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Miscellaneous - 11 EDMANDS ROAD 4/30/2018 (2)
11 EDMANDS ROAD 210/020.0-0051-0000.0 I i I Date .I)x . . 5�'fTbN cQd^' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ;This certifies that. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... _ . has permission for,gas installation . .. . . . . . . . . . . . in the buildings of. -- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . ,.� . . (XU�!1S . . . . . . . ,North Andov Fee .� er Mass. ((__� l.t�. . . . . Lic. No. 15.) � . . . l,� a GAS INSPECTOR,/ Check# w� 1 v 8542 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY j MA DATE I - ` 13 7 PERMIT# JOBSITE ADDRESS OWNER'S NAME _2 l____ GOWNER ADDRESS ISTE _7 A-6t' 172 FAX� ( TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:[A RENOVATION:E] REPLACEMENT:El PLANS SUBMITTED: YES F-11 NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .- .. . ._. ... I I.. . BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ I - DRYER FIREPLACE FRYOLATOR _ FURNACE GENERATOR GRILLE INFRARED HEATER I _ LABORATORY COCKS LL(�_--� -_. _ - 1 _-�I --1 -- - -—1 __ - -1!T _ _ MAKEUP AIR UNIT I _ OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT I _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER L -J ._._ 1-- I --.1 I I��— _ I OTHER ........._..... ...._........... ......_..... ._...._. INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES IN NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY E]I B 0 N D �]_f 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 �]_I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tr and accurate to est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co Iia a wit II rti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEA�L1s _ '/'' ► LICENSE# jSJ_ I ATURE 7�(� MP 29 MGF[ JP Ej JGF LPGI CORPORATION F # PARTNERSHIP 0# LLC E #-E- COMPANY NAME: ]Jqv' -PZ�12l-Z���d d _I ADDRESSj�Z CITY __I STATE _y�^ ►l ZIP 1 Z�1 TEL �I 7 FAX CELL Sal P1 L---EMAIL 1 IWSv\ on.. ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ / FEE: $ PERMIT# L� 2 A/1 3 PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 ,Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizati(in/Individual): Address: r5 T'�4 e g-_)P %1 ZAreCity/State/Zip: Phone#: 9 7 e_� - 6 ' 1F3 b 3,z-- 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 2.0 I am a sole proprietor or partner- listed on the attached sheet. ? E]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 1011 Electrical repairs or additions L❑ I am a homeowner doing all work right of exemption per MGL 110 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' comp.insurance required.] 13F]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. contractors 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 iformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: ib 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 u15 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 -up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Lvestigations of the DIA for insurance coverage verification. do hereby esti un er Ite in and penalties of perjury that the information provided above is triteandcorrect i nature: Date: lone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or.other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 shouldyouhave any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax-numben The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1877-MASSAFE evi.sed 5-26-05 Fax#617-727-7749 www,mass.gov/dia. 4 J COMMONWEALTH OF MASSACHUSETTS r s . . • ... . :• • . PLUMBERS AND GASFIT.TER.S _ , LICENSED AS AWASTER PLU14��BER ISSUES THE ABOVE UOENSE TO § _g �F�D„AVID 0 ;PEREEN SWI>NTHR0P ST "# ESSEX`S MA 1619-i - 120 151`53 05101ill �. ` '5299 xz 7 i / . f t )I t i GENERATOR APPLICATION DATE: I I o LOCATION: I I Om Uj9 OWNERS NAME: Nj/Ie-, GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: % I�✓� �1 P�Q K ee� PHONENUMBER: - ELEC GAS ESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: pi lo-p� *CONSERVATION APPROVAL " VLJ i ��� ,own of North Andover Page 1 of 1 • _-�• , III Base Map Zoning 2012 Aerials I Watershed Zone Utilities Size00E] Selection Legend Location Markup Help Scale 1"- 35 ft - ....... Select iParcels - -- �. c , (sho Owner ;Pro.._.ID_ �A w all) P� f titi #n 11 EDMANDS ROAD REALTY TRUST;020.0-0051-0000.0111 EI 3 1 selected To Mailing Labels To Spreadsheet Property Building Permits FPlannin7gl Septic Puffl Print `sem Owners 11 EDMANDS ROAD REALTY TRUST Owner2 NOBLE,JAMES JR&PRISCILLA TRUS Address 11 EDMANDS ROAD •< spy , PropertyID 020.0-0051-0000.0 c Lot Size 5227.2S z a Fiscal Year 2013 Land Use 101 ode Get Pictometry Imagr-�Go I. 0.2.0 AppGeo Save Map a as Ima e g ' •`. .13 mev w.annnQ Wmrv,,Wm does rmmsxe"wmaMv.ewe> of hphed.fw rePmwo Lihft*ye a€vW emamnacy.mmwlet . cruormmmd0eceoggftkftmai ss nP�9}Dataaranyomerd=pmaas0fteaia Tears Oes not taMmepuce0aamfrsswrWs,n--y and his na tel"maetnesneer.sty.nor.aeon.Orextzem:eatageOgapnctsapmwop4eyaMorpa"nes mWffmxcsV2netPlmng coraft&W w \ MZanyLee dmsaroMSknbeaceorr"I-dtysfdelasemrssame sort0eM M%AVaSWtPbmdagGm=1W scMMtlmtftmakeS,mvmrfia 0i ROWMUMM as to tre acaraey of Said Mffn eaa Arty Le at msm imrmn Is n Re rtcloem-smn 6W �44r�•Ilmimor m�/r\n nrn/I\T/rfb O1 NOW Z • ��1 �Y ��j�3 71 0� V 6�1 Date...CP�11.q......... 10677 O too TOWN OF NORTH ANDOVER tioox PERMIT FOR PLUMBING t This certifies that.." .................................................................................................................. has permission to perform... .....A,04.Y.Mj.. ............................. plumbing in the buildings of......... ....a le— .................. at ...... .......... ............... North Andover, Mass. Fee.',/.. ....Lic. No. ... ..... ............................................. PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYI MA DATE[j i [ PERMIT# ID�0 7"7 JOBSITE ADDRESS A. OWNER'S NAME $ POWNER ADDRESS TEL FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT ?61 CLEARLY NEW: 0 RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES® NO FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( —_I _ i _._.J I .___. CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM III—Al—.1 —3 ._--J1 I ..._- DEDICATED GREASE SYSTEM _J -ji__-I -__ f _..___i .___._.J f ..___._-I ^I 1-7—f DEDICATED GRAY WATER SYSTEM { ( ______1 ___._ J=== DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN i ..___....J i I _._ _1 I 1 ..__.._.i J ..__J i INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY f l ROOF DRAIN .____I SHOWER STALL SERVICE/MOP SINK TOILET I .._I _ I } I 1 I J ._ ` �._I J _._.._ E __. _f __71 RINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I f d OTHER INSURANCE COVERAGE: 11 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _f BOND M 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 -i AGENT 10 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 compliance with all Pertinent provision of the Allassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME - _ LICENSE# SIGNATURE VIP JP Q CORPORATION PARTNERSHIP# _ LLC ti COMPANY NAME i ADDRESS CITY ;STATE ZIP � _ TEL — FAX CELL EMAIL ! ROUGH PLUMBING INSPF.CTlrONlWOTFS BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No '7�i ��✓ ` THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES re • ,s �d r • a r a i A y The Commonwealth of IVlassachusetts - Department of lndii fstrigl Accida-ts Office Of Investigations 600 Washington Street Boston,MA 02111 www.mass govIdla Workers'Compensation Insurance Affidavit:BuiXders/Conti°actors/Electriczans]Plimbexs Apullieant]nform.ation Please Print Legibiy Name(Businessiorgani'zation/.individual): UA im( ag h Address: PQ e29 City/State/Zip: _ mk.ai 2x&7 hone#: -20ty Are you an employer?Check the appropriate box: Type of project(required): _1 LIA I am a employer with 4. ❑ I am.a general contractor and I �...—_ 6. ❑New construction employees(frill and/or part-time).* have lured the sub-contractors 2.El am a sole proprietor orpartner- listed on the attached sheet. '7. F1 Remodeling ship and'haveno.employees These sub-contractors have 8. [[Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ElWe are a corporation and its required.] officers have exercised.theix 10.[]Electrical repairs or additions 3.[( I am a homeowner doing all work right of exemption per MGL 11.r5rumbing repairs or additions myself[No workers'comp. c.152,§1(4),andwehaveno 12.❑Roofrepairs insurancere ed. employees.[No workers' a 13.❑other comp.insurance required.] xAny applicantthat checks box#1 mustalso fill outthe section below showingtheirworkers'compensation policy information. T-Homeowners who submit this affidavit indicatingthey ke doing allwork and then hire outside contractors must submit anew affidavit indicating such. 1'Contractors that cheok this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X a;n an e!?2lJr0yEt'that isproviding wOYXieYs'Compensation insurance for my employees Below it the policy and job site infor7atadon. Insurance Company Name:. ` Policy#or self-ins.Lie.9: Expiration Date: ti Job Site AddressA%,bMu>Ay:�, City/State/zipA . A K (/M . Attach a copy of the workers'compensation—policy declaration page(showing the policy number and expiration date). Failure to secure coverage as req* dander Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a i7n e 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 fm 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&under the pains andpenalties ofperjury that the in,formation provided above is true and correct. - Si afore• Date: Phone#• b13 4315), 20—to 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 'K. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statate,an employee is defined as"...every person in the service of another under any contract o hire, express orimplied,oral orw.ri-tten." An em to er is defined as"an individual,partnership,P Y,#. , p r6i xshtp,association,corporation or other legal entity, Y,ax an two ox more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a•deceased employer,or the receiver ox trustee of an individual,partnership,askelation or other legal entity,employing employees. However the owner of a dwelling house having notmore than three apartments and who xesides therein,or the o coupant of the dwelling house of another who employs persons to`'&maintenance,constructign 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,p ermit to'op urate a business or to constx ct buildings hlthe cmiiibrion ealtTi 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhavebeenpresentedtot the contractingauthority." Applicants Please fill.out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,if n6cessary,supply sub-conixactor(s)name(s),addresses)andphonenumber(s)along withtheircertifxcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,axe notregiiired to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required. Be advised thatthisaffidavit maybe submitted tothe 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 thepermit 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 refezence numbed:`Tn addition,an applicant thatmust submitmulti le ermithicense applications in an given ear,need only-submit one affidavit indicating,ft6nt oIf—., onr atioii(if ii ec P nary)mind under"Job Site Addres"the applicant should vizite"all locations in____;(city or town)."A-copy of the affidavit that has been officially stamped or marked by the city or town may b e provided to the applicant as proof that a valid affidavit-is on file'for future Hermits or licenses. A.new 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 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 f*number: 1.Q MQu w E`a -L'lI�J P f I fMama� ttS �'• Dep.at ane t Q Zudu xxaI.A,cCX&atS Office ofImstigamiRa 6bG Wasbagtoa Strut Boston,MA 021 If AM Revised 5-26-05 F #617"727'7749 ' vv�'.z?�ass,,govfdia . t COMMONWEpLT HOF M1�SSACHUSETTS ? I PLUMBE#tS AHD GASFITTERS ISSUES THE FOLLOWING LICENSE ifCENSED ASA MASTER PLU ER - ROBERT B BLANCHETTE PO BOX Jul I' ,A1OftTH Aex- NDOVER MA 01845-0228 8 0209 23 I � Date...... ................ 0 r.................... ORr `F °�N``° '•�ti TOWN OF NORTH ANDOVER �'?:' -� • roc o p PERMIT FOR WIRING ss�a,us� This certifies that .. .. c �G ..1...�� '�. A...1�,,�...................... has permission to perform .............. ............... .��-1M d t��............................... wiring in the building of...............N.06A P......................................................................... at ......1.1....... ........................... aAL Andover Mass. Fee. 6..... ....Lic.No.�DU,,t3 " PECTOR Check# 2—S�L 2- Commonwealth of Massachusetts Official Use Only ' t Permit No. Department of Fire Services a� BOARD OF FIRE PREVENTION REGULATIONS �� Z I APPLICATION FOR PERMIT TO PERFO / All work to be performed in accordance with the Massachusetts Ele //1 M (PLEASE PRINTWINK OR TYPEALL INFORMATION) D /111 ' City or Town of: NORTH ANDOVER T By this application the undersigned gives notice of his or or intentiP n to per! .. Location(Street&Number) �� n"ur)L.5 l�(/) e�{�( -yi�U��► �N W Owner or Tenant J q n1 t S C'i Owner's Address Is this permit in conjunction with a building permit? Yes I� Purpose of Building_4 mU � PurpMilli: Existing Service—ZLC'Amps / Volts Overhead E]New Service Amps / Volts Overhead❑ Number of Feeders and Ampacity Location and Nature of Pr°js Electrical Work: I ��'-�� Completion of thefollowing table may be waived by the Inspector of Wires. ' No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)FTransans of Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA ' No.of Luminaires Swimming Pool Above ElIn- E] o.o me �g tmg rnd. rnd. Batter 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 g Tons No.of Waste Dis posers Heat Pump Number Tons KW No.of Self-Contained P Totals: ....................... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection Heating Appliances ger SecurityN Dev lc No.of Dryers , s 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 No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ; 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 cov,9tage,is in force,and has exhibited proof of same to the permit issuing office. UR CHECK ONE: INSANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and p altiesJ f. j ,that the information on this application is true and complete. FIRM NAME: . ��G E/ LIC.NO.:10, nn Licensee: 6-Z� Signatu e LIC.NO.: 6 93 (If applicable,er}t ,"exem ' in th$lice a um ine. Bus.Tel.No.: ,t, C Address: / / Ir /� d Alt.Tel.No.- /��� *Per M.G.L c. 147,s.57-6 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 f 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 r, I 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 IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ SII Inspectors Comments: k- Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: i ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments• Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r Commonwealth of Massachusetts Official Use Only r Department of Fire Services Permit No. o Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.i/07] peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code gaE 117 ��0 (PLEASE PRINT W INK OR TYPE ALL INFORMATIOA9 Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his orer intenti n to perform the electrical work described below. Location(Street&Number) '� n^u .5 Owner or Tenant ' S/17r NO 14-1 Telephone No. Owner's Address irtL. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service_2Lc vAmps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Prrsf Electrical Work: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA ' No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers , Heating Appliances KW SecNo.urito Systems:* ev ices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value 9f 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 cov age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:) I"cergy,tinder thepains andvgnaltres f.perj ,that t�; ,he information on this application is true and complete. FIRM NAME: . �G / ✓ LIC.NO.: Licensee: Signatu e LIC.NO.: Al applicable,erije lexempb'in tl licepaeytumb ine.� �, Bus.Tel.No.: / �''! Alt.Tel.No.: / d *Per M.G.L c. 147,s.57-6 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: $ 7 Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed t 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 * r c r 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($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: i p g PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: i ROUGH INSPECTION: ` Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments VMA Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: j DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . Address: 1 r\ City/State/Zip: Phone#: // Z_ Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ployees(full and/or part-time).* have hired the sub-contractors 01 Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. 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. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL I L❑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.❑Other f comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T-Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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.#: ExpirationDate: Job Site Address:, /� 411A S /V A.7 City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insuranc coverage verification. I do hereby certtfy un the ains a d penalti of perjury that the information provided above P true an4 correct Si 1151 Signature: Date: 1-5/ Phone#: 1 / 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.PIumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 v 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 co of the affidavit that has been n 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 CQmmonwalth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA.021.1.1 Tel,#617-7274900"t.406 or 1-877MASS.A.:FR Revised 5-26-05 Fax#617-727-7749 www.mass,govldia r-� Iv t COMMONWEALTH O�11AASSACHUSETTS - ' ME BOARD i3F f -SSUES THE FOLLOW:l•!G VITEN is R �';lOURNEYMA�t Eli t R f C;CY j 4 4.t41 l3 GARI EpY +` 7 MAP''::E ST `a v A0 18607 1"} }. a Date "pR': o TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMB4'NG 40 0 SSACNUSE� ;. f / This certifies that �!�-G��.f .�. . . ' t�C. r�. . ��' . . . . . . . . . . . . . has permission to perform . . :� . . . . . . . . . . . . . . . . . • . • . plumbing in the buildings of . . . . . . . . . . . . . . . . . . ��, — A r at . .�,/�. . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. 9 r. . . . Lic. No.D.5. . . . . . . . d.!�.� -/`T.. . . . . . . . . (PLUMBING IN ' Check # l 8003 7MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO.DO PLUMBING . -: - (Print or Type) D e N . Msss .Date Permit# 1 2 0 �. lA BUQding t:+�catioCl �:I &VI�QA Clvme�s:Name Type of OccupaneY... I New ` Renovation a Replacement.:Q Pians Submitted: Yes O No .ice FIXTURES Z z a: a � • r ar.`. .+ .. .r v < � . W.. W y .Z fA < U. Z O. :� O W r .tU .p. r .Q; W Y '< m a' -- r rt. W lY p .•r , W L: ID r X: W a Y J ID. .ID d ID .�_ i� �.• �". C7 ;t ZL tr SUR—BSMT.. BASEMENT IST FLOOR tqwm � 2ND FLOOR •. . 3RD FLOOR..- i 4TH FLOOR ..... STH FLOOR 6TH FLOOR. 7TH FLOOR STH FLOOR Insulting Company:.Name= 174 '�rt � Check1609 one Certrffca#e AddressVon 4 1 --Sp,Partnership Business Telephone t ® / D FumlCo. ,"�=t d facensed Plumber R, . INSURANCE COVERAGE: Itiave.a carr liabifty rosy policy ors substantial equivalent which meets fibs regttlrements of`MGL Ch142..; Yes: No If you have eciced yet, please Indicate the type coverage by checking the°apprppr%te box A:I'lability Insurance policy Over type of indernnfty O Bond d' OWNEWS INSURANCE WAIVER-6.1 Am fhatahe licensee dost not.have theansummdt tOverage.required by Chapter 142-d the Mass.'General Laws. and that my:signature on thlt.permlt application waives this cequfrerneht.. : Ch'' oRe (awrrer_ :7 Agent l] Qnatutaof Owner.o ownet•s Agent I hereby certify Mat all of the details and information(have subrrirtted(or eirteredJ in abo+re$poi�oatJon are true and axurate,ta the:best of my knowledge and that all plumbing work and.installations performed"under the pelt iss ted for th>s appf�caUon will be�n compliance with.ail ; pertinent:provisions of the Massachusetts State Plumbing;Code and dater 142 of the General Laws: ;� gnature or Licensed Number e' Title T 17 Joum ` yE' of License:Master eyman;d City/Town i APPROVED(0 IC U -.ONL License Number _ f ' Date. . ~ °. . MORT#1 <,��° •rho TOWN OF NO TH ANDOVER PERMIT FOR PLUMBING .� ,SSACMUS� - This certifies that . LA k( -r. . . .4 P�: !t . . . . . . . . . . . has permission to perform . . .130 d?.� ?'.L^. . . . . . . plumbing in the buildings of . . . . . . . . . . . I . . . . . . . . . at . . . . . ... . . . . , North Andover, Mass. v Fee 3?."� Lic. Nol Sti-?. . . . . . .(2�i=(� 'c..' -�.'. . . . . . . PLUMBING INSPECTOR Check # 7784 3 ? ' .,:MASS-AC'HUSETTS UNIFOR-M AP#'L.ICATION FOR PERMIT fi{� l ±b fiASF1T ING (print or T ) c Mass Date1�. "19?c�g Permit # Building Location ' l �DWIF1 Ovrm°er's Name n$�►�r �'ype Of OCC.Upan �i111G�ir� New. CJ Renovation ;r RePlacernen# p Plans Subr#rtted Yes[] Nb: t a? N• N 'C) :�0.' _ }' '.i.'-. >' �'Fri .� Z Z O. F' w � a m:, 3- WW O- dJ C'f'' W Q: 2 Z t'. to O > LI cr rr l...:. tsr Z. U W... {r d tJ Z t itJ FIV - v5 W W 41 1 h' .r rpr Q SJB BSMT 1.. 7 z 1ST FLdOR r g 2RD FtflOFt 3RD FO:O�R 4 I 41'H F SDR � - 5'T::H - S:TH 0:0 R 7;7 H FL'O OR 'z $THti�OR i • j < . Cbck ©nrr Certrfigate Installing Cortpany;t�ameTPO Address rx rt�an t tori N b• 1AraAO� • {8 � `� Partner7h'i� Business Telephone ?8+ . ZD• .17� D F crrrlCo Name of lJce>serf Plumber or GaS"_ef INSURANCE:COVERAGE: I have•a .curz Dia, insurance..policy or ds substantial equivalent which meets the Fequirernents of MGL Gtr: 742. . Yes NO It yoci Have checked Yes please lnciicate,the tyA coverage by>checiCing the appro riate tsbx of irdemn C� 6ind D: A liability insurance policy Clther type rty OWNER'S .INSt1FAtJCE Y1/AIVfR;,;l am aware tftiat the:licensee does not,have the insutriee ci5verage regtrtred by . Chapter 142 of.the Geheral Laws;and that my signature on this perrtiit apPl�canonwarvs<thts,rquiremeht . . CecK cine (.�vvnetl4J: :Argent p Sigr�aiure of rainier or C w' s Agerity hereby cern that all.flf the details and arifbrmatian I have„submitted(Or eriteredl in at�ove application are Cilie and acGWram'1n B :(h all my Ih Y �' . 04c, knowledge and Utat all.:plumbing>varlc end installations petformed:under:•&permit:isst7ed-tar this applrcatlrsn will be co p pertinent provisions of the Massa husetts,Atate N'' CoQe:and•Chapter 14 of the Gene taws 0 By T of Ueense :: U . Signature of Licensed Plurritrer or ao Frt#er Title Gasifier Master - License Number: i�ay Crty/7own J..3ourneyrnan-., At'.PF�C7VED(OFFICE USF ONLY( Date.......`�.��.�. ....... p0RT" °f�"`°:',"° TOWN OF NORTH ANDOVER 1 40 ' PERMIT FOR WIRING This certifies that .. ..................- .f .......................................�...... has permission to perform ... wiring in the building of... ? ...................................................... at..//........ .......... . North Andover,Mass. Fee/ ....(.1..... Lic.No.���� .............. .�*-IcLilw4sp/ ELEcTO .�. Check # 1230_3 ` A99R "I'\ Commonwealth of Massachusetts official Use only ©epartment of Fire Services permit No. BOARD OF FIRE PREVENTION REGULATIONS . Occupancy and Fee Checked /00- [ [Rev. 11/991 (leave blank) APPLICATION. FOR PERMIT TO PERFORM ELECTRICAL WORK _ All work to be performed in accordance_with the Massachusetts.Electrical_C.ode.(N EC),_527-CMR.12.0.0____ (PLEASE PRINT LV IIJK OR TYPE ALL INFORMATION) Date: `7--1 'a City or Town.of: . ()or Qao&-- To the Inspector of Wires. By this application the undersigned gives notice of his or her'intention to perform the electrical work described below. Location(Street&Number) Owner or TenantTelephone No. Owner's Address q n ,S CM 6 K 1-7 8 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) Purpose of Building k&,,-0 Utility Authorization No. Ezisting Service 100 Amps 1a() / a11OVolts Overhead 2 Undard❑ No.of Meters ({ New Service 00p. Amps /altoVolts Overhead Ik' Undgrd ❑ ho.of mefs Number of Feeders and Ampacity Location and Nature of Propel wow. rrrir r Cam letiarrthe{ollowin table may be wai ped by tate L=e=r cj-W-v s No.of Recessed FELlures No.of Cei7.-Susp.(Paddle)Fans o. Total Transformers KYA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures "7 Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting d. d. Battery Units No.of Receptacle Outlets No. of Oil Burners . FIRE ALARMS No.of Zones No.of Switches No. of Gas Burners o.o etection and Initiating Devices No. of Ranges No.of Air Cond. Tota[ No. of Alerting Devices Tons g Heat Pum _...umber Tons KW o.of el - 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 S stems: No. of Devices or Equivalent No.of Water KW No. o No.o Data Wiring: Heaters Signs Ballasts No. of Devices or Eq uivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Winng: No. of Devices or E u%ent OTHER: Attach additional detail if desired, or as required by the Inspector of PF'ires. 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. CBECK ONE: INSURANCE V BOND ❑ OTIMR ❑ (Specil�:) Estimated Value of Electrical Work: ��6m0-(� (When required by municipal policy.) (Expiration Date) Work to Stant: � Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the ns and penalties ofperjury, that the information on this ap lication is true and complete 1~IRM NAIL: -r-. 3aiJ z2W C. ALIC. NO.: Ila Licensee: rn Signature _ LIC. NO.: 13 a�� rIf applicable, nter "exempt"in the license number line.) Bus. Tet. No.: q7 Address: &D 01q.,AAlt. Tel. No.:7`)k J!S 6-TU OWNER'S INSURANCE WAIVER: I am aware that thLicensee does not hen)e the Iiability insurance coverage normally required by law. By my signature below, I hereby waive is requirement I am the(check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. FP—TRjkffT FEE: a i 7- -d ' The Commonwealth of Massachusetts i Department of Industrial Accidents Office of Investigations 600 Washington Street :: Boston, MA 02111 f r1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I saa %411 ttYV1 T—�szYo a Address: Pt) &>o 7� City/State/Zip: Phone #: �'-310 0' �15 3 AWyo--am u employer?Check the appropriate box: Type of project(required): 1. as employer with JV 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. E] 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. lectrical 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 12.0 Roof repairs insurance required.] t 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 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: \�^- Cd icr Policy#or Self-ins. Lic.#: ,9O 3 5 � 533 Expiration Date: qr10 `-'� Job Site Address: ( a/VlCl.t/,L -�s—r City/State/Zip: &SOU)" Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains d pe a ies of rjury that the information provided above is true and correct. , Si nature: q, Date: _ 0 Phone qT3 s Oficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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. r 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 pen-nits 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. #617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia �E COLLOPY ENGINEERING CONSULTANTS 65 AYER STREET METHUEN, MA 01844 FRANCIS H.COLLOPY A RESIDENCE:(978)685-7969 ROFFICE 1 FAX:(978)685-8069 EG.PROFFESIONAL ENGINEEER CIVIL STRUCTURAL DYNAMICS June 24, 2008 Mr Gerry Brown, Building Commissioner Town of North Andover 1600 Osgood St North Andover, MA 01845 Dear Mr Brown: I am writing tin in regards to the construction at the Noble Residence at 11 Edmands Road in North Andover. I provided therequired structural faming elements and design in myApril 24 th letter to you. I was requested by Mr Bert Roy, Contractor to visit the site and to inspect the framing in place and to provide you with an affidavit to the completeness of his construction. This letter is to notify you that on June 23, 1 visited the site and inspected the ridge beam, the header, and the supports and construction details as shown on my design drawings, and that in my professional opinion the finished framing is in agreement with the design plans. If you have any questions in this regard, please do not hesitate to call this Office, and we can discuss it further. Sincerely, t,�°Fa�s,� COLLOPY ENGINEERING FRANCIS H. COLLOPY » �/- 60" 20172 y '6po' a18t Francis H. Collopy, P.E. �fssI NA1,E� Structural Engineer cc: Bert Roy Date3334 Date./. HpRTM TOWN OF NORTH ANDOVER 0, y PERMIT FOR GAS INSTALLATION 9 �9SSAcmU`'Et �� f This certifies that . . . .?�d.�'.�f�:: �:.'.�: . . . . .�. . :� . . . . . . has permission for gas installation . . . :.`�.s. 1/.c.>. . . . . . . . . . . in the buildings of ° �J. . .�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .s . . . . . . . . . . . . . . North Andover, Mass. Fee. .A-!�-. . . Lic. No..�:. .3. GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer _.._.. 62 MASSACHUSETTS UNIFORM APPLICATION FOR PER TO DO PSG (Type or print) -- --. 3 '33 5/ NORTH ANDOVER,MASSACHUSETTS t c / Date 1 L (4 G Building Location t' �d/ AOkci � Owners Name 6 Permit# Amount — Type of Occupancy -_ New Renovation Replacement ❑ Plans Submitted Yes No - FIXTURES w w a rAa acr) w Hca . 9 a acc Cn A w � a xx a F a w x W '+ CC z cn KREM i? BASE" [C - lSE Rfm - MFlom 3MFLOCR 4MHIM 5IH FLIM 6M RfM 7M FBM 9MK - (Print or type) / Check one: Certificate InstallingCompany Name�D , Corp. Address �—(j d y I— z)t2 ct �^ — ❑ Partner. Business Telephone Q ZiQ 13- Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy Other type of indemnity Bond Insurance Waiver. I,the-undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance — ignature Owner ❑ 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 pgfortned under PermitIssu for this pplicatiori will be in compliance with all pertinent provisions of the Massachus Stat u bing C and Chapt 142 o e General Laws. By: igna ot 17censeaum e Type of Plumbing License Title City/Town iceum (e Master Journeyman APPROVED(OFFICE USE ONLY - Location .. J s_ No. Date: � TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame P rmit F ee $ a crev MusE� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ }p Water Connection Fee $ TOTAL Building Inspector Div. Public Works . Oi3l13l96 11.2��,� � 45 QO PRI PER311T NO. _3 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 ,MAP i-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. 7 — LOCATION EE) P'P�)c7S PURPOSE OF BUILDING Q i Roe OWNER'S NAME � ry p, AL NO. OF STORIES i` SIZE OWNER'S ADDRESS S t � i� BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME ,.y ., a• \i\O g SPAN --- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND 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 EST. BLDG. COST -200®1 PAGE 1 FILL OUT SECTIONS i - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 1 PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING INBP[CTOR SIGNATURE W JEDYR-•AUTHOR -ED A ENT pp/ F E E OWNER TEL.# LAO&— 1792- PERMIT GRANTED CONTR.TEL.# / ` gr/a"z2- 19 CONTR.LIC.# 76 H.I.C.# f 0-5- 39 3 lot 3 BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY —I S ORIES 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 I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 (3 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT 11 AREA FULL FIN. B M AREA _ '/, 1/2 �/, FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW D ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH Q FIX.) GAMBRELMANSARD TOILET RM. 12 FIX.) _ t FLAT SHED WATER CLOSET t f ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING — r TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO t 6 FRAMING I 11 HEATING WOOD.JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. b 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 OIL _ t 8'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING r . r... .. _- ._..•.N - ._� ... _ _ s _ vy OFFICES OF: : �`_Town Ofj,120 nAsin street --.- APPEALS - - _ ._ -_North Andover. APPEALS . •1�►.y: - NORTH ANDOVER BUILDING t MBSSaCllusetis O 1845 CONSERVATION DMISION OF HEALTH PLdx.NN1\G PLANNING 8r COMMUNITY DEVELOPMENT _ KAREN HP_NELSON.DIRECTOR _ In ac;=dance with ;he S -. zi conditicn of Building P-,--,;t Number -386 is s ^'is resultinc frcthis work shill be disnosec: cf ... a ?renes a:: _slid ; s:e _s^cst. :ac:i ra....:..c:: by MGL, c 111, S 150-1 i ne debris will be dispose:! cf in: Cf FaCilit.� 7 4)f r 5jt::.at:..,. of Pc:tnit Applicant Date NOT': Demolition permit fr= the To%.-a of '.forth Andover must be obtained for this project through the Office of the Building Inspector. NORTH TONM of 0 dover No.3 60 Y o rt dower, Mass., 19 COCHICHEwICK AORATED 7 5 - BOARD OF HEALTH Food/Kitchen �D Septic System PtR IT T BUILDING INSPECTOR THIS CERTIFIES THAT ...........7(.Z^_ 'es..........�JQI-00..,.......................... .. ' ' "" Foundation has permission to erect.......(L'e..as). ... ....... buildings on ...:.:...l...l.....� W!.. .......s.............'.................................. Rough to be occupied as ........S.k\AJQ... . �u�.�l . . ..............:..........�...C,'}:,dZPIP.....�1--...�.�..��d.F.}........................ Chimney provided that the person acc�pting this permit S4111--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 Fina' UNLESS CONSTRUCTION S .-I-,S ELECTRICAL INSPECTOR i Rough ..................... . ............ ..... ..................... Service LNG INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough nal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det.