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Miscellaneous - 11 FIELDSTONE COURT 4/30/2018 (2)
010 Date!.I.k h.?............ "ppT"_ ti TOWN OF NORTH ANDOVER pF ,�•o , C „ PERMIT FOR PLUMBING This certifies that.. :.+ '1.e.....{ � g ....... ......................................................................... has permission to perform...�(,A r�. V\k? ................................................... plumbing in the buildings of��' �...... .. 9x � ....... at... ..�... "h..P 1 c� �., ......................................... North Andover, Mass. Fee...� ".......Lic. No.�.� ��. .... 4............................................................. PLUMBING INSPECTOR Check#3Z-Cooc:� .\ IrInVVMV1IVVL IV W11111 VI\Irl r%rr L-IVPI IMV t vn n rL- Irll1 IV rL-I%I VI\Irl VL.%JIrILJIItlV Yr VI\r\ CI MA DATE PERMIT#APjdw16,u JOBSITE ADDRESS OWNER'S NAME OWNERADDRESS l TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1 DEDICATED GAS/OIL/SAND SYSTEM l; DEDICATED GREASE SYSTEM 5 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Y NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY. OWNER [IAGENT ❑ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this applicationlaref rue and accurate to the est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be' co pliancewith all Pert' t r islon f the Massachusetts State Plurpblqg Code and Ch pt r 142 of the General Laws. PLUMBER'S ME W r r� LICENSE# S GNAT MP JP CORPORA T ON❑# PARTNERSHIP❑# LLC❑# COMPANY lNAME f ADDRESS CITY J-QVN, STA ZIP—&L�—� TA)� FAX CELL EMAIL ......:............. NORT�y TOWN OF NORTH ANDOVER � � p PERMIT FOR GAS INSTALLATION 88'�CHUS� i ` This certifies that .... ..... . .:..: . .{�Iwn-. ............................................... has permission for gas installation .1 : .!'�� ' in the buildings of.. Jvc Y.... .`� � :...:.;.(.vv.............................. at.......� ..... ..P <. r ... .t....................... North Andover,Mass. Fee .!.......... Lic. No. I.PA.6...... ..................................................................... _ GASINSPECTOR Check# 2�PC MASSACHUSETTS UNIFORM APPLICATION FOP A P MIT TO PERFORM GAS FITTING WORK CITY CMA DATE PERMIT# JOBSITE ADDRESSE!213:�- OWNER'S NAMEV WL GOWNER ADDRESS F TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V ` PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[ ]� PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS- BSI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT �1 TEST N UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE 1 have a current flatiffityinsurance policy or its substantial equivalent ich meets the requirements of MGL Ch.142 YES ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the rlcensee 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 AGENT I hereby certiry that all of the details and information I have sibmilted or entered regarding this application and accraate to best of my knowledge and that all plumbing work and irrstallations performed under the permit issued for this appin�tion wilk be in iance with all vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J PLUMBER GASFITTER NAME(, L � 'r°� LICENSE# SI TORE MP n-'144❑ JP Q"JJGRj3"LPGI❑ CORPORATION❑# � ERSHIP❑# LLC❑# COMPANY NAME 1A ADDRESS PN i, CITY STATdW. ZIP TEL FAX CELL_ EMAIL V`� Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ....................................-................................................................................................................................................................................................................. Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:ADAM C. HOLMES REFERENCES& HAVERHILL,MA RELATED INFO NEW SEARCH Disclaimer Regarding "This Licensee has additional Licenses,click here to view them."" Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER More... License Number: 15685 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 3/18/2010 Exam Date: 3/18/2010 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday,February 17,2015 at 10:06:50 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://Iicense.reg.state.ma.us/public/pubLicenseQ.asp?board code=PL&typeclass=_M&li... 2/17/2015 -t t 1 � Date... . .. ............ �NOR7N, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION X17 °++•a° �.�'� • s`TACHUS� r This certifies that . .. 1� - ....................................... has permission for gas installation ... v/...s Q: P in the buildings of........................ .-,e,-4lr.. �,,�..,,.......... . 1rJS.A0.,J.e...... ..............0........, North Andover, Mass. Fee..3.&.. .... Lic. No. Zc) J.15�. ..................................................................... Q GASINSPECTOR Check# fp Division of Professional Licensure: License Search Page 1 of 1 i The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ....................................................................................................................................................................................................................................................... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:ADAM C. HOLMES REFERENCES& HAVERHILL,MA RELATED INFO NEW SEARCH Disclaimer Regarding **This Licensee has additional Licenses,click here to view them... Website License Searches _. Glossary of License Status Codes Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER More... License Number: 15685 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 3/18/2010 Exam Date: 3/18/2010 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday,February 17,2015 at 10:06:50 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=PL&type class=_M&li... 2/17/2015 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _y_ -'`''� __ r "( MA DA ERMiT# JOBSITEADDRESS[ Ir NER'SNAME �- OWNER ADDRESS TPPWT OCCUPANCY TYPE COMMERCIAL�J EDUCATIONAL RESIDENTIAL CLEARLY ° NEW.Ej RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z _ FLOORS-- BSM 1 2 3 4 5 ti 7 8 9 10 11 12 13 14 BOILER =- —j BOOSTER J= CONVERSION BURNER COOK STOVE __J IF DIRECT VENT HEATER DRYER —J _ _ :I� ��"I� -# Ty.tii FIREPLACE FRYOLATOR FURNACE GENERATORs#(.: _1 _ 1 GRILLE INFRARED HEATER — __ Y—.J LABORATORY COCKS _—!� I _..:,I •__-� _ __�J —��1 C; fi_ _1 �i ^ _ l __.J �J .:�r_# MAKEUP AIR UNIT __( OVEN �- _ " --- - i —sem _ s POOL HEATER ROOM/SPACE HEATER - __s_J ROOF TOP UNIT TEST _ w UNIT HEATER UNVENTED ROOM HEATER U1 TER HEATER OTHER _,.. V_ -1 -. J[-- # •.._- �. ,-�-- ------------I L-1 I --A= INSURANCE COVERAGE -- i 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 THE TYPE OF COVER/11Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1j, OTHER TYPE 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 Ll AGENT r SIGNATURE OF OWNER OR AGENT I hereby-certify that all of the details and Information I have submitted or entered regarding this application are a nd accurate to the b t of my kno%vledge and that all plumbing%York and Installations performed under the permit issued for this application will be in corn is'ce with ail Parti nt rgviplonoftha Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME I LICENSE# _ SIGNATURE 1!OP��! I MGF I JP JGF LPGI© CORPORATION[3#[=PARTNERSHIPL1## � -__ LLC COMPANY NAME: - �_ ADDRESS --_( -_ -5 _ jCITY -_j STATEiP TEL FAX - ELL � _ IL e ti,,,.i �� I i L f a ' COMMONWEALTH OF MASS ACHUS TTS aLLMBEZS' !ND GAa;f;:;I ffll�S ' i Stiil: S 3'HE F�1LLO�lI ' L 1`CENSE .. i L I EtJSE 'Ate A JOURNEYMAN�LUMBIER ♦1. I!Z `6 RUTH C1CLE S 'a 010 832-8 fo 4O:: OMMONWEALTH OF MASS, HUSETTS,,,~� • •... •. PLUMBEF'v::::: ND G;�SI:T`T.::::<'<>;;''' d. ISSUE; THE FOLL ER$ '' OWfN LICENSE +' LtOENSFt AS < P� .: : STER ir HOLMEs � f 6 RUTH lA VE R H ILL >:::: r' MA 01832-`1��,�::::.;< 1ti � 0 :J4,Tb ?x+24 4 Date 1/?�//�.......... 7 TOWN OF NORTH ANDOVER „ PERMIT FOR PLUMBING gs�c►as� Thiscertifies that... ......... ... ........L. .............................................................. has permission to perform....���.!'r.Sly✓...�j.°-� ............................................... plumbingin the buildings of.........................:.................................................................. at...1.k A ,! ...............................................i... North Andover, Mass. Fee......................Lic. No. 6.4.4 .. .. . .. .. ... . . . ................................... f PLUMBING INSPECTOR Check#�1a� l/ r s l Date........X.21.,(./.�....................... r F N°FIT), TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �8,+causs This certifies that f( � Hv�........................... ............................. ....:. has permission for gas installation ...4.. ................................. k in the,buildings of....................................................... . at..A.:� �!�.-e�d....I ;...K. ....................................... Notthh Andover, Mass. Fee....................... Lic. No. .A%—..,fir... -... ... '/................................... 1 GAS INSPECTOR Check# 1' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY fit _ j� _ MA DATE +_ ( PERMIT# JOBSITE ADDRESS . OWNER'S NAME _ POWNER ADDRESS 71 oe I TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NOFI FIXTURES Z 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 GASIOILISAND SYSTEM _-_ € _ I ,__- t _. __ I __J1.__.__- DEDICATED GREASE SYSTEM -_...._E .-_.- —__f _I ___ 1 �_J ...____J __I _.... -( _ IL—._I DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM i _._.-_._.J. ____._I DISHWASHER _._t _...._._I ._... _I f J f .___. I i ._.._ .__-. I.= .._..._J I _.-..__I DRINKING FOUNTAIN __ Ii I FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ i f I. ......_._1 KITCHEN SINK LAVATORY _{ _—_J ._ I ---..-_-" _ f ! _._.__.l -__- ! ---_.__1 ROOF DRAIN =]_j--_._l _.__-_l ____f _.-.___f A__._._j1= _.__._- SHOWER STALL S',4RVICE/MOP SINK TOILET f . ( _._ _ I. I I i . _—I ------J J_j I ____j __.__ ( ___S URINAL _-f. ___J WASHING _..___ s ...._ .._•` ...___-....__( ..... .. ......_ L ......_._I WASHING MACHINE CONNECTION 4 i � WATER HEATER ALL TYPES s WATER PIPING OTHER ----------- ! .______l _�_I I I • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES S_WQ_.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 �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: OWNER0f, AGENT J[_ 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 accurat fie best of m kno hedge and that all plumbing work and installations performed under the permit issued for this application will be in compliant it Pert'-int p ovi ' the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _jILICENSE# SIGNA U E IVDP El JP E-31 CORPORATION # PARTNERSHIP 04 LLC COMPANY NAME ��- ; ADDRESS CITY i.2r STATE [ _ � E ZIP TEL FAX - CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION DOTES Yes No 3 0Arl THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES f I ' s t ' The Commonwealth of Massachusetts - - Department oflndustrialAccidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Cont°actors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmi'zationftdividual): .A.ddress: City/State/Zip: Phone M Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. F1 am a general contractor and 1 6. E]Now c6nstruction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.$ 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their ME]Electrical repairs or additions required.] 3.❑ 1 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.QRoofxepairs insurance re edemployees.[No workers' �' .] comp.insurance required.] 13.[J Other xAny applicant that checks box#1 must also fill out the section bel6w showing their workers'compensation policy information. i'Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam 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.#: Expiration Date: Job Site Address: 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 MOL e. 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 DIA for insurance coverage verification. X do hereby cert under the pains and penalties of perjury that the information provided above is true anti correct. Si�ature• Date: Phone#• 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 9: Information and Instructions Massachusetts General Laws chapter 152 requires an employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service o£another under any coiiixact of hire, express orimplied,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, hi 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. Anew affidavit must be filled out each e year.Where a homeowner 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 oflnvestigations 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 aid fax number: The . onuponwealthofM-0ssarhvsP#s Depart=lt Of fndusWal Accidmts Offtce QUIRVestigati'tons 6.0Q Wasb gtm Sixea TQ1,#617-727-4900 at 406 or 1-877-MASSAFF, Revised 5-26-05 Fax#617-727-7749 _WWW-Mass,gov7dia Irjnvvr%%0# .I Iv V I M I I vl%Ir I nrr 4wM 1 ww 1 vI%n r6.I%IrnI 1v rLw WI%IVI rtvIrIun Vv rw1%9% CITYDO0MA DATE I PERMIT# ' $ JOBSITE ADDRESS ` e �� OWNER'S NAME e �tffk!S POWNER ADDRESS�� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY . ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES e WATER PIPING OTHER INSURANCE COVERAGE: I 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 TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicatio are rue and accurate the,best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be c pliance with al rt ndnt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAME 1 C (r) S LICENSE# I s�qb� SIGNATURE MP JP�� CORPORATION❑# PARTNERSHIP❑# LLC❑# Hol me L. s COMPANY NAME Plumbing& Hpatit ---- ADDRESS Circle CITY Haverhi . MA 018STATE ZIP TEL D FAX CELL EMAIL j"66--l—ee-XS da �(� ,5 f b C I i P7 �� Date./t',/.Y.`7. ?.. . .. . NORTH 32 '` TOWN OF NORTH ANDOVER O D `� " PERMIT FOR GAS INSTALLATION �9SSACNUSEt This certifies that . . . l Ly.'.:.! . . . .���.l�. . . . . . . . . . . . . . . has permission for gas installation . . U.& . . . . . . . . . . . . . . . . . . . in the buildings o(. . !�4A�.4'. !�5.'�-. . . . .`. . . . . . . . . . . . . at /1 7 . .j.it .(I JA L . . . . . . . . . . . . .. North Andover, Mass. . Fee. . . Lic. No. . L.>. 3. . / .f . . . . . . . AS INSPECTOR Check# 6196 i MASSACHUSETTS UNIFORM APPUCATON FOR PERMiT TOM GAS G (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations ���j (' - - Permit#••ice Amount$ Yi'sr- Owner's Name New Renovation ❑ ReplacementPlans Submitted � a w v�' U U a a F FO UO F a O W Q a z z O F w w a z u w x z a p x >Z 1z w w v, ., d x a a w w F A F x z w > w a > m zz o z W o x x O x 3 A a Ov a° > A a F O SU B-BASEM ENT BASEM ENT 1ST. FLOOR I 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR —[MI 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR /111L4 (Print or type) Che k one: Certificate Installing Company Name Corp. Address Partner. usmess I eleplione C o. Name of Licensed Plumber or Gas Fitter ' INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes D No If you have checked yes,please Indic fie type coverage by checking the appropriate box. Liability insurance policy Et Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: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 performed under Pe 'ssued for this appl' ati II be in compliance with all pertinent provisions of the Massachusetts State Gas Code d a r 142 o G er By: S' ure of Licensed Plumber Or Gas Fitter Title LrPlumber City/Town aas Fitter (cense um er 1-1 Master APPROVED(OFFICE USE ONLY) Heyman Date..!o ........ -7 4, TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSACHUS This certifies that ....... ........... .................................... has permission to perform . .......... . .. ....... ................................ wiring in the building of...... .......... at... .......Y'r-4--e, North Andover,Mass. ............................................. ...... Fee?d..............0................ Lic.No.FIV . C.�.IA" ............ ELECTRICAL INSP` ACTO Check # 6 67 Li Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 05/26/2006 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) 16 Fieldstone Owner or Tenant Wood Ridge Homes Telephone No. 978-423-7867 Owner's Address 10 Wood Ridge Drive,North Andover,MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box) Purpose of Building Residence 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: Replaced romex feed for bathroom power Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- Elo.o mergency ig mg 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 g Heat Pump J.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 Kms, Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 X BOND ❑ OTHER ❑ (Specify:) (Expiration Date) 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. 1 certify,under the pains and penalties of perjury,that the information on this ap If ation is true and complete. FIRM NAME: Landers Electrical Co.,Inc. LIC.NO.: A5912 Licensee: Terrence J.Landers,Vice-President Signatur LIC.NO.: 9743 (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.: 978-686-3828 Address: 1000 Osgood Street,North Andover,MA 01845 Alt.Tel.No.: 978-686-3829 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. $2 0.00 �� �;� a ^ G Date.-' "d ?. "O RT: TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SgACMUSE� This certifies that '" -r . . ?. ?. . . . . . . . . . . . . . . . . . . has permission to perform . -:L . ,a .,.. `'a"'. . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . at. .,� . . .l"t. .P -P•.. ,n . f. . . .`North Andover, Mass. - Feer rS'o Lic. NA �,._... . . . . . . . . . . . G PLU4817G INSPECTOR Check # --f-- 6826 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS -n Date ©�o Building Location p �(1r Owners Name ermit CA Amount ,�7•��� Type of Occupancy New Renovation Replacement plans Submitted Yes ❑ No FIXTURES > PC o w x a o Cr Cn Qw a p4 A A A Z z W� W � a ..�s q-�-p•,ti,- H � d A Q a � F ST &HW RASEVINT IST:FIjOOt M FMOR 3M RfM 4IH)FLOOR M FL" 6TH HDM 7M FIOM SIH HJOOR (Print or type) Check one: Certificate Installing Company Name41.'14ve- Corp. Address C Partner. Business Telephone Name of Licensed Plumber: Insurance Coverage: Indicate the t of insurance coverage by checking the appropriate box: Liability insurance policy El--�-- Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(orrt in ove application are t d ac rate to the best of my knowledge and that all plumbing work and installations pe Pe ss e or thi licati n will be in compliance with all pertinent provisions of the Massachusetts S 1 Code d C r142 th eral Laws. By: Signature ot Licenscaum er Ty e ofPlumbing License Title City/TownRO1cense um er Master ❑ Journeyman APPROVED(OFFICE USE ONLY Date. � �. .`. . . HaRTM 'O ,ti TOWN OF NORTH ANDOVER Of '• 0 - p PERMIT FOR PLUMBING ,SSACNUSf This certifies that . . .1. q !.F . . PJ.. . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . .{,.C. .l- . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . �.`:`.'. J .k.! .� :. . . . . . . . . . . . . . at . . ..... . . . . . . . . . . . . North Andover, Mass. Fee. Lic. No../. . . . . . . . . . .c.f r j. --�. . . . . . . . PLUMBING INSPECTOR /Check # ` 6$91 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS � Date BuildingLocation Owners Name W A6y3ermit# � _ �n Amount Type of Occupancy New Renovation 0 Replacement Plans Submitted Yes No 1-3 FIXTURES N z Cr o � w wz z z V W O d wa z a z ¢ a a a Z E, A C U W SLR» pA Y i�-s1Ai N SE HIM mHf= i 3M HDyf] wui 11]lJl.3l SM HDM 6M 111Jl.lil 7I HiM gf wm n (Print or type) C❑heck nCertificate Installing CompanyName Corp. Address Partner. VVX mess Telephone irm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate th ype of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the andrsi ned have been made aware that the g licensee of this application does not have any one of the above three insurance Signature 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 perfqqnedd under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus Its State Plu e an hapter 142 of the General Laws. By: igna ur 1cense RumDer Title T e of Plumbing License City/Townis nse Mumt) Master Journeyman APPROVED(OFFICE USE ONLY El Date..7/4-/.. . . . . ... .. NORTH Of'-to 16, or TOWN OF NORTH ANDOVER 41 PERMIT FOR GAS INSTALLATION SACHU5ES ` This certifies that . . . 4 .�. . . . . ` . . . . . . . . . . . . . . . . . has permission for gas installation . .i 4 I-f. . . . . . . . . . . . . . . . . . . . Nin the buildings of . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . .. North Andover, Mass. Fee. ./1.. . . . Lic. No..�1. GA6,NSPECTOR � Check# � ) / 54 '5 uASSACUSEM UNIFORM APPUCATON FOR PERM TO DO GAS FiT wG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations�© r -p - �I 'g l Permit# �J/ Amount Owner's Name New Renovation Replace mentum/ Plans Submitted ❑ H O C OCG ; F GF y F C o� 0 a 3 A t�7 o a 40.. H o SUB -BASEM ENT BASEM ENT IST. FLOOR 2ND . FLOOR 3RD . FLOOR t 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or ty* Ch*one: Certificate Installing Company Name ' Corp. :address� t�l �� p Partner. L Business Telephone I _ 1 Firm/Co. Name of Licensed Plumber or Gas Fitter ��^ �/, D VL i LA) 1 INSURAINCE COVERAGE Check one• I have a current liability Insurance policy or it's substantial equivalent. Yes NoD If you have checked yes,pie se indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 11 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 erformed under Permit Issued for this application will be in _�:mpliance with ail pertinent provisions of the Massachusetts Sta G s ode and nd�pter 142 of the General Laws. rill Signature of Licensed Plumber Or Gas Fitter By. Title Plumber Z / CitwlTown Gas Fitteric��nse, uQ mvr rM Master APPROVED OFFICE cse CNLYi luurneyman O Date .�. . . . . . + TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING ,SSACMUSE� This certifies that . ... . .� L1: . . . ..• • . . .. . . . . • • • . • • has permission to perform .. - -!- -. . , . . . . . . . . plumbing�i, the buildings of J.. .. . . . .�1` . . • . . . p at ®. . . . -- . . . . . . .. North Andover, Mass. Fee. . . . .'. . .Lic. Nola 9P . ,t�[-r. . . . . . . . . . . . . PLUMBING INSPECTOR Check # 6747 r A%ACHUSETIN UNIFORM APPUCATON FOR PERM TO DO GAS FfTI'NG (Type or print) Date (p NORTH ANDOVER,) � MASSACHUSETTS /� / r� Building Locations 1`` t (u s���` 4- l 4 Permit# Amount.$ �4H', v(9 Owner's Name New D Renovation ❑ ReplacementPlans Submitted U z o Hz ca t" a. 004 41 P4 pp�� CW G zF F 0 �t Qj a o 3 A o a a o SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print r r'1 ' �/f n �J C e one: Certificate Installing Company Name Lj Corp. Address �� `� � "��" s - '75 E] Partner. usiness Telephone C _ F' Co. Licensed Plumber or Gas Fitter Name of a N INSURANCE COVERAGE Chec o 1 I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes,plea e' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 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 installationrfor By: med under Permit Issued for this application will be in ne compliance with all pertinent provisions of the Massachusetts Sta s ode and Chapter 142 of the General Laws. Signature of Licensed Plumber Or G Fi ter Title Plumber City/Town Gas Fitter License Numer Master APPROVED(OFFICE USE ONLY) Journeyman Date. . NORTI, �? <� "„•.�"o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SACNUS� I This certifies that . . . l. . ! /. . . . . has permission to perform plumbing in, he b ildings of �.L � . . .�! l(�T at,!/� '. ... . . . . . ... 7� .4 ., North,Andover, Nass. Fee •. . . .Lic. NoA,,v—.3. / PLUMBING INSPECTOR,/ Check # ' 6391 MASSACHUSETTS UNIFORM APP ICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS c� Date �d J Building Location/)'i CXR Owners Name / Q Permit# Amount Type of Occupancy New Renovation Replacement0 Plans Submitted Yes11No ❑ FULTURES AREM &S94 M' EE HDM ZD RDM �FIDQt 4IIi 1GID[R 5M HJ" sIH 1HIOCR 7M FLOM gmHf= (Print or type) Check one: Certificate Installing Company Name / Corp. Addr ss 7 �� � 5 ��� Partner. 1 v Business Telephone Frm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy fri Other type of indemnity ❑ Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner ❑ Agent I hereby certify that all of the details and informatiqIubmitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing workons rformed under P 't Issued for this application will be in compliance with all pertinent provisions of the Plu 'ng o d Chapter 142 of the General Laws. By: SignaE re of Ocenseam Type of Plumbing License Title -2Y/ 3 1 City/Town Icensenumver Master Joumeyman APPROVED(OFFICE USE ONLY 1 ✓� Date. . . . . . . . t c'<HO°T�,�p TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUS� This certifies that has permission to perform ( t plumbing i/.n'theb�u"ildi gs of, �.t//� [.r .`. .. !.( ..r � _ ; North Andover, Mass. Fe&-, ) .Lic. No., 1 313. PLUMBING INSPECTOR Check # 6390 MASSACHUSETTS UNIFORM APLIGATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date �' o�Sr—`c)Building Locatio C:b Owners aZe � / 0 Permit# Amount Type of Occupancy New 1:1 Renovation 13 Replacement Plans Submitted Yes No ❑ FIXTURES ad SLSBavIC B�,�v>avr 1S1l:1�ID(R ant>�1xR �MHOOR 4M KjOa t 5MROOR 6MHB t 7M HJ" gm Hfm (Print or type) Check one: Certificate Installing Company Name / '-� ❑ Corp. Address -2 Partner. �1i�221�r'l m>9.�5 o>83a usmess a ep one ,�� , O/ / Firm/Co. i i Name of Licensed Plumber: �(//1j �tj/LSo Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: r Liability insurance policy Other type of indemnity D Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner Agent I hereby certify that all of the details and information I ubmitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing wo�sachuse install 'ons rformed under P t Issued for this application will be in compliance with all pertinent provisions of the s S Plu ng o nd Chapter 142 of the General Laws. By: Signature or License Title Type of Plumbing License �3 City/Town cense NumDer Master Journeyman APPROVED(OFFICE USE ONLY Date4/e. �:-.� NORM h TOWN OF NORTH ANDOVER o 40 _ PERMIT FOR PLUMBING 40 SSACNUS� This certifies that . . . Gi: /!" 1. . .! /!L. . ./ . has permission to perform . �t �! l� : % �!!;!�� . . , . . plumbing in he buildings of � / �j.�/. s4 0/ . . . . . . . . �, ... /. . ., North Andover, Mass. Lic. No...,:2,/,.5 / . . :% t • if p'j. PLUMBING INSPECTORwt Check # (I(i{' 6389 MASSACHUSETTS UNIFO APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS 1 Date � Building Locatio Gb �wn rs Name / Q Permit# Type of� ccupancy Amount New 0 Renovation 1:1 Replacement F Plans Submitted Yes ❑ No ❑ FIXTURES R4SEU M' >1S)C HOM �t FIDQt 4]HBDM 5MHDM 7M HDM SmHDM (Print or type) Check one: Certificate Installing Company 'TLInk ❑ Corp. Addrgss �� � s El Partner. � 0.)&2c;2 Business Telephone Iq Firm/Co. Name of Licensed Plumber: Wil///� Gey/LSOrI Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity D Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner ❑ Agent 11 I hereby certify that all of the details and information I ubmitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work install 'ons rformed under P t Issued for this application will be in compliance with all pertinent provisions of the sachuse s S Plu ng o nd Chapter 142 of the General Laws. By: Signo ens Type of Plumbing License Title 6 City/Town ` icense NumoerMaster D Journeyman APPROVED(OFFICE USE ONLY " Date..... .Q.`�... �aOdT1i °f' °:•�" TOWN OF NORTH ANDOVER .- PERMIT FOR WIRING C •D1�TID��`1' ,SSACHUSES This c..ertifies that ... ... has permission to perform `!Pcf f J1 wiring in the building of....... at.. {!/.:�.P.��...��....�:. .......... orth A�ndove�r,�MaSs. Fee... ........... Lic.No.�. .` �/1.... „zr .�;�T...�' ��.......... ELECTRICAL INSPECTOR r Check # I� ! 4984 C ommonwea(1/r o�/C/aadae/eud¢1� Oficial Usc Or ly i ('I cc'� cc77 Permit.No. ' ..LJ¢ParEm¢nr`o�,}iro �orvica� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ` Rev. 11/99] {leave blank) APPLICATION � FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be perl'ormed in accordance with the assachusetts Electrical Code(l•IEC),527 Chltt I?,t)0 (PLE.ISE PRINT IN INK OR TYPE.,ILL INFOR.Ibl TJ N) City or'1'own llalo: /9-01-/ of: �/o �gyJo e;e To Me Inspector of i•Vires: By this application the undersigned gives notice of l►is r her intention to perform the electrical work described below. Location (Stree( & Number) /9 �Sy"©�,� Owner or Tenant Woo ©r'�7C' T�/clepltonc No. Owner's Address Is this permit in conjunction with a b p )'eS No uildinermit? ,/ ,,t ❑ '(Check Appropriate Box) Purlins.of Building �s Utility Authorization No. Existing Service r\nips / Volts Overhead ❑ Undgrd ❑ No,of Meters'. New Service Amps / Volts Overhead❑ Undgrd ❑ No.of itiIeters: Number of Feeders and Ampacity ` Location and Nature of Proposer] Electrical 1York: j��' �G7f r�•� &/1 Com lesion of the folbneine table njoy be iraived b•the Ins'cctor o�lVires. No. of Recessed Fixtures No.of Ceil:Susp.(Paddle)Falls t °• ° ota Transformers KVA No.of Lighting Outlets No.of Ilut Tubs Generators KVA No.of Lighting Fissures Swimming Pool A Jove ❑ In- ❑ t o.o mergency tg t utg rnd. rnd. Baste Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARr1IS No.of Zones No.of Switches No.of Gas Burners r o.o election an Initiating Devices es Ai ? No. of Rnnvi'otal — b No.of r Cond. Tons No.of Alerting Devices No. of Waste Disposers !TZT2!E� KVV-- o.o e - onta..c Detectiott/A(ertin Devices No.of Dishiti ashers Space/Area Heating K%V Local❑ untetpa ❑ Other No.of Dryers Connection Heating Appliances KW Fr ty Systems: No. of Nater .of Devices or E uivalent t`l o.n hIeaters KW Sins Ballasts iringNo.H}'dromassage Bathtubs No.of�(olors Ofllev(ccs or E ulvalettt Total hIP mmunuattons Irutg: OTHER: ivo.of llevices or E uivalent INSUR NCE COVERAGE: Unless waived by the owner,tnoladditional permit for tile Performance of electrical work may issuejWl ss. the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The ss undersigncd certifies that such coverage is in force,and has exhibited proof of same 1lc permit issuing office. CHECK ONE: INSURANCE X BOND ❑ 0-11-113110 (Specify: Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Wort: to Start: f,/2— ©1/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, «ndc4•the iris and penalties of perjury, lint the ittrarmadorr ori tlris a 1pliea11 1 is trite and complete IrII01 NAI I Licensee: LIC.NO.: -W Signature�.� �_ (If applica a n(cr flip r 11171'c nse ttrauber lire i LIC.NO. ('S' b Address: ��` �� OtiVNER'S INSUKA,NCE WAIVER. I am aware that the Licensee docs not have the— liability�t�i su ince coverage normally. required by law. By my signature below,I hereby waive this requirerrtcnt. I am the(check one)❑owner El owneragent. grrtt. Owner/Anent Signature 'Telephone No. JPi;RM-IT gmr s re Location No. _ �� Date NORTITOWN OF NORTH ANDOVER F 9 . i Certificate of Occupancy $ cMuBuilding/Frame/Frame Permit Fee $ s� se 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ���" r✓ Check # i676 � �"� r-, Building Insp or The Commonwealth of Massachusetts State Board of Building Regulations and . TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code 780 CMR APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OF OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number. . Date Issued: o�a 'l 9 -acl -a00-3 Signature: 7z�— Building Commissioner to of Buildings Date (� , SECTION 1-SrrE INFORMATION 1.1 Property Address: n 1.2 Assessors Map and Paroel Number- Map umberMap Number C�,3 Parcel Numbs 1.3 ZoninY Iofmistioa 1.4 Property Dimensions: Lot Area(sq) Fromar(8) Zarin Diatrid Use 1.6 Building Setback 1 Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided 107 wa Qsupply 9M.O.L.C.40.4§34i 1.5. Flood Zoos Lrfarnatioo 1.9 sewerage Disposal System: — Publk Private o Zen° Outside Flood Zane Q Municipal Q On site Disposal System 2.1 Owner of Record (4)00,�C 0 Name(Print) Address:. 10 wnoALsrt d Q 12 c� t/e/ Signature Telephone 4,� Iv82 704 3 CA) 2.2 Authorized Ag F t4 a (31 d r _' Name(Pent �v�l a Address 3 W t-1 fi a nIS k4 u) (a v,.�"A Signature Telephone p (O Z SECTION 3 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN XODO CUBIC FEET OF ENCLOSED SPACE 3.1 Licensed Construction Supervisor. Not Applicable Q :Tok V1 1 Licensed Construction Supervisor-, License Number Addd 33��3 1e ( 1 (l Q w1 S ied 10 �l t� Expiration Date S 2� Signature Telephone q 2 C7 3.2 Registered Hoge eme�nt Cog�raCtor:�� Not Applicable Q Company Name Registration Number O l Address Expiration Date l 50 to 2-0 Signature Telephone Rcvised 1997 JMC SECTION 6-DESCRIPTION OF PROPOSED WORK check all livable New Construction Q I Existing Building Repairs U Alterations Addition 13 Accessory Bldg. E3 I Demolition I Other 0 Specify Brief Description of Proposed: S T > n s. q- SECTION 7-USE GROUP AND CONSTRUCTION TYPE USE GROUP Check asapplicable) CONSTRUCTION TYPE A Assembly A-1 A-2 A-3 IA Q A4 A-5 1B O B Business 13 2A Q E Educational (3 2B F Facto 13 F-1 F-2 2C Q H High Hazard 0 3A Q I Institutional (] I-1 I-2 I-3 3B E3 M Mercantile 4 R Residential 13 R-1 R-2 R-3 5A Q S Storage E3 S-1 S-2 5B Q U Utility Q Specify: M Mixed Use 0 Specify: S Special 1 E3 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 SECTION 8-Building Height and Area BUILDING AREA Existing ifapplicable) Proposed Number of Floors or stories include basement levels Floor Area per Floor Total Area Total Height ft SECTION 9-STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural EngineeringStructural Peer Review Re uired Yes Q No Q SECTION 10a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, ,As Owner of subject property hereby authori -77 , &)M7-154-5-154-5 IZ-n C . to act on my behalf,in all matters relative to work authorized 6y this building permit application. Signature of Owner Date revised bldg form/state JMC SECTION l Ob-OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date SECTION 11 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to Official Use Only be completed b permit applicant 1. Building (a) Building Permit Fee Multi Tier 2. Electrical (b) Estimated Total Cost of 6 Construction from 6 �1 3. Plumbing Building Permit Fee(a)x(b) DO 4. Mechanical AC 5. Fire Protection 6. Total= 1+2+3+4+5 Check Number �i� i��om�nooaeecr�!/� ✓�aaaa�uaelta n ' 6Q A QF 9.0 i {{Ilacense: CONSTRUCTION SUPERVISOR 1' NumbR 033843 1955 i S•i;• i• Tr.no: 19350 r JOHN T HAFFE <; 3 WILLIAMS WAYLAND, MA 01 -�•„� Admfnistrstor x. r Board of-Building Regulations and Standards x = One Ashburton Place - Room 1301 i i Boston_ Massachusetts 02108 f Home Improvement Contractor Registration t Registration: 108945 Type: Private Corporation Expiration: 8/27/2004 J. T. HAFFEY BUILDERS John Haffey 3 Williams Rd - ---- - -- -- ------ -- ---------- --- Wayland, MA 01778 — Update Address and return card. Mark reason for change. # F' Address !—! Renewal Employment Lost Card s Board of Building Regulations and Standards� License or registration valid for indiyidul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: M1�:> Board of Building Regulations and Standards Registration: 108945 One Ashburton Place Rm 1301 Expiration: 8/27/2004 Boston,Ma.02108 Type: Private Corporation J. T. HAFFEY BUILDERS John Haffey 3 Williams Rd _� i Wayland, MA 01778 Administrator \•ot valid without signature SECTION 4 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.r.152 §2SC(6)J 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 S- PROFFESSIONAL DESIGN AND CONSTRUCTIOR SERVICES-FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 3 000 C.F.OF ENCLOSED SPA 5.1 Registered Architect: No Applicable Name(Registrant): Address Registration Number Expiration Date Signature Telephone 5.2 Registered professional Engineer(s) Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name): Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone Name Area of Responsibility Address Registration Number Expiration Date Signature Telephone 5.3 Geneml Contractor Not Applicable Company Name: Responsible ' spo m Charge of Construction Address Signature Telephone ,1 1 .The Commonwealfh,t�f,� t�aY��sa�fw.setts Department of lents Office of lnvesfigatlons 600 Was ` Boston, Mass. 02111 Workers' Compensation Insurance Affidavit S , Name: {,(�•©odz rt e Nm�eS Location: 10` h 9©od R L coq e_ City: iy o rt-tn A vtd.a ve - MA Dhone# ❑ I am a homeowner performing all work myself, ❑ I am sole proprietor and have no one working in any capacity I am an employer providing'workers'compensation for my employees working on this Job. Company name: f —i H o'�L4 bur(dam T-1 c— Address: 4 3 Ujl l u int% i24 City: (CIL. rYtt� l'I Z phone# SCC S Co 242`1 l k0 8 Insurance co. � Q policy# W G(92 �, r 3 F o 2xio i 2—+s'-0 ❑ I am sole proprietor, general contractor,or homeowner,(circle one)and have hired the contractors listed below who have the following workers'compensation policies: Company name: Address: City: Dhone# Insurance co. policy# Company name: Address: '+ City: phorfe# Insurance co. ', policy# Failure to secure coverage as.;G OR0.0.undef Section.;..SA of M(3L'142 cat!le d;to'th4: !?P, iVon of criminal penaltles`of a fine up to$1,500.00 and/or one years Imprisonment as well as:clvil penalties In the form of a STOP WORK ORD snd,a flrta�of$100.00 @ day against me. I understand that at copy of this statement may be forwarded to the'Office of Investigations of the DIA for,covera0e verification. I do hereby certify under the palm and penalties of pedury that the lnformatlo i;povlded above is true and correct. Signature Date Print name ;..Phone#-- .0 2 .0 Z� `l l l0 8 Official use only dpot write In this area to be completed bclky ofvlm official . City or town: loemtlt/license# ❑Building Department ,. ,4^�k.+ ; •� Licensing.Board poheck if immediate response is required Selectmen's Office, Q Health Department poptact person: one. : Other r,ft, }:. :`:,�7. .�71•.i�!.. .. ..,.,.. ..:': „a �t��i. ......�;7a ri.i:. :. .,.....•.L'.,.tY..:��-ni:,1t..�t.�w "Fi ��:4t.f.:r.r-. :ykr .'Lt"%irjph�l. it r xta A'.,ih'4i iYr}k,..!\• "::, I:,i.,�?r l�:�;�'76' North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: I a uy-)-tcw-), M et s s — �11�•,� s po s0. (Location of Facility) Signature of Permit Applicant Date • NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector AORTH Town of Andover . to No. o?,; O L AO dover, Mass., q-a q A- COCMIC M��WICK �oRAT E D P P�t�y `l H ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT W".0 ............................... ......... Foundation.14m!s COOP.!........ rt has permission to erect��P N0'......... 4) p ........... buildings on I ....... Rough to be occupied as.... l O W 5�.. 0 0�/ Chimney ............................................. provided that the person accepting this permit shall in every respect conform to the term of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating t the Inspection, Alteration and Construction of Buildings in the Town of North Andover. .2,3/r) 10 vd) � PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARS ELECTRICAL INSPECTOR ♦ Rough . ..........A... .... ...... .. ...... Service Ac 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 REVERSE SIDE Smoke Det.