HomeMy WebLinkAboutMiscellaneous - 107 LIBERTY STREET 4/30/2018 107 LIBERTY STREET
210/090.B-0059-0000.0
Lam
Dat ...........................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
1,z
HU
This certifies that ..0 .......... . ..... !!'fin'. ...J...........................
has permission to perform ........... ........... ..........
............. .......................................................
wiring in the building of........ ............... .,/X:.....................................
U Cv fr,............. ........North Andover Mass
Fee... ................Lic.No?,ql7., ..........................
t. 'EiC,TRICAL iNINSPECTOR
Check#
11604
Commonwealth of Massachusetts Official Use Only
it No.
Department of Fire Services Perm
� —
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/071 Qeaveblank
M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEG),527 CYR 12.00
l� (PLEASE PRINT ININK OR TYPEALL INFORMATION) Date: j
City or Town of: NORTH ANDOVER To the Inspector o Wires:
a By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
a Location(Street&Number)_/0-7 71e4.&i"
�J Owner or Tenant�(y//',rj (, '�j'J1� Telephone No. SOW10
\ Owner's Address 1 '040i:
Is this permit in conjunction with a building permit? Yes ❑ No FV (Check Appropriate Box)
Purpose of Building�,0AAZ.�/�r Utility Authorization No.
- Existing Service d6n Amps �V01ts Overhead® Undgrd❑ No.of Meterr"s---e--
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: h1l-
Completion of thefollowing table may be waived by the Inspector o fres.
No,of Recessed Luminaires No.of Cell:Susp. ans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tub ___Z Generators KVA
No.of Luminaires Swimming Poolbove In- E] No.of Emergency Lighting
rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of nes
No.of Switches No.of Gas Burners No.of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devic s
Tons g
No.of Waste Disposes Heat Pump Numbe Tons KW No.of Self-Contai d
Totals: "' '"""'"''"""'"""""""' Detection/Alertin evices
No.of Dishwasher Space/Area Heat' g KW Local❑ Munic' al El Other
Con ction
f No.of Dryers Heating Appli ces KW Security Sys ms:*
No.of Wate KW No.of No.of Data W'
f n vices or Equivalent
H ters Si ns Ballasts
No.of Devices or Equivalent
No. romassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Q9 Attach additional detail if desired=or as required by the Inspector of Wires.
Estimated Value of E ectric 1 Wo . / (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,.and upon completion.
INSURANCE C VE GE: 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 thegins and,pe al 'es ofperjury,that the information 71is application is true and completes
FIRM NAME: 6 1�(/ f� " / LIC.NO.:
Licensee: "IC
.066C1,i,411g Signature LIC.NO.:
(Ifapplicable,,e ter'exempt"int license number e.) Bus.Tel.No.:
Address: e- % h'j C72;9AV_Qz�
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
Signature Telephone No. PERMIT FEE:$
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the '.
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed /
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
PassM Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
d
SERVICE INSPECTION:
Pass EN Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INS TION:
Pass' Failed 0 Re-Inspection Reqdired($.)❑
Inspectors Comments:
Inspectors Signature: a_ X,- Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth oflVMassachusetts
Department oflndustricrlAccidents
Office Of investigations
600 Washington Street
Boston,MA 02111
www.massgop/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plulmbers
Applicant Information Please Print Le ibl
Name(Businesslorganization/individual):
Address:
City/State/Zip: /01111 Phone#: Cf %W ���O l/ • .
Ar on an employer?Check the appropriate box: Type of project(required):
am a employer with 4. El am a general contractor and I 6. Ll Now construction
employees(full and/or part-time) have Hired the sub-contractors
2. I am a sole proprietor orpartner- listed on the attached sheet. 7. [JRemodeling
ship 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 10.[J Electrical repairs or additions
required.] officers have exercised their
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),andwehaveno 12.❑Roof repairs
insurance •required.] employees.[No workers'
13.❑Other
comp.insurance required.]
*.Any applicant that checks box#1 must also fill out the section betow showingtheirworkers'compensation policy information.
i Homeowners who submit this affidavit indicating they tfre 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'compens ion insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:. �� �T
Policy#or Self--ins.Lic.ff: VExpiration Date:
Job Site Address,_/–O/— ZL/ City/State/Zip'
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage s requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
Rue up to$1,500.00 and/o 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 a • st the violator. Be advised that a copy of this statement maybe forwarded to the Office of
'Investigations of the D for insurance coverage verification.
Af
X do hereb ert' n e thepains andpenaldes ofperjury that the information provided abov Istrue d correct.
Si atur : ADate:
Phone
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License 0
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other -
Contact Person: Phone M
D
I _
Information and Instruction-8
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...everyperson 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 orm
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the ore
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 ofits political subdivisions shall
enter into any contract for the performance ofpubhc 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 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 LL C 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'
compensationpolicy,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 submitmultiple 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 Iicenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or'-ermit not related to any business or commercial venture
j (i.e.a dog license orpermit to bum leaves etc.)said person is NOT required to complete this affidavit.
I
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 ladustrial Accidents
Office oflntvestigaMms
600 Washington Street
Bast gn? .021X1.
TO,##61.7 7274900 eyt 406 ox 1-877:MASSME
Revised 5-26-05 Fax#617-727-7749
Location
No. rDate
ca �
H°RTh TOWN OF NORTH ANDOVER
o ; Certificate of Occupancy $ �?
i
Building/Frame(Frame Permit Fee $ 21, g.
�, ,•'. 9
�ss�cNustt Foundation Permit Fee $
o �
Other Permit Fee $ .
s Sewer Connection Fee $ �°
c.
ao
Water Connection Fee $
TOTAL $ ox
�K /09/ Builpfng Inspect&
9845 Div. Public Works
t
•I - • s�
PEaacIT rro. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER,_ MASS.- PAGE .
MAP 4.40. �® 1/�LOT NO. O�— 2 RECORD OF OWNERSHIP (DATE (BOOK :PAGE
ZONE SUB DIV. LOT NO. (�
.:. - Ste_
y�COCATION � PURPOSE OF BUILDING
L• .SCt2 Prr 2 % opt c6, U iyr �sc 3 d¢c
-- OWNER'S NAME u S NO. OF STORIES % SIZE ` Zr
f
--� OWNER'S ADDRESS �O 7 Lf /_ �i BASEMENT OR SLAB
ARCHITECT'S NAME �J SIZE OF FLOOR TIMBERS IST 2ND 3RD
1loa)ILDER'S NAME _. cam_ - SPAN /L� Mgr — -
DISTANCE TO NEAREST J'3UILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET - ppSTS
v-,"DISTANCE FROM LOT LINES—SIDES REAR 4 '0 " GIRDERS /
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW 812E OF FOOTING X ` L it 1(
18 BUILDING ADDITION MATERIAL OF CHIMNEY o
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
7
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER --�
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EBT. BLDG. COST
PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.
' PAGE 2 FILL OUT SECTIONS 1 - 12
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
: ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING. .. 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS -
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
- 06TE FILE V � 3' �o
1r
NUILDING INSP=CTO!
SIG RE OF OWNER OR AUTHORIZED AGENT -
F E E OWNERTEL# 6YU G 2 7
PERMIT GRANTED CONTR.TEL# �
CONTR.LIC.#
_.. ., .
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY S'OkIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY oFFICEs LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE dI 2 I3
CONCRETE BC K. PINE -
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL _
UNFIN.
3 BASEMENT I -
AREA FULL FIN. B'M'T' AREA _
14 1/I I/ FIN. ATTIC AREA
N_O B M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS 9 FLOORS
CLAPBOARDS 8 1 2 3 _
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HAROW D
ASBESTOS SIDING _ COMMON _
VERT. SIDING ASPH. TILE _
STUCCO ON MASONRY
STUCCO ON FRAME
B IN MASONRY ATTIC STRS. d FLOOR I_
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIOR QR —
ADEQUATE I� ONE 11
rj ROOF 10 PLUMBING
GABLE HIP BATH 13 FIX.) _
GAMBQEL _ MANSARD TOILET RM- 12 FIX.)
71AT1 I SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY _
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING
TAR S GRAVEL STALL SHOWER _
ROIL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DAOO `
6 FRAMING i l HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS.6 COLS. STEAM
STEEL BMS. & COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS AIR CONDITIONING
RADIANT H'T'G -
_ UNIT HEATERS
7 NO. OF ROOMS
GAS
pll
B'M'T 12nd `_ ELECTRIC
lil 3,d I NO HEATING
TOWN of NORTH ANDOVER
AFFIDAVIT
Hine Cu&mrtw law
to FeMit AEp iration
MM G 142 A reg dies that the'mirnstar "c,_ alum, ranuatim, repair, oamEdan,
impcovama-t, remml, dmlitian, ac cmstnttim of an aritim to any Pte- bmld•"
irg cmntair&g at least one hilt mt mice t1mfar daell i g uni ...ar to st r�*ps.4rich are adja=it to
srh,wider rn or tuii irg"be doe by registered artmct 3m, udth eatain a ce ticm, along xdffi odor
Type of Work: S G� 1,�i�5 i i��.ec a,� �,r:sh;�ra��/�E`st. Cost L o
Address of Work / 0 -7 d
Owner Name: c.c i S
Date of Permit Application: 3—
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law ramlit Iib.
_Job under $1,000 Date
ding not owner-occupied
Owner Other (specify) n pest
Notice is hereby given that:
OWNERS PULLIM THEIR OWN PERIL r OR DEALING WITH UNREGISTERED 00NIR1kCMRS_-
FOR APPLICABLE ME IlMPROVENNT WORK DO NOT HAVE ACCESS TO THE ARBITRA-
TION PROGRAM OR GUARANTY EW UNDER MGL c. 142A.
Sim u-d--- patialties of pert my:
I hereby apply for a permit as the agent of the owner:
I
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the
owner of the above property:
Date er Name
/ b7 L S
� T• � I 01996 I;
LOT 2
' ?33.50'
r) N
4
12uoe`� FM'sT�',yr W
LOT GA �
EXISTING FNON. ���—�— 72.7' LLI
(_QT 1 I—
�.
T f
d 43.574 S.F
z ►--
Ljj
�xjsT-�a n9.5'
293.50'
N/F
II.G. SONS & ASSOCIA'r-S
THIS PLAN IS INTENDED FOR
ZONING PURPOSES ONLY, IT
WAS COMPILED FROM EXISTING
PLANS AND RECORDS WITH
BUILDING LOCATION CONFIRMED
IN THE FIELD. IT SHOULD NOT
BE USED FOR PROPERTY LINE
D ETERU WATIO N.
WE HEREBY CERTIFY THAT WE
HAVE EXAMINED THE PREMISES
AND ALL EASEMENTS,
ENCROACHMENTS AND BUILDINGS ZONE: 1l-1
ARE LOCATED AS SHOWN. ALL REQUIRED SETBACKS:
BUILDINGS SHOWN CONFORM TO FRONT 30'
THE ZONING LAWS OF THE SIDE 30'
MUNICIPALITY WHEN CONSTRUCTED. REAR 30
THE BUILDING IS NOT LOCATED CERTIFIED PLOT PLAN
IN AN ESTABLISHED FLOOD
AREA
IN M. RromvE�\ )MA.
AS PREPARED FOR NOaN%I mr bvC!,Ex �orozTnv«IotJ co
Auk �`'' SCALE 1'l:,U' DATE Pi?l\l . 01'q
MARCHIONDA & ASSOC., INC.
1?
ENGINEERING AND PLANNING CONSULTANTS
80 UAPLE STREET RF.D. 16
14
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NORTH
F
TONM'
of OL dover
O
Z0 {_ Ll rt " dover, Mass.,
coc H I C HEWrCK
F DRATED PP Cl
5F BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR y
THISCERTIFIES THAT..............................a,L..,..1 . ..5........... ./ .. 1 .. ..!...IO.................................................... Foundation
has permission to erect.......4-0.P fi.D..N.. b &-on ........./..Q.P7........ ..(.. ' .!�. .Y.......S..777........ Rough
tobe Occupied as............................................. ........... .�.��.L' ............................................... 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 Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION S .AR
Rough
.. . .. .......................:................ Service
B DING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises - Do Not Remove RouFinagh
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
Smoke Det.
L4 Commonwealth of Massachusetts
W City/Town of NO. ANDOVER
System Pumping Record
wM
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use 108 LIBERTY ST.
only the tab key Address
to move your NO.ANDOVER MA 01845
cursor-do not City/Town State --7j�Ggde�,,;.
use the return
key. .
2. System Owner:
tab
PHIL QUINN fl
Name
Address(if different from location)
TOWN OF N
,r MEAITM p�PARTM�NT
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 12/15/11 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
JAMES H. CURRIER H79 406
Name Vehicle License Number
J's SEPTIC&DRAIN
Company
7. Location where contents were disposed:
GLSD
12/15/11
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1