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HomeMy WebLinkAboutMiscellaneous - 107 COVENTRY LANE 4/30/2018 107 COVENTRY LANE �Q 210/104.0-0140-0000.0 1 I f I I Date...... of Noprh TOWN OF NORTH ANDOVER O p PERMIT FOR WIRING ,S$�CHUSE This certifies that ............................................................................................................................ has permission to perform ...... 1 ,—A "N"Ute` , ............................................................. ................. wiring in the building of..1......0 L,-%NJ ..................................................................................... at ....LU�.�.Gy.�' � '� �f'............................North Andover,Mass. .................G........................ Fee.....�.. .........Lic.No. I 11„I.... ' +8 ........:........................................................................... ELECTRICAL INSPECTOR Check# �269-S- 12 / r' i 1 / Official Use Only Commonwealth of Massachusetts11 a Department of Fire Services Permit No. 'ZI Occupancy and Fee Checked w BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/o7] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(1VIEC),527 CMR 12.00 (PLEA SE PRINT IN NK OR TYPE ALL INFORMATION) Date: - Z3" ( L/ j City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (6:7 C,py 2 h T P!, Lex K P Owner or Tenant Ld,r J,�, �u N Q1 Cc, w:,a n Telephone No. 17 W 126- q6 35-- Owner's Address U P h h Is this permit in conjunction with a building permit? Yes 9 No ❑ (Check Appropriate Box) Purpose of Building $ i V%A le-f, M, t 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: 8 C,,+k ro0 "N -- P.e n I as Q Ut o (l L tT L Ce L ' I �u t P s - c4 Ll-e h� hj Ce,,l t S le)LhaJ r-CA N Completion of the following table may be waived by the Inspector of Wires. —47 No.of Recessed Luminaires No.of Cel Susp.(Paddle)Fans No.of Total c— Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingAbove In- o.o Emergency Lighting Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones 10 No.of Switches No.of Gas Burners No.of Detection and =_ Initiatin Devices No.o g Tons g No.of Ranges No.of Air Cond. Total Nf Alerting Devices (�) �— No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained " Totals: " " '-""""...".............. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW 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 Eq uivalent { OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: f t 0 0 0 (When required by municipal policy.) Work to Start: y -a 3- ( `f Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless �+ the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify,under thepains andpenalties ofperjury,that the information on this application is true anti complete. FIRM NAME: . J. v�s e LIC.NO.: Licensee: _Jas2� h G- Le L,t S Signature LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: 1i 7f Let? ,,�I k 3 Address: Alt.Tel.No.: ri k<E/ I *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ I Signature Telephone No. a ❑ 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 conceming the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: 1g Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed IN Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Com s: �L U Inspectors Signature: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 1 � y.i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street { Boston,MA 02111 1 s� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 11 Name (Business/Organization/Individual): LQu Cs 1,2 C_ ycc CC, _1 Nr i Address: :t.s 4 le U. S C) k -�- I C 3 lty/State/Zlp: (U. ([� vt Jei y ,- Phone#: cf Z t( tp,f-? Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet.t [�-Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. [t ,We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] -11 Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Dontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: :)b Site Address: City/State/Zip: ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ' ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under thepains and pen Ities o rjury that the information provided above is true and correct. i nature: Date: "' l hone#: 9'Z k" &Jr 7 'a-7 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: I 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-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 Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax#617-727-7749 www,mass,gov/dia ���.cunnmvnwr.�►��n �r m�,a�;r�triv:�c� f�'::� a o • - o e • BOARD OF ISSUES THU,101LOW11 IS R1: I S EREO MASTER ELECTR I Cl AW. . d NEVI S ELECTRIC C0 114C ;J(35EPH' LEVT- 1fl PLEl1.SAI'1T S7 u, AN001tE}�. MA.0�84 � 06 ._ 5 7 9.979 A a7/3t/16 2339 f Date.... ..'.. ..'� .. I 076 r t p10RT## TOWN OF NORTH ANDOVER n PERMIT FOR PLUMBING ss,�c„�sE ,M This certifies that...1.!..'.s. 'k......C. . .............................................. . ... . . . . . . .. has permission to perform.....`h-(A........ . . . . .. . .. ..................../......................... plumbing in the buildings of...J.,4,0.0-#4 1 P g g .. at......................................................�Ur ..., NortAndover, Mass. Fee......................Lic. No. ..................... ................. UMBING INSPECTOR Check# I� - �� ► 24 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l. CITY C1 l�U MA DATE 9.. _ ( PERMIT# 11 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL RESIDENTIAL ,,. PRINT Q CLEARLY NEW: � RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES© NO y� FIXTURES'l FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM .__—._I _ ( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN II-__J FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) `'<ITCHEN SINK s ATORY OF DRAIN ,EWER STALL P � f _A RVICE/MOP SINK TOILET URINAL P ..._.___i _ _._. l J P _._ _._( _-_- _( WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ___-.J OTHER INSURANCE COVERAGE: y 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESML NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY / OTHER TYPE OF INDEMNITY © BOND Q 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 F-1 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc:er rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 8 L � CAI 6-L"� LICENSE# I " a�� E Ae MP W JP CORPORATION F#PARTNERSHIP D# ;LLC COMPANY NAME -n46- 901t 6L-( ; ADDRESS Q a- L(JYY� �Vl S { CITY l ---------JSTATE ZIP 01 W —� TEL - FAX - �CELLI EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r a 1 The Commonwealth of Massachusetts - Department ofIndustriglAccidents 07 Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bI i7p Levib Name(Business/Organization/Individual): T� ` Address:/ n A ` L A/W � S City/Stat e/Zip: f Z Phone Are on an employer?Check the appropriate box: Type of project(required): 1. , am a employer with 4. ❑ I am a general contractor and I 6 ' employees(full and/or part-time).* have hired the sub-contractors ❑New construction ! 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.0 Other comp,insurance required.] *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:.Imo/`tl Policy#or Self-ins.Lie.#: Expiration Date: �/ Job Site Address: / _ /t) ' C_ City/State/Zip: Attach a copy of the workers'compensation p olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X doIzereby cert under the p ' s an enalties of perjury that the information provided abo a is tr a and correct. - 5iature- Date: C Phone#: d 17 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#: t Information and Instruction's . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications 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 Gommonwealtb,ofMassaclhusetts Department of Industrial Accidents Office of Investigations 6.00 Washington Street Boston}MA 0211.1 Tel,#61.7-727,4900 ext 406 or 1-8777MASS.AFE Revised 5-26-05 Fax#617-727-7749 __www-wass,gov1dia I C21 Date—It...IAOJI�...... OR ttORT TOWN OF NORTH ANDOVER No PERMIT FOR PLUMBING 4t .......... 0�,-. gsACHUg� Thiscertifies ..... ...... .................................................................... . ................... .... .. has permission to perform..... ............................................................... ....................... plumbing in the buildings of.......... OLSAAIL...................................................... at........1.1........... ....................... North Andover, Mass. vo * ... ..'--+J., �'l'i" ..H Fee.4 .......Lic. No. J..... ..D.................................................................... PLUMBING INSPECTOR Check# �-� - �- . $ 12 z-1 1 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ I CIN MA DATE >.--13.-DPERMIT# 67/� JOBSITE ADDRESS t1Jc 1 n ;rte OWNER'S NAME L.�o►ti POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL © RESIDENTIAL' PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:Qi PLANS SUBMITTED: YES Q N0 ]I FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ill__—II _'Jl € f DEDICATED GREASE SYSTEM _j __ —j I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _f J _--_f { ____--I { FOOD DISPOSER --Ill I 1 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ..____j L_Jll= LAVATORY ROOF DRAIN _______I _.1 .--. J . d JE. -- SHOWER STALL J ___I _ _l SERVICE/MOP SINK __.I _- -� { -_! ..___! _D Ill___ ._ _j _ _I ( , TOILET I _-.__ f _ _- I J= [,SINAL I W SHINGMACHINECONNECTION �- WATER HEATER ALL TYPES — WATER PIPING _I ► ______( _! -_-_--_ .._.. ._ __...._- — I __..___ ! �" OTHER I ----------- =-- -J ----- INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .-._I NO �I IF YOU CHECKED YES,PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _i OTHER TYPE OF INDEMNITY DI BOND P__f -I�WNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT 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 compli ce with all Pertinent pro ision of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME es ,-. (L ___11LICENSE# 6 S ATURE 41- MP d JP 0 CORPORATION[Y# Z rte{PARTNERSHIPQ# LLC COMPANY NAME DDRESS (� T CITYA ' _.._�STATE ,j�'�_� ZIP n��,�L/ � TEL41 _.. ---- FAX �CELL 1 EMAIL -------- -- -_ .._...------- -....__ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No AO f THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ..r t 4 T The Commonwealth of Massachusetts - Department ofIndustrinlAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busine�sss/Organization/Individual): Sv Address: I` 0 02. City/State/Zip: ),e ,A�' Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[lam a employer with-_ - 4. ElI am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Pr�C S 0 Policy#or Self-ins.Lic.#: p C)0 Expiration Date: 7 r/ Job Site Address: 107 coU ✓4� City/State/Zip: L �" Attach a copy of the workers'compensation pol y declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert u der the pains andpenalties of perjury that the information provided above is true and correct Si ature: c ry�—��j 1/ c Date: Phone#: 97t S — 7 D 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#: '1 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-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 ofMassachvsetts Department of Industrial Accidents Office ofIavestigatim 600 Washington Street Boston,MA,02111 Tel,#617-727,4900 ext 406 or 1-877,7MA.SSAF& Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia COMMONWEALTH OF Niw63 F USITTS PLUMBERS AND GASFIT 'tRS REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: ._IAME�S A BURKE SR °m I)URKE 9 SONS PLUMBING & 'HEATING'. 73 WILLIE ST HAVERHILL MA 01832-3041 : ,2727 05/01/1413921907- - i DEPARTMENT OF P�BLIC SAFETI' Journeyman Pipefitter License Number: PJ 030100 Expires: 09/28/2013 Tr.no: 98.0. Restricted: 00 1 JAMES A BURKE SR 73 WILLIE ST HAVERHILL, MA 01832 Commissioner OM �-,.. MONWEALTH OF MASSACHU: LICENSED-AS A JOURNEYMAN PLUMS ER,' F ISSUES THE ABOVE LICENSE TO: F j JAMES A BURKE. t 73 WILLIE ST HAVERHILL MA 01832-:30.4 18716 05/01/14 142619 11 Date.......!. ." ................ ATN j TOWN OF NORTH ANDOVER PERMIT FOR WIRING i 01 i CMUSE This certifies that ............/.-779 2 ....S/.........4m�.................................... has permission to perform ....Ha`s ip 2 pe,D 1-d v ................................................................................:............ wiring in the building ofJw ......................................................................... . . .... at ...1 D.�.. UF..1�7`I L, North Andover,Mass. ................/LEcTRicAL Fee ...........Lic.No. .......... � �...... ..... ..... INSPECTOR�� t-/ U Check# i Commonwealth of Massachusetts Official Use Only Permit No. l 11 Z Department of Fire Services 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 ),527 CMR12.Q0 (PLEASE PRINT M NK OR TYPE ALL INFORMATION) Date: ,� J/ f% , City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /Q 7 COV4!r tIR-y' Z,AA1 e Owner or Tenant L o uRy 01)u_j 19/`,/ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building e-11 e ` c 9 Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the 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 Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers ......................_...._........................... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.00f Water KWNo.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 Equi valent OTHER: RnvoM � N 0 & >2U�� �✓ A � S c_cgC p� e110 / NRIfte/Act /i 5 i;0 9 F d W)`t ach additional detail zf desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify) Icertify,under thepains andpenalties ofperjury,that the information onthis app1. ' is true and complete. FIRM NAME: - LIC.NO.: a 76 Licensee: c�Qk'e-5 -0/t_ Signature LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No. 97 e 37a Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)[]owner ❑owner's agent. Owner/Agent [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 p permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 1 on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: ' Pass V Failed Re-Inspection Required($.) ❑ Inspectors Com ts: ./k✓ Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments Inspectors Signature: V Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com p The Commonwealth of Massachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Budders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organi'zatiorAndividud): -Fop, Address: City/State/Zip: 1 O 1 <632 Phone#: � 7 2 Are you an employer?Check the appropriate box: - Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction Oployees(full and/or part-time).* have hired the sub-contractors tap ma sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling and'have no employees These sub-contractors have 8. ElDemolition working for me in any capacity. workers'.comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12,❑Roof repairs insurance ,required.] employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. ) - Insurance Company Name:. Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: ) 0-7 Co V ell /° City/StatelZip:,N, Do(/(2 2- 1� 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 maybe forwarded to the Office of Investigations of the DTA for insurance c . e verification. X do Izereby cerci gins andpena es ofperjury that the information provided above is true/and correct. - Signature: Phone#• q") 2, - Official ,Official use only. Do not write in this area,to be completed by city or town offrcial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityifown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An 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 employes." 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 ofits 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation insurance. If an LLC or LLP does have s employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that most submit multiple permit/license applications in any given year,need only-'submit one affidavit indicating current i 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license oz 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 Gorraapoaawca1t� ofMassachvsett� Departmeat offadustriaI Accxdoats OfAce ofIn.V06gations 600 Washiaagtoa Street BostQnMA0411 Tel,#617-727-4900 oxt 406 or 1-877,MASSAFE Revised 5-26-05 Fax #617"727-7749 VAM_mace anvfrl;n I . Y COMMONWEAiH'* O ,M 1$ ACHUSETTS Amomol As.. WOOAa LECTICIANS a ISSUES .THE FOLLO; I NG Lt CENSE AS A, (: REGiSI'Et ED MAS" ER ELECTRIC AN x FILL. ��}Rf EST R CURRI ER 125 HI LLOtE A`VE HAVERII LL; MA 0, 832-3832 a 548 ► ..: 0 /3b 32678 J e � .. COMIIIIONWE. OF MAS'SAOHUSETTS:. :R,,l Cl AN$ Issu SY-Tflf FOLLOWING :L PC JOURNEYliAN :EL,E.CT 1-C'I FOfRREST R CURRIER � `ry 125 HtLt+pALE. ST y Z HAV tF#tLE MA 0832 383 27658 .. 07/3t1� :. . . 32680 r 7 4 J Date/ ,�Y.. ... ' i i NORTH o? ' °� TOWN OF TH ANDOVER ' • PERMIT GAS INSTALLATION �,SSACMUSEt `f This certifies that has permission for gas installation . . .1Q1'/? .. in the buildings of . . 411-4-4- . ��. . `.:� . . . . . . . . . . . . . g e-n � at . . U �' ✓.�''+.�'. . ./4&.-e—,�orth Andover, Mass. Fee301—v Lic. No. . . . . . . . . . . . . . . GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: AZ e-h MA. Date: 0 Permit# Building Location: ® C P 0'v"8wners Name: co q,/ Q, Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ ReplacemenPlans Submitted: Yes❑ No FIXTURES W Z � N U = H m = O 0W O CD ® H O 2 W W O Z y q O d' P U � W OO Q H fA III ¢ o Q d F- Q o W x W ~ Q W W af W Z g N = W O W Z W � W W Z O "I F F O Z J 0 LL N � W H W Z W } l y J Q Q m W O Q Z O ~ Z v IX o 0 LL 0 0 _ _ O a a W H M > > O SUB BSMT. BASEMENT -i"FLOOR 2 FLOOR 3 RuFLOOR 4 FLOOR 5TH FLOOR 6 TH FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: 616 t El Corporation Address:? C p fk Nfl-V City/Town: 1 A 1 114 ( LLA) State: ❑ Partnership Business Tel: 5-0g- f-L`�?— 3`L Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑ J If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy IV Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By Plumber Title Gas Fitter Signature of Licensed Plu er/Gas fitter Master City/Town Journeyman License Number: / APPROVED OFFICE USE ONLY ❑LP Installer >r WCALTH F-M-A- $,i#`GRU,,- LICENSED AS A JOURNEYM N PLUMB { ISSUES THE ABOVE LICENSE TO: ( ., VASILIOS PANGIOTOPOULOS 19 COUNTRY CLB DR x TEWKSBURY MA 01876-163 q` ,. 18259 05/01/12 78842 X FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(S) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME (&TYPE OF BUILDING LOCATION OF BUILDING SKETCH jo PLUM ER,GASFITTER LP INSTALLER / K LICENSE NUMBER: PERMIT GRANTED DATE: GAS FITTING 1NSPECTIOR Date. . l �fir:. ..... � J NORTIy pF ,tea° 3j �` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION ACMUSES This certifies that . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . , . . . . . . . . . . . . . . . . . . . . in the buildings of . . .(f° . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . .CP.k,cL:�lz, . . .L`.`. . ., North Andover, Mass. Fee. 3Qx r:7Lic. No.. .31�. 7l. . . . . . . . . .`. GAS INSPECTOR Check# 66 '18 MASSACHUSETTS UNIFORM APPUCA'TON FOR PERK r TO DO GAS FITTING (Type or print) Date / NORTH ANDOVER, MASSACHUSETTS Building Logations _107 Permit# �C _ A,y' W-e,c Amount$ Owner's Name ` New❑ Renovation ❑ Replacement U Plans Submitted ' a zw On w O U m E, Z ' C C F dF >. 'D p z F W x i u w x �, i F p a > w W W e x x U 0 > Z W- > C� .Fr F. �W CQ Z m O x 3 0 aU cc > o a N O SU B-BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FL00R 5TH . FLOOR 6TH . FLOOR 7TH . .FLO0R. 8TH . FLOOR. (Print or tvD0 I Name I C N0,0,I 1J�V�Ct V Check one: Certificate Installing Company 77 � Corp. Address W© �y`'y �oP . �b c �ksv, (A ❑ Partner. usmess Telephone '� - (S—_ 9 3 . ❑ Firm/Co. Name of.Licensed Plumber'or Gas Fitter C I �Q,V INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes If you have checked yes,please indicate the type coverage by checking the appropriate box. No❑ Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: IAm aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13t hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus a as ode Chapter 142 of the General Laws. By: Signature of Licensed Plumberr Gas Fitter Title D Plumber �I ` (I Ci /Town, ty 0 Gas Fitter cense Number 1. ❑ Master _ APPROVED(OFFICE USE ONLY) ® Journeyman Date �/IP.�'. 4 NORTH TOWN OF NORTH ANDOVER PERMIT FOR NUMBING f i a SSACNUS� This certifies that !. . . . . . . . . . . . . . 7 has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 plumbing in the buildings of . .`..k.c �-r-. . . . . . . . . . . . . . . . . . . . at. . .f D. . . .�a �' V orth Andover, Mass. Fee. �pt �- .Lic. No. 5!1. . . . . . . . . . . .`�.�. . . , . '. . . . . P UMBING INSPECTOR Check # 7924 MASSACHUSETTS UNIFORM APPLICATION FOR PE RMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location /©7 COVQVI 6A Owners Name ✓ Cp m Date Permit Type of Occupancy Amount �.40 New ri Renovation ® Replacement ' Plans Submitted Yes ❑ No rl FIXTURES H � 0 0 a H a 14SM ME al�rKBM sin F sMRDM 9MFLO R µ (Print or type) Installing Company Name r7A•< a2( Zk/1-C fit/ Check one: Certificate f n Corp. Address Wa °� t0 "Y' �CA gc' 16' C" 04 t 4 Partner. usme.ss elephone 7,r- /5 — S—cJ I Firm/Co. Name of Licensed Plumber: c C a AL Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Ej Other type of indemnity ❑ Bond Insurance Waiver. I, the undersigned,have been made aware that the lic rl three insurance ensee of this application does not have any one of the above Signature Owner El Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the M a e Plum',Code and Chapter 142 of the General Laws. By. bignawre ot Lacens um er Title Type of Plumbing License City/ own 3 I icense Yumber Master El Journeyman APPROVED topics vsE om..Y N° L57B Date.......�.21....l o............ NORTH "`°;•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �SSAcHUS Thiscertifies that ............................................r................................................ has permission to perform :..: �� :..�. �t :.Y�`� .......... ................. wiring in the building of... -.......................................................... A.............. .North Andover,Mass. Feel-;.ZS —...... Lic.No.:/.. G ... . J........ CELECTRICAL INSPECTOR Check # �' "✓ WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Official gUse,OvJnly 7f5(��??N6722�/54Z?W d577?2sg.S.Sri? Permit No. ON— � ��s BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 1 Occupancy&Fee CheckeqmJ5 69) _ 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) r r . ZO w Date_ 7_ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number `p 1J{ W T r V �N . Owner or Tenant Owner's Address -56 WILL — A Is this permit in conjunction with a building permit Yes ❑ No ❑ Check ( Appropriate Box) Purpose of Building_ . r 1•rJ Utility Authorization No. Existing Service Amps Vcits Overhead ❑ Undgmd ❑ No.of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot fuse Total No.of Transformers KVA No.of Lighting FixturesAbove ❑ In ❑ Swimming Pool grnd ❑ grnd ❑ Generators KVA No.of Receptacles Outlets ! No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone No.of Ranges Total No.of Detection and No of Air Cond Tons Initiating Devices No.of Di osaf Heat Total Total No. Pumps Tons KWfA No.of Sounding Devices No.of Dishwashers Space/Area HeatingNo./of Self Contained KW Detection/Sounding Devices f)o.of pryers Heating Devices ❑ Municipal ❑ Other J KW Local Connection Signs No.of Water Heaters KW No.of Low Voltage Si nss Bailases Wirin No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includi ompleted Operations Coverage or its substantial equivalent YE NO = have submitted•v99d proof of same to the Office ES— NO = If you have checked YES please indicate the INSURANCE be BOND = OTHER = (Please pecifY) type of coverage by checking the appropriate box. Estimated Value of Electrical Work$ (Expiration Date) Work to Start Inspection Date Resquested Rough y'l 'GV Final Signed under the P�??n (ties of pejjy FIRM NAME C. /� J�_ e e J it i LIC.NO. Lkensee Al Signature �J�J b�/ LIC.NO. L Address_(.,l` �SsC �C S� Bus.Tel No. 8 S'O 3 v Alt Tel.No. OWNER'S INSURANCE WAIVER: 1 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) I (Signature of Owner or Agent) Telephone No. PERMITTEE $ Locations No. `���' v Date �aRTM TOWN OF NORTH ANDOVER 'c Certificate of Occupancy $* i + P Y r � C Nus s'• Etn Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �� Check # `f C', `' U 2 v Building C pector TOWN OF NORTH ANDOVER i BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �qy BUILDING PERMIT NUMBER: iQ / DATE ISSUED: Y D Q to SIGNATURE: Building Commissionerfln2eEtor of Buildings Date Z SECTION 1-SITE INFORMATION I 0 1.1 Propett Address: 1.2 Assessors Map and Parcel Number: D a v f°w Y cA ����U•� � }n/�® Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: �\ Zoning District Proposed Use Lot Area Frontage ftv 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required Provided ReqWred Provided 1.7 Water Supply M.GL.C.40.11 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 rn 2.1 Owner of Record Name(Print) Address for Service: w Signature Telephone 01 y 2. O er of R rd:. game Print Address for Service: o M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ 0-0.yV1 e S ; y-® Y Licensed Construction Supervisor: l� �✓' i' '� 0 yam, 9-pb(,f/1�j �� License Number mn 0—1 s -aa 0Q CExpiration Date ngnature Telephone 9&- 3.2 Registered Home Improvement ntractor Not Applicable ❑ / w- s pany Name Registration Number r 0Y tz rlr t,P�>✓ P" ress ?, CCi / Expiration Date v ^� nature �7T=phone v• SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: u-ete PmRC 4 �Ir CO?tis�n D [� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant I. Building (a) Building Permit Fee �p Multiplier 2 Electrical (b) Estimated Total Cost of Construction ` 3 Plumbing Building Permit fee(a) x (b) 4 Mechanical HVAC 5 Fire Protection ` 6 Total 1+2+3+4+5 Check Number 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 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 Print Name Signature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS 1 ST 2ND 3 SPAN r DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i T=! S P,_A\, Vv''.AS D>:-,AWN `OR MGR-GP, MANZ I ENG 1 NE:-:'-(!NG ACJS NO TO 5E RECORDED OR CONSTRUEDASA I 13 H?LLTOP ROAD 53UNDARY SURVEY. PLAISTOW, NH 03865 6C3- 382-7582 1 � io -_-------- 7 EniTE1 1��I�__-- -�-Dy- TONY MANZ i i L✓_o_;_� r f''_A2Jp�a'J�. _ S`, __ I PROs,ESS I ONAL ENGINEER I i DEE SC- ON -LYS --- -�r`U= 7Vc �0vE: rV7 IZY LANA 1 I ! i S 3q* 3! 35 " E� 23`"50 L o T 9 h OT ;✓ 1 HEREBY CERTIFY THAT: THE BUILDING ON THIS PLAN. !S g APPROXIMATELY AS SHOWN HEREON AND THAT IT COMPLIES WITH a THE ZONING LAWS OF THE TOWN FovrvDATIONCONSTR- UCTED. , IN WHICH LOCATED WHEN CONSTR UCTED. �2 CK TO THE BEST OF MY KNOWLEDGE --- I AND BELIEF THE: PARCEL DOES ! NOT FALL WITHIN THE FLOOD PLAIN AS SHOWN THE F.E. W 4-1 FLOOD AND HAAZARDNBOUNDARY M.A. = MAPS. j C� JOD NO �N514OFIf, . o'y :o` I o`'3 Ardl"y . ��� DATE - ---- NZOVE ' 32341 O y" BOOK — -____--- _ PAGE L 90,E 6/STEP h L 7 ! 3,/ 3 .30' 112.7 �V3y i9'yy iA/ Izz,TI' PLAREFN ------ il SCALE ------ a F i' i FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. ............................................................................ APPLICANTS,r• , m ia) �e, yU PHON`g: '3 5— ASSESSORS MAP ABER 0 LOT NUMBER D SUBDIVISION LOT NUMBER STREET C 0 ���° �'� � �0- STREET NUMBER G / ..i'..................... ■.........■............................... NN o C sn .3 . em aso�J t pp �.......................... OFFICIAL USE�ONLY..................... .�.. .. I l y x � 7 RECOMA ENDATIONS OF TOWN AGENTS I o X I o Nson ENEWEENE DATE APPROVED CO RVATION ADMINISTRATOR 1' DATE REJECTED DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED 2— •��V DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMTr DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE ' I II � - All, 6anvnan"Aearffe a{� l�aasa to el a BOARD Of BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 062195 Birthdate: 08115/1955 Expires: 08/15/2001 Tr.no: 3229 ' Restricted To: 00 JAMES R ARMSTRONG 1 WELLSVILLAGE RD APT 1 � r SANDOWN, NH 03865 Administrator i HONE I11PROVENFUT CONTRACTOR /. Registration 106106 w Type - INDIVIDUAL x Expiration 07122100 A„ JAMES R. ARMSTRONG 20 Shady Lane �stou LTH 03865 ADMINISTRATOR • ,I i ' 1 i The Commonwealth of Massachusetts ` Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: ea-� � A. �' �( � "q 0 r City yy 0D tv n) /I/ Phone am a homeowner performing all work myself. 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. a Company name: Address City: Phone#: Insurance Co. Policv# Company 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'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do herby certify under the pains and pe hies of perju that the information provided above is Ute and correct Signature .1 a� Date 6 Print na a - Ct_r-n 2 C /C i /✓-Yn S-/ro W 0 Phone# D C Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION III Town of North Andover o4 tAOR=N tj�tPd ,6, yo Building Department o 27 Charles Street North Andover, Massachusetts 01845 O ' (978) 688-9545 Fax(978) 688-9542 Arm DEBRIS 4SSAC!•IUS�� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in/at: J n� o /. Ju Facility locati Signature of Applicant 7-17- 00 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this Project through the Office of the Building Inspector. r,adams 3 PART Carbonless 3816-bO ETAr, Jl rlda /' A�� �/ ' � PROPOSAL NO. 01- /<- ; ! SHEET NO. /� 11 DATE 30POSAL SUBMITTED TO: WORK TO BE PERFORMED AT: AME ADDRESS ADDRESS . ✓ A LV �13'�J --_ U _ 1t/ t DATE OF PLANS �+y PHONE N0. ;?7 9 ARCHITECT e hereby propose to furnish the materials and perform the labor necessary for the comilletion of 01 All material is guaranteed to be as specified, and the above work to be performed in accordance with the dr �wings and specifi- cations s mitted for above work and completed in a substantial workmanlike manner for the sum of.�f/ p � ----Dollars {$ 1 with payments to be made as follows. �6 ��� 6/- .i Respectfully submitted Any a teratspecifi ion � deviat�from- above cations involving extra costs - will be execut only upon written order,and will become an extra charge Per over and above the estimate.All agreements contingent upon strikes, ac- cidents,or delays beyond our control. Note—This proposal maybe Zwithdtivn by us if not accepted withinys. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby acre ted. You are authorized to do the work as specified. Payments will be made as outlined above. i Signat Date Sign ture '.Adamsnir.gniu_Fn NORTH Town of No. 386 L dower, Mass., COCHICMEwICK AD'QATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... ,.. ' .r ... ......... ...d..���/'' Foundation ........... ........ .................... .................... ................ ��� � � has permission to erect..../Q .� ............. buildings on ...... ......... .................... ...................../........ ..... ................ Rough to be occupied as... .10" P50C Chimney ........ .................. ........ ................................ ................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Ins action, Afte ation and Construction of ;:Buildings in the Town of North Andover. e r 3 So GN 40" • 1% a PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. rn 1D y jo !y oo? Rough J Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS. CONSTRUCTION STAINS Rough ........... ....................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det.