O y, J O J r i a < 0 a I J_ u p W 7 m O W W 8} t N G 0 W < 0 K W 13 L 0 > 0 F m U i a �i W OO L J m U W M � p W J_ W 1 W4 P- 14 0 Qf W z c 0 0 � ~ C J C l Yi' � 4 0 K ] 0 N z Z p C 0 J L U 3 � a D _ IL O F p W 0 O a 1 C N z W F Z r M 70 O ( W o z O 2a u N O 01 z O W m_ a m W W F W W W 7 7 W p O y, J O J r i a < 0 a J_ J_ u p W 7 m O W W U t N G 4 W < 0 p W J_ W 1 W4 P- 14 0 Qf i c � m w 3 y _ p W r Z K 0 F W W K W d i f � y �> G Oy Tn i O as O Ov AA - D Oxy? UI ZZOAAn-NNA znnn-= 0 a 00 DV W> a+ 0n n0Q OiA-°I A T 7C Xnn' N „Z Nv n nnnv N z 3: D 00 S ZZAZZONO 00,6 O O my �T _JiN O y Z Z 0 T TZ= Q. O TZ O D Za NO;DN D -300O z >I,, O°' 0- Zx = > O to Z �� <m < Z ^ Z -, y 0 OQ _ it l illlllliil IIIIIIIIIIIIII Z�OG1"AD=rn 0 - D? o A 0 O v v o y Oz �` D <D f p j O o c m a "� N n a; x D A AO n (� OM. Z r <D >Z A m z O? 3 v N O T A Q S D m= A 1 O A n = O ` n p 9-. z N A T -al0 a"Z-! z xa O Z`^ O 00 O�r0m.N<0;T A z?CZD A" a0 �A T A H -C) Xzo T ZDV_; m aAv 2 O A -r O O y A 2 C X F Z Z X 7C N N O A Z D Z T D D IA A Gi N y G I f T� D D A A I I I Ia z V T 3: 2 T T >; A "p Z I a0a v A O Z Z II I III I 1 I I 1 1 1 I, I I I- I I I I -111 II 11T, 1 1 1 1 1 1 3 .. / 0 0 z 1 C n 0 z JEf C\ I C9 IL O H c � O a o N W w O aQ' °� v u w° v V) 0 U z O z a w° U is w a 0 W z : w°' � w ° z ". W w°' cn w a O MoD w z W A w ao G 2 v v cn 0 cn O H c cm MCC Cn CD E _ _ a� m c Oca CLJ NOm�'n 14)D o C m ' [1 rv� Ci L L —{ : CA Ncc o w 0 �a N ;r y C .a m cm CLL) i m Cc L 05 CD C2 cr- s= c LI.a O J a G p Q W CO) Z v O m co :tm .'� O O - c Z c �...J V V C .r `•coo c O to E- m ymc a C 'r = CD :mCD oo N C. Nm w-+ cc m om.. c LL m .m o - w •E c cm CD CD m p m c Q c � O o N o V �h : 6cOV -a-0 -0 V C. •oo �' O y c cm MCC Cn CD E _ _ a� m c Oca CLJ NOm�'n 14)D o C m ' [1 rv� Ci L L —{ : CA Ncc o w 0 �a N ;r y C .a m cm CLL) i m Cc L 05 CD C2 cr- s= c LI.a O J a G p Q W CO) Z v O m co :tm .'� O O - c Z c �...J V V C .r `•coo c O to E- m ymc a C 'r = CD :mCD oo N C. Nm w-+ cc m om.. c LL m .m o - w •E c cm CD CD m p m c Q _Town - of tz `st" _ OFFICES OF: �-� EALS _ - North Mdover. APP BUILDING NORTH ANDOVER Massachusetts o 1845 BUILDING CONSERVATION DIVISION OF HEALTH PLANNING- I't�.NNIG tPLANNING&COMMUNITY DEVELOPMENT In accrrdarce with the previsic -_s ..: :,G;. a S S:, a cor,diticn of Building Permit Number s ",Zi ;n-- dctr-ls resulting "rern this work shall be disposer' of ... a Preneri ...,-.:s:.-. _clid •wastey as ..:..c:: by ti' .GL.cI11.S i ne debris will be disposer' cc i::: t:..: char. cf : aciit; of Pcrmtt Applicant Date NOT_: Demolition permit fr= the To,. -a of: North Andover must be obtained for ~ this project through the Office of the Building Inspector. Restricted To: 1@ 2589%6 8C DEPARTMENT OF PUBLIC SAFETY �J _ CONSTRUCTION SUPERVISOR LICENSE BB - None Number: Expires: Birthdate:; 1A - Masonry only CS 022416. 11/11/1997 1111/1955 16 - 1 5 2 Family Homes Restricted To: Of Failure to possess a current edition of the Massachusetts State Buiilding Code ROBERT R TIMMONS is cause for revocation of this license. 2 HANSHIRE LN POBX 416 LONDONDERRY. NH 03053 HOME IMPROVEMENT CONTRACTOR Registration 117426 Type - DBA - Expiration 10/03/96 TIMMONS CONT ROBERT R, TIMMONS �.� te(ARMARAND RD ADMINISTRATOR LONDONDERRY NH 03053 r Location OD l'bX � G�1 Rco No. ` Date 6-0�4 ` p2- 14ORT" TOWN OF NORTH ANDOVER . L Certificate of Occupancy $ cHu9 �� Buildin /Frame Permit Fee $ a s�st Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a G Check # ✓803� 15666 ;X Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ' Yr r� All •'��' ' BUILDING PERMIT NUMBER: 9e DATE ISSUED:V SIGNATURE: Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 ]!.oyelfy Address: 1.2 Assessors Map and Parcel Number: C, Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Sb r\(L Mme (Print) Address for Service : Signature Telephone 2.2 Owner of Record: Print Address for Service: ,N/ame / V� )° -Y-L t d S t-� n ((-70 06 c� Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 icensed Construction Not Applicable ❑ -Supervisor: 6 k ✓? Licensed Construction Supervisor: @�Z ! 6 L. License Number Address ��' - °3 x,03-`13q-9-3&� Expiration Date D atu� Telephone 3.2 Registered Home Improve Contractor `k\-� Not Applicable ❑ Rbbe-VT R � o S Company Name /F �W R4 0i [E SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2506) 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 buildin it. -Signed affidavit Attached Yes .....' No.......❑ SECTION 5 Descri tion of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 A Addition ; Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brie // scription of Proposed Work: J �g SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be. Completed b permit applicant '(}FFICIAL:USE 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 6 3 Plumbing Building Permit fee (a) X (b) % �- (� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize / C to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief nt N me r' Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB t/ S SIZE OF FLOOR TIlvIBERS 1ST2ND 3 RD SPAN a& C;> DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY - S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U .-LOT RELEASE FORM u1 INSTRUCTIONS: This form is used to verify that all necessarya pro0-1,11 �� ��� Boards and Departments having jurisdiction have been obtained. This dovatses no Ire fror the applicant and/or landowner from compliance with any applicable or requirements. vE -NrIJLIL;ANT FILLS OUT THIS SECTION**********************. C"APPLICANT �� �ze LOCATION: Assessor's Map Number 3 SUBDIVISION STREET PHONE�03— V3 PARCEL LOT (S) ST. NUMBER ***************************************** OFFICIAL USE OF CONSERVATION ADMINISTRA' COMMENTS AGENTS: DATE APPRO 2 D p DATE REJECTED / TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR—HEALTH SEPTIC INSPECTOR -HEALTH CO DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS — SEWER/WATERaCONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INS Revised 9\97 jm ATE____ .J�ItF;-�/J(t77F'777Oi7fLX-'IIGIfrt�.. '%�(I:WQCIt(Iutrwq BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 022476 Birthdate: 11/11/1955 Expires: 11/11/2003 Tr. no: 9642 Restricted: 00 ROBERT R TIMMONS 2 HAMPSHIRE LN/PO BOX 416 LONDONDERRY, NH 03053 Administrator 1lltC �Prt�»z4rzrrrec7.lfJl. r� %%rir;i:7rrr71>rde�; Board ot'Building Rc3uianons and Smadar;ls HOME IMPROVEMENT CONTRACTOR Registration: 117426 Expi}a ti on : 10/03/2002 .. Type: DBA TIMMONS CONT ROBERT TIMMONS 2 HAMSHIRE LN LONDONDERRY, NH 03053 Administrator North Andover Building Department Tel: 978-688-9: 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: t`-UcdUwn Or r-acl►tty) Signature of permit Applicant Date NOTE: Demolition permit from tide Town of North Andover must be obtained for this project through the Office of the Building Inspector 0 The Commonwealth of Massachusetts A- Print 0 - ) 0-) r`-) am a homeowner all work myself. 01 am a_sole proprietor and have no one working in any capacity f am an employer providing workers' compensation for my employees working on this job. Company nam`e/: �.�.� t AJ,- c Address 2 Obmoarly name: Address Cty Phone #� - - - - ---- - - �_ ..._. �"'�.,,•°•• •" �•��•"•"'• rrcnues,OF a rine up to $1,500.00 and/or one yeams imprisonment as -well as civil penalties mn ttme.form of a STOP WORK ORM and a fine of ($100 00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investig0jons of the DIA for coverage verifiesion. /do herby cert�rwhh-J-1-r the pains and penalties of perjury Umat the inforrmatk n provided above is true and correct Print name Phone eaO V 3 y - Official use only do not write in this area to be completed by city or town official' E] Building pept A OCheck if immediate msponse is required _ Building Dept p Licensing Board Contact person: -A-t" e Phone* 4 0 Selecti]' anis off, -c& Q Health Department Ofher Wil WORKMAN'S COMPENSATION AIA Document Alos - Electronic Format Standard Form of Agreement Between Owner and Contractor for a Small Project Where the Basis of Payment is a STIPULATED SUM 1993 SMALL PROJECTS EDITION Because this document has important legal consequences, we encourage you to consult with an attorney before signing it. Some states mandate a cancellation period or require other specific disclosures, including warnings for home improvement contracts, when a document such as this will be used for work on the Owner's personal residence. Your attorney should insert all language required by state or local law to be included in this agreement. Such statements may he entered in the space provided below, or if required by law, above the signatures of the parties. Authentication of this electronically drafted AIA Document may be made by using AIA Document D401. Copyright © 1993 by The American Institute of Architects, 1735 New York Avenue, N.W., Washington, D.C. 20006-5292. Reproduction of the material herein or substantial quotation of its provisions without the written permission of the AIA violates the. copyright laws of the United States and will subject the violator to legal prosecution. This AGREEMENT is made: MAY 25,, 2002 (Date) BETWEEN the Owner: Karl Gladstone of Fox Hill Road, North Andover and the Contractor Timmons Construction, P.O. Box 416, Londonderry, NH for the following Project: All labor and materials to construct one story addition to existing home on Foxhill Run Road as per drawings. The Architect is: Joseph D. LaGrasse & Associates, One Elm Square, Andover, MA 01810 The Owner and Contractor agree as follows. ARTICLE 1 THE CONTRACT DOCUMENTS The Contractor shall complete the Work described in the Contract Documents for the project. The Contract Documents consist of: .1 this Agreement signed by the Owner and Contractor, .2 AIA Document A2o5, General Conditions of the Contract for Construction of a Small Project, current edition; 3 the Drawings and Specifications prepared by the Architect, dated , and enumerated as follows: Drawings: Sheet A1.0, plans and elevations, dated 5-15-02 Sheet A2.0, foundation, framing, site and sections dated 5-15-02 Specifications: Specifications are noted on drawings .4 addenda prepared by the Architect as follows: None .5 written change orders or orders for minor changes in the Work issued after execution of this Agreement; and None O 1993 THE AMERICAN INSTITUTE OF, ARCHI ECTS, 735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006-5292. AIA DOCUMENT A105 • OWNER -CONTRACTOR AGREEMENT • SMALL PROJECTS EDITION • AIA® • This document was electronically produced with permission of the AIA and can be reproduced in accordance with your license without violation until the date of expiration as noted below. User Document: A105MAST.CON -- 5/24/2002. AIA License Number 1215401, which expires on 10/31/2002. Electronic Format A105 -1993 1 '.6 other documents, if any, identified as follows: see Article 6 ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE The date of commencement shall be the date of this Agreement unless otherwise indicated below. The Contractor shall substantially complete the Work not later than August 10, 2002 or sooner, subject to adjustment by Change Order. (Date of commencement shall be June 10, 2002 or sooner.Insert the date or number ofcalendar days after the date ofcommencement.) ARTICLE 3 CONTRACT SUM 3.1 Subject to additions and deductions by Change Order, the Contract Sum is: $41,000.00 (Forty-one thousand dollars). 3.2 For purposes of payment, the Contract Sum includes the following values related to portions of the Work: Portion of Work Value Demolition $2,400.00 Foundation/slab $10,000.00 Framing and enclosure to weather tight $1$,000.00 Gypsum, insulation, and finished floors, walls & ceilings $9,100.00 Electric labor and wiring material, owner to supply fixtures $1,500.00 Total $41,000.00 (HVAC and mechanical N.I.C.) 3.3 The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. ARTICLE 4 PAYMENT 4.1 Based on Contractor's Applications for Payment certified by the Architect, the Owner shall pay the Contractor as follows: (Heremsen payment procedures and provisions forretamage, ifany.) 4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of , or in the absence thereof, at the legal rate prevailing at the place of the Project. (Usury laws and requirements under the Federal Truth in Lending Act, similar state and local consumer credit laws and other regulations at the Owner's and Contractor's principal places of business, the location of the Project and elsewhere may affect the validity of thjs provision.) ARTICLE 5 INSURANCE 5.1 The Contractor shall provide Contractor's Liability and other Insurance as follows: (Insert specific insurance required by the Owner.) $250,000 General Liability with certificate holder under the name of Karl Gladstone, Fox Hill Road, North Andover, MA 5.2 The Owner shall provide Owner's Liability and Owner's Property Insurance as follows: (Insert specific insurance furnished by the Owner.) 5.3 The Contractor shall obtain an endorsement to its general liability insurance policy to cover the Contractor's obligations under Paragraph 3.12 of AIA Document A205, General Conditions of the Contract for Construction of Small Projects. 5.4 Certificates of insurance shall be provided by each party showing their respective coverages prior to commencement of the Work. ARTICLE 6 ® 1993 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006-5292. AIA DOCUMENT A105 • OWNER -CONTRACTOR AGREEMENT • SMALL PROJECTS EDITION • AIA® • This document was electronically produced with permission of the AIA and can be reproduced in accordance with your license without violation until the date of expiration as noted below. User Document: A105MAST.CON -- 5/24/2002. AIA License Number 1215401, which expires on 10/31/2002. Electronic Format A105 -1993 2 OTHER TERMS AND CONDITIONS '',Insert any other terms or conditions below.) 1. The owner will supply all light fixtures for installation by the electrician. 2. The owner will supply and install under separate contract the entire HVAC System. This Agreement entered into as of the day and year first written above. (Ifrequired by law, insert cancellation period, disclosures or other warning statements above the signatures.) Fox Hill Road, North Andover, MA 01844 (Printed name and title) CONTRACTOR (signature) Robert Timmons, Proprietor Timmones Con., P.O. Box 416, Londonderry, NH (Printed name and title) LICENSE NO.: JURISDICTION: ® 1993 THE AMERICAN INSTITUTE OF TR-CHITECTS, 1 5 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006-5292_ AIA DOCUMENT A105 - OWNER -CONTRACTOR AGREEMENT • SMALL PROJECTS EDITION • AIA® • This document was electronically produced with permission of the AIA and can be reproduced in accordance with your license without violation until the date of expiration as noted below. User Document: A105MAST.CON -- 5/24/2002. AIA License Number 1215401, which expires on 10/3112002. Electronic Format A105 -1993 . U) m C/) Cl) m CO) C d CO)CD C'7 n Z CO) CL o 0, c � C 0. _• CO) 'v o o v CD CD O CLQ d CD CDo CD C O W CD CL v CO) —• O CO C 5 v CO) O CD Z O CD0 CD C ?� co m S O V! O C N 3:0so.0 CO) s*am8 O CA S 2 o',o h _I = m Of s' N Z1 =r =r a?m = N O O Cl) H 0 0 �� ; O ? !!R m _ = m CA G m O� o O ` J. .0 M C.) \ Qj a = ` m do >\ mO m N (n m , 0 4 C CL 90 CA to f\ -^J n CD y OCA � O m CD m O o Q Gl n Z o PON a3 :\ CD N o � o ?: _,� ate: �o b n o= o cn cn ., � C c 5' o :v S T o CIO t4 tri ro z a Pj 0 -z '� x o n x ,,d 0 p 0 d M b Go-mw t M omq 0 9