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HomeMy WebLinkAboutMiscellaneous - 11 WOODLEA ROAD 4/30/2018Vi J TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that Z�-n....4- ....... has permission to performzzz ....� .............. r....... wiring in the building of at.(...s���...................Q'r North Andover M s. Fee ..... Lic. No... 0..�..j.. ............ K.. iLCAL Check #IS;�!X 107916 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the ;} permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall_be limited as to the time of.ongoing construction activity, and may be_deemed-by-the,Inspector-of _Wires abandoned_and-invalid-iflme—.. _ or she has determined that the authorized work has not commences ,m, has nit 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 extendingUrough August 15, 2012. ule 8 — Permit/Date Closed: Note: Reapply for new perm i 0 Permit Extension Act —Per i ateClosed: Commonwealth of Massachusetts De partment of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Onnnll Permit No. / d Occupancy and Fee Checked [Rev. 1/07] (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 (PL EASE PRINTIN.INKOR TYPEALL NFORMATION) Date: JQ? %r-L�,, City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice ofps or her intention to perform the electrical work described below. Location (Street & Number) /% Ll>twNi 1p& x2 2 Owner or Tenant 4,I., If NJ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building /_ No ❑ (Check Appropriate Box) # 691® Utility Authorization No. Existing Service Yee) Amps IIZQ12 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: Recessed Luminaires Completion o the ollowin table maybe waived b the IBLector o Wires. No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA Luminaire Outlets No. of Hot Tubs Generators KVA Luminaires Swimming Pool Above ❑ In- rnd. rnd. ❑ o. o Emergency Lighting Batter Units Receptacle Outlets 3 No. of OR Burners FJRE ALARMS No. of Zones onael Switches No. of Gas Burners No. of Detection and Initiatin Devices Ranges No. of Air Cond. TonsTotal No, of Alerting Devices Waste Disposers Heat Pump Number Totals: Tonsµ KWNo. "' """""""' ofSelf-Contained Detection/Alertin Devices Dishwashers Space/Area Heating KW Local❑Municipal ❑Other Connection ryers .oatero. Heaters KW Heating Appliances jar No. S* Bal as Si s Ballasts Security Systems:*. No. ofDevices or Equivalent Data Wiring: No. ofDevices orE uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent / OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value ofElectrical Work: `�� . °O (When required by municipal policy,) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C ERAGE: 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 exhibitedroof of same to th p permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) /i�e v4I A C_j_ `sob � I certify, under the ins andpenaltaes ofperjnr t .at the information on this application is true and conzplfete FIRM NAME: $ Q(G LTC. NO.: Licensee: Signatu LIC. NO.: 30SI (Ifapplicable enter exe pt' i e license ember 'ne.) 0 us. Tel. No.-,, 0�2 5 Address: �� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of ub is Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ ow is uent. Owner/Agent Signature . Telephone No. PERMIT FEE: $ . �/li r' .- .�+J.�JL1�dJlt{.� �{����•i�-yv-Jy(.-,���-Lf/1":R��ye•�•�®��p�j �i�('� •� J.l,`�F7J. �`U.K.n.�,l,�( A9Ji/3. �J•`.�� _ .nJ1UJL'.1 �-+.+.?6�-�Vl.•W .nJ.\�.R �•�V.f. ®.10. `•� • .. ._ � ' �_ r passed- �uspectors oxaxne�afs: ' (rug ectoxs' Signature , x o ii*s) Pate Ma� (Xnspectors'Pignature -):to inifials) Date U!tod DER G'GROTND )NSPXCTXO': rs' coxoments: (1nspectors' Signaf ire -• iso kifials) Pate 4. INSPECTION --S �C! CE: Failed— �specfbxs' eomine�is: NAM: . nspeedonrequired ($50.00) •• [ � (Xutsp ectors' Szgnatuxe - Bio Wtials) Bate �. INSPECTXON •- OTBER: $assed--• [ IX+aiied--[ ]. ?fie-iuspectzon xer�wixecl ($50.00) [ 7 aspectoxe cohmmts: -' (�.sp ecfors' Signstwre xto xnifials) lbafe • DC)OR TAGS .AM TO DE F'HT RD OUT AO MFT OX WE V THE.APXA. TO 3E INSPECTED 19 NOT A.CCESMEE.AND ARE -INSPECTION OF $50.00IN TOW, CHARGED. . 4 lcx The Commonwealth of Massachusetts Department of Industria[Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: X City/Slate/Zip: �f ic�x_)44 Phone #: Are you an employer? Check the appropriate box: 1.1�1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew 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. 11" ` ` Insurance Company Policy # or Self -ins. Lic. #: 0 Job Site Address: Expiration Date: City/State/Zip:_ _ /� c 7'N&L,f', A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify uWer the paing JCnd penalties of.Berjury that the information provided above is true and correct. 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Commonwealth of Massachusetts Department o#'Zndustriai Accidents, Office of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877�MASSAFB Revised 5-26-05 Fax # 61.7-727-7749 www.mass,govfdia 09933 IAORT Pate, of TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.. ................ has permission to perform ... ................... plumbing in the buildings of. . .................... at . A � Wot P �. �.. . . . , a v w�lfl ........ North An :) r, Mass. Fee�2.) Lic. No? -3/ -!-?*5 . . ce-l-ler ... ... PLUMBING INSPEgTOR Check # DateUR TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... ,. • „�i� has permission for gas installation .... ... ........... in the buildings of .. r��,�... ..... _ ..... . at ... .. y�� ........... North Andover, Mass. Fee .)'D 4 d,:3 . Lie. No.9 . C'' �% ... ... GAS INSPECTOR Check 8684 �'�� •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY�•4�.0 �wti _ MA DATE I = t " f 3 II PERMIT # JOBSITE ADDRESS 11 w�„�al , n'� _ OWNER'S NAME .u,"I rh "n1 ock,, OWNER ADDRESS S _ TEL[—_ FAX[ TYPE OR OCCUPANCY TYPE COMMERCIAL 01 EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: EI RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES[]I NOF APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _. { I--1 - 1. ._ - _ .. -_ __. _ 1 , . -_. — —_ DRYER �.. FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS l—_- MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNV'ENTED ROOM HEATER WATER HEATER OTHER F J _ I L f _ =1 _ I I I 7— 11 INSURANCE COVERAGE have liability insurance its the MGL. Ch. 142 YES ONO a current policy or substantial equivalent which meets requirements of IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY EA BOND E] 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 r_1 AGENT �{ SIGNATURE OF OWNER OR AGENT I, hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n �_ � C. PLUMBER-GASFITTER NAM �, H -L. ff,�.• • LICENSE #E::::]_ SIGNATURE MP El MGF El JP JGF D LPGI�_i COR—PO—RATION Q# PARTNERSHIP 0#= LLC M# COMPANY NAME: _f... s�-_� C. J'-,'Tk _ _,.. - -II ADDRESS 2-o r.tt+�.• w CITY {r 1,, ��ti --� STATEF;r t4 _. ZIP(TEL CQ o3 -4 s-4 - lb >r,' FAX CELL EMAIL HLODzz 0 H U a CC 4 w o El z 0 y❑ W OE-4 a ftz LU � 3 a W 5 IL uj w w w W N �d z a a a J a < �r � ui x w H LL H C) z z 0 H U W a Ln 4 U 6 c�7 ' a The Commonwealth of Massachusetts 07 Department of IndustrialAccidihts Office of Investigations 600 Washington Street Boston, MA 02111 UV www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): "(21_% S-- I I L, c�i� •:l �� �'� �' Address: 2 City/State/Zip: , ,,,1 o 3 Z' -Yr Phone #: Are you an employer? Check the appropriate box: Type of project (required): L ❑ 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 �• El 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 workingfor me in an capacity. Y p tY• workers' comp. insurance. 9. EJ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.[JOther comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ai-e 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. #: Expiration 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 MGL c. 132 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 herebypert jq under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: 6J 4J-4 d 7 5)' - Official )'- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # P-15 -1 > 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 shallnot because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigatlons 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFF Revised 5-26-05 Fax # 617-727-7749 _WWW-Mass,govldia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY /t7 , Z cv:� MA DATES -'1 1- 1 II PERMIT # JOBSITE ADDRESS OWNER'S NAME Ayii W1, �-`h.► P OWNER ADDRESS TEL -FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: F1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NODI FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM I I _.._._.J � __.._J (1 .___.J ___.__� -...------- DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN (_.__.._{ __._.J I __._..._J (f i .__.--- J k ___._..J .___._-_i _( .._._.. FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) (f .__..._.-i J _.._ i J ..____.I l _I ___A KITCHEN SINKl_-__— LAVATORY _( ► .._.___� ( ------ _..... J .:_..___I ___....J ROOF DRAIN SHOWER STALL._I SERVICE /MOP SINK �( --I_-�! ___-� _-^� ____! --- ----- �-.-._—( __.._._� _, TOILET URINAL WASH NG MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ -- ._( _ . i _ _1 ---- - ------ ( J _ ! (_-._.. _YJ OTHER (_...._. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _i AGENT �0 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���ccc ' ompliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z �— PLUMBER'S NAME i vts�u C, f;...;h _j LICENSE # T31 ; SIGNATURE VIP El JP CORPORATION Q# #L:=PARTNERSHIP 0_.( # LLC COMPANY NAME L . fes-, ;ADDRESS CITY /VcwS�+.�-`- - - STATE ZIP cy1ZS'� --� TEL FAX !CELL ! EMAIL (�SAtu,�.5_Q_'P7S H °z 0 H U W a rA4 91 w o� z ;04Z w ❑ W LU O W a- u u _ 3 ® a w ar IL W ® W co a p o a � w ¢ U .I IL a �r C/3 w x w 1- LL z z o H U W a r z z a P-1 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 uq.F�,! www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Nall (Business/Organization/Individual): Address: 23 City/State/Zip: /U 5��� /v4 Phone #: co 3 - -� s--1- 8 -) 4 .S'- - .re you an employer? Check the appropriate box: Type of project (required): ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* I am a sole proprietor or partner- have hired the sub -contractors 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 10. El Electrical repairs or additions required.] ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11TM Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.0 Roof repairs ins4ance required.] uit q ] employees. [No workers' Un Other comp. insurance required.] y applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. >meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rtractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n tcn employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Irmation. trance Company Name: icy # or. Self -ins. Lid. #: Expiration Date: Site Address: City/State/Zip: ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ,stigations of the DIA for insurance coverage verification. h ereby * under the pains and penalties of perjury that the information provided above is trice and correct. tature: -Z Date: 13 —1 t,1-,4514 ©-KN fficial use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License # ;suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other Information ion and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retuned 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 )f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. °lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant hat must submit multiple permitllicense applications in any given year, need only submit one affidavit indicating current 3olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or own)" 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 rear. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Tease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of lndustdal Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TAl 15:42 FAX J05/13/2013 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the 978 957 6612 COUGHLIN INSURANCE [a 001/001 zy, DATE(MM/DDrVVVV) CERTIFICATE OF LIABILITY INSURANCE 05/13/2013 THIS CERT'FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICA—C DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A GONTRAGT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Cf a les J Coughlin insurance 14 E inle Street R D Box 10 NAMEACT Colleen A Coughlin PNONE ea,l(978) 957-3588 IC No): 978-957-6612 ° aALE , colleen@coughlinins.cnm Dracut, MA 01626 INSURER(S) AFFORDING COVERAGE NAIC 0 INSURERA' Main Street America Assurance Company 29939 INSURER B: INSURED RLs'iell L. Smith INSURER C: 28 Fortune Lane Newbury, NH 03255 INSURER 0: INSURER E : MED EXP (Any one person) S 10.000 INSURER F: ,:LWS-MADE M OCCUR VVVCRNl7G•1 —1... —.—...... -- THIS IS TO 'ERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. tioTW7rHs AmDING,A-NY'REQUIREMEt3T, TER:!-3R-€ONMTI0N--OF.ANY CONTRACT -OR -OTHER DOCJIMEpT-0TH RESPECT_ TO WHICH THIS CERTIFICAT: MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSION i NND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I LT R TYPE OF INSURANCE KD—DL wvnSUBR POLICY NUMBER POLICYEFF LTR /YYYY /DD MM/DD/WYY LIMITS A _ GENERAC.IABILITY COMNERCIAL GENERAL LIABILITY MPT3992B 07/12/2012 07/12/2013 EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED 500,000 PREMISES Eaoccu enoe $ MED EXP (Any one person) S 10.000 ,:LWS-MADE M OCCUR PERSONAL!?, ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000.000 GEN'L AGC -R :GATE LIMIT APPLIES PER: PRODUCTS . COMP/OP AGG $ 2,000,000 $ POLICY PRO- LOC COMBINED SINGLE LIMIT AUTOMOB LIi LIABILITY Ea accident) BODILY INJURY (Per person) $ ANY /Ur0 BODILY INJURY (Per accident) $ ALL C VWNED SCHEDULED AUTCS AUTOS NONOWNEO HIREIIl.UTOS AUTOS PROPERTY DAMAGE $ er accide t $ UMBF.E.LA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCES!:LIAO CLAIMS -MADE $ DED I I RETENTION $ WORKERS CDMPENSATION AND EMPLD'ERS' LIABILITY YIN ANY PROP tli_TOR/PARTNER/EXECUTIVE WCSTATU- GTI+ R�' E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/A E dBER EXCLUDED? ❑ (Mandator, in NH) A NIA E.L. DISEASE- POLICY LIMIT $ Ifyes,des DESC'iteuE.6descnder RIPT ON OF OPERATIONS below DESCRIPTION OF C•PERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addttional Remarks Schedule, It more space Is required) Plumbing.& Hanting . rAwvcr r AXInM V77760-GUIV AA.VKU IrVRI'VRHIIV I7. Mn nynw rcoclvca. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TJwn of North Andover THE EXPIRATION DATE THEREOF, NOTICE ' WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ' V77760-GUIV AA.VKU IrVRI'VRHIIV I7. Mn nynw rcoclvca. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 9396 Date..! /2*/Z- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that IWXe�4 ............ ,&4/ has permission to perform ...... plumbing in the buildings of ..... . i ......................... ---c at ... -44:%0-q ........... .... P., No th Andovei, Mass. Lic. No. Fee.. 4 PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLIGATION FOR A PIERMIt TO PERIFORM PLUMBING WORK jr T -0-E-011 PRINT CLEARLY CITY M4 DATE q PERMIT It JOBSITEADDRESSI 0 Waa,—k(C4 AJMEJ OWNEWSNA j,'I [0 W 0 c OWNERADDRESS TEE IFAXI I OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL I RESIDENTIAL NEW: K RENOVAT00,4 REPLACEMENT:1 I PLANSgUBMITTED: YE81 I NO] I FIXTURES I FLOOR-' 13sM 1 2 3 4— 5 6 7 8 9. W 12 1311 � 14 BATHTUB CROSS CONNECTION DEVICE V DEDICA71 Eli 8RECIALWASTE VOTEM DEDICATED GASIOILISAND SYSTEM DEPIQATW GREASE SYSTEM 'DEDICATE 0 CRAY WATER SYSTEM DEDICATUMTER RECYCLE SYSTEM DISHWAtVLA DRINKINO FOUNTAIN 1 FOOD DISPOSER 1. i .."T. FLOORIAREADRAIN INTERCEPTOR (INTERIOR) i KITCHEN SINK LAVATORY v7--1 ROOF DRAIN SHOWER STALL SERACEIMOP SINK TOILET URINAL WASNING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING .,OTHER INSURANCE COVERAGE' 11have actil-rdnt. hsilmicO polis .or its subManlital.cquiValent vibich meets the f eqa.jrerfieh.ts of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGEBY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'81INSURANCEWAIVER: Iain aware that the liceiiseia.tibes not Piave ihe'liistiraiicecoveraDe required byCWptee142of the Massachusetts General taws, and that-o1y signature on t1fis permit application waives thisreqLdmpienf. .0tCK-ON09LY: OWNER I AGENT -1.1 SIGNATURE bFoWNFUP, AGENT I hereby certify lliat till of [lie details and ififormaVon I Itaveslub5illted otdnlered iegardlngjhis opplicalion are true and accurate to the best otmy knovitIddo.e, and that all plumbing work and Mlallallon .s performed under the permit Issued for this application W11 be' ompliancerAlh all Pertinent provision of (hd h1assachusells Mate 'Plumbing Code and Ghapl.e,r 142 of the General Laws. PLUMBER'S NAME L ILICENSE #1131" I SIGNATURE MPI I jP,;K1 CORPORATIONS jlti' jPARTNERSH.IPj' !Vl' LLC 10 COMPANY NAME JADDRESS I 29 CiTy I"' JSTATE J',VV4 )ZIP1. 03L� TEL FAX CELL EMAIL j'2LSPIor.,,3 U r r LU k U) to � V J Q. Q � LL! LU F— Le: ifI The Commonwealth of Massachusetts Department of Industriql Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/fndividual): LW-wk% Address: 2.00 City/State/Zip: N&w 6iti: (v4 oo Zsj' Phone #: SY -8 ?��r 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. F1 New construction employees (full and/or part-time).* have hired the sub -contractors ?• remodeling 2. I,�l I am a sole proprietor or partner- listed on the attached sheet. I 1 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. FJ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. F1 Electrical repairs or additions required.] officers have exercised their 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. ❑ Roof repairs insurance required.] t employees. [No workers' 13. [i Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that 1s providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. #: 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 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 certto under the pains andpenalties ofperjury that the information provided above is true and correct. z c,a� -`�'Z1- e7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -2)-1z 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 ofhire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for futurepermits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigation 600 Washington. Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877,MASSA.FB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dla • r ° 5 3 1 Date ...... /A TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ........ G_c✓2it ,- .Uj................ has permission to perform .......... .w ...... � Ute ............... ................. wiring in the building of C2 .� .'> ;' at .......4. �...... W ��1 .� (......!r�............ 10,, dover, Mass. Fee.A7,).,W.. Lic. No. 1.fWZ�............................................................... ELECTRICAL INSPECTOR c � *a,3c WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1i 011E &MIU011wrattlj of fflauladjUBEtto 1hpurtutcut of Public eafctu BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 ffice Use Only Pe Ott No. Occupancy &Fee Checked ����% do 3/90 (leave blank) 7111 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date � �� / q �8 City or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform //the electrical work described below. Location (Street & Number) �r>'�. '* // f�Jn���l�s� n C1 f`C \Q Owner or Tenant i 14r_214,? Owner's f7// -P Owner's Address -4'yn Is this permit in conjunction with q building permit: Yes p No ❑ (Check Appropriate Box) Purpose of Building S/ AA Tr, Z_ Wi KJ c. Utility Authorization No. gn 2 �9 Existing Service Amps —1 Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service ZOO Amps IZO / '—"10 Volts Overhead ❑ Undgrnd 9' No. of Meters 1� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- ❑ ❑ grnd. grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners - Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of Air Cond. Total tons Initiating Devices No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices LocalMunicipal ❑Other ❑ No. of Dryers Heating Devices KW Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Competed Operations Coverage or its substantial equivalent. YES NO ❑ 1 have submitted valid proof of same to the Office. YES f NO ❑ If you have checked YES, please indicate the type bF coverage by checking the appropriate box. INSURANCE 41 BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ _ Work to Start q- /S-- 5% Signed under the Penalties of perjury: FIRM N/ Licensee Address Inspection Date Requested: Rough I'd t (( C -,;,-(L Final OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Ow ' rte% Agent (Please check one) � ��� 4 %� `� Telephone No. PERMIT FEE U•1 (Signature of Owner or Agent) x•6565 Date.................................. L 3?0;t�`'°:°�"°°� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SSAv� This certifies that .... .... �`'.. ......... .................:� .... .:........................... has permission to perform ............................................... wiring in the building of ...:........................................ at ... .....''....,...................................... ....... . North Andover, Mass. "a �pFee ....:. .___ ELEcrmic,AL DasPE x r Check # 3 8.135 a--\ (ron,,,wnwraLCh o� �asdecchwaEfs Official Use Only c� Permit No. d`e3 4 _(JaParimatr� o�Ju't �arvicaJ ,�` �oa Occupancy and Fee Checked :U BOARD, OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) -- APPL.ICATI,ON FOR PERMIT TO PERFORM ELECTRICAL WORK ; All wor(C to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTNINKORTYPEALL INFOPjIIATION Date: %--6 City or Town of: i\J P J00VU` 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) \PJpaMINA k - Owner or Tenant K NLe-r- Lp0`kX hr Telephone No. 4 0(„_ Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No n (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts .-Overhead ❑ Undgrd ❑ No. efMeters New Service Amps / Volts Overhead ❑ Undgrd 0 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A. t a -Y, o eGu.r t d rF1 re- La: rrl r.... ..lonn.. nr,{,v fn//nwino mh/.- - ha wn%von h.• AP tnrnnrtnr n(Wiroc No. of Recessed Luminaires No. of Ceil: Susp.,(Paddle) Fans No. Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs .. Generators KVA No. of Luminaires Swimniino Pool -Above ❑ n- ❑ o rnd_ grnd. o,o merge, cy Lighting. Battery Units.,_= No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS _77No. 'N'o: o'fZones of Switches No. of Gas Burners o. of eteng D an 1 :itiatinQ Devices No. of Ranges No. of Air Cond. otal Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number ITons KW oof Self -Contained Detection/Alertin Devices No. of Dishwashers S /Area Heating KW ace P a Local ❑ !Y unicipal ❑ Other Connection No. of Dryers Heating Appliances KW Security ystems:* No. of Devices or E ivalent i o. o ater KW ...eaters o_ o o• o Si ns Ballast,; Data Wiring: No. of Devices c- E uivrm— No. Hydromassage Bathtubs of Motors Total HP e ecommunicat>ons firing: ' No. of Devices'or Equivalent , /rNo. OTHER: Estimated Value of Electrical Work: (When required by municipal polity.) Work to Start:'inspections to be requested in accordance with MEC Rule 10, and upon completion - INSURANCE /� OVE A E: Unless waived by the owner, no permit foe the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) 1 certify, tender the pains andpenalties ofperjury, that the information on this application is true and complete. f '5_3 3 3 C - FIRM NAME:�T S�Gctrt'� Sc rtilCePs _ LIC. NO.: Licensee: SignatureLIC. NO.: e licens>f num er line Bus. Tel. No.: 59 Addreicable, enter 1 9 p '� ,vrm t [ %ts k),q a3 q? Address: L 1 ��- '�` Alt Tel. No.: *Per M.G.L. e. 147, s. 57-61, security work requires Department of Public Safety "S License: - Lie. No. .S' CC 0 G ! 175 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, (.hereby waive this requirement I am the (check one) ❑ owner ❑owner'stacnL Owner/Agent PERi11XT FEE: $ d� Signature Telephorig No. J 2 C4 r n m Z ' m z C2 m m W A A r ' N _ W W �c�'+mc psOTt.:e. J ; CJ) E, u r- rz•CZ CD"COs =o m 0E: NG�i�0 -4 LL u �.ZZ CO J l m DA OZ S s (n z -� m C: �: C x v': Q 0. "� ��„C�vt.n.J rConrFu Z. M: mzO m Ln M O 0550 m m J n r D 0 m D Z D (co ,rpt,, _Q N O � O N m� r D cn O -I cn m n O n a ,� 00 3 { 11< CD Q m C3 0 z O o�7 oilc J 2 C4 r n m Z ' m z C2 m m W A A r ' N _ W W I �c�'+mc psOTt.:e. J ; CJ) E, u r- rz•CZ CD"COs 010 1 NG�i�0 -4 LL u �.ZZ CO J l m DA C S s cn m C: �: C x v': Q 0. "� ��„C�vt.n.J rConrFu Z. M: r m I I IIIYII els� z a C RI cn m n c7 C7 � 1'I n �•+ r m Ln M O m m J n r D OCD CO N D Z D (co ,rpt,, _Q N O � O m� r n O N 00 11< CD Q 0 z O oilc < t: o m 9 r� o ` I I IIIYII els� z a 3 a CD � � N cn m c7 C7 � 1'I n oD-{ Ln M O m m J n r D OCD CO N D Z D (co ,rpt,, _Q N O � O m� cop 00 11< CD Q 0 O Location V No Date /g q 77, ,. NORTp 'TOWN OF NORTH ANDOVER. Certificate of Occupancy $ Building/Frame Permit Fee $ !►�a ,^°"'�<�' Foundation Permit Fee $ .. sACMUSt - f, 4QAber Permit Fee $ '12 Sewer Connection Fee $ lo�•4a b 2,c TOTAL $ ` _`9 t nidi Ins NOH'i h ANDOVER G ;.'_ Div. P&is Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTIt ANDOVER, MASS. PAGE 1 INSTRUCTIONS SEE BOTH SIDES w. PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 • ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING LOT NO. ' I 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE �., SUB DIV. LOT NO. (20 P.JV LOCATION 1 1 vdcs - - - w'P l T /j� �7 y/1 PURPOSE OF BUILDING 1 �S 1 �, �I�+G' 1 OWNER'S NAME Co Z'! 1.6 5"ro nl E D G�V�'Q��T� �•7 G/Y. NO. OF STORIES 2 SIZE J �% 1..� C�- 6•/log OWNER'S ADDRESS AA oo �2 BASEMENT GiiiiB l O Q p (•'f ARCHITECT'S NAME 2c.h,-fG�7..a ` vs -Toy L SIZE OF FLOOR TIMBERS IST X/2 IND 9 X�'L 3RD G` `',# BUILDER'S NAME MGL CaNSTQ11G7/ov%/ eo Tr SPAN ly ...,. IC •..n a DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS •>! '• POSTS S-rvo 2if4 DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES 7f o REAR !— GIRDERS .3/2 K/2 � y ! Y 30 AREA OF LOT �, 7L �f FRONTAGE ' b0 HEIGHT OF FOUNDATION �. THICKNESS /I0 0" IS BUILDING NEW \/�SG• i SIZE OF FOOTING 2- X / IS BUILDING ADDITION .1vU MATERIAL OF CHIMNEY ate lck IS BUILDING ALTERATION V40 IS BUILDING ON SOLID OR FILLED LAND c, /,t> WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Y6.5 IS BUILDING CONNECTED TO TOWN WATER %S l\/LCr BOARD OF APPEALS ACTION. IF ANY /1f�V IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINEd' 6Cr INSTRUCTIONS SEE BOTH SIDES w. PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 • ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF f4,ER OR AUTHORIZED AGEN - ti F E PERMIT GRANTED ? 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST / EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY SUILDINa INSPECTOR OWNER TEL. S D� �o t f; 7 3 0 CONTR. TEL. # vb3 _ 64601- 00y0 CONTR. LIC. # c� % S H.I.C. # l� I . rt _ BUILDING RECORD 4 1 OCCUPANCY 12 SINGLE FAMILY SiOk1E5 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY LOT LINES AND EXACT- DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. OFFICES y APARTMENTS __ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL K. BRICK OR STONE HARDW D _ PIERS PLASTER DRY WALL _ _ UNFTIN . 3 BASEMENT AREA FULL '/, '/r 1/1 FIN. B'M'TAREA _ FIN. ATTIC AREA N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 i FLOORS CLAPBOARDS B 1 2 3 �_ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING CONCRETE EARTH HARDV✓'D COMIACN ASPI. TILE Agog STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY. BRICK ON FRAME ATTIC STRS. 8 FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD, A TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES K LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR Iq TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & 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 n. GAS OIL NO ELECTRIC HEATING B'M_ T �I 2nd I t:r 3rd y O FM4 ti. �¢ x A czlz w z w a w a w W a a a V) A w° U w o c w' w o w c w o w w rA o cn o cn C O `m c 1W O y tO vV �r Cc W ; m C :gym q,w 4 y� c L WL 0 CLm 0 CD C.2 ,r (Q1 * C*l ,t: cm m c y -a E ymm a J o .�my a 4 =Co C ea c O ,�•+ y _cc O : m O y m °c tL o cm :moa dCt �� O p m N O O Z Ol G7 d' C H ® y m c .O = CD `m r=„ 3 N � :a o $ ya,0 o W0 O r=... LJJ ;; F. •v) CL= c Z o .-. W •E V 6p1 O CLC.3 d cm p p 0 C H • = A = F- Z 40 . a.=.. m .� I a W cm C iH Q AE m m CD CD L- CA - .0 ~ _ .�C CD 00 CJP C2. CL cpQ ca CDCp cc a o ,°r ezs C.3 CO) c C C c y 0 , rSt1t � f ' UlI � M ��,jj 3. I 3 � „pp �t a rn .u) 6 • ,s 1 s ,ri 'li Netr. 'fix 1 t4 rn N IF �g t A� . cr ,r.,,o•'a9'GIMF14, 1 � • .,� 1;�( P���. 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T ` yy H by S �m T ~ � W 'i � ANt a Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) Map and Parcel: Purpos§Af Appli tion (check below) Phone Number - Applicant: Single Family Two Family I e undersignedappiicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit iq issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in ex istence as of the effective date of this by-law, provided that no additional residential unit is created. lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6."re met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior' shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as above. Further I understand that the submittal of misleading and or inaccurate information, or a ecking off of an above item which does not comply, whether done to my kno e r not, is gro or refusal by the Buil 'ng Department to issue a Building Permit. YYY ignatur ne or thorize Age t ned the A ched Building Permit Date T mus be a ched to the wl ing Pe upo application for such permit. FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: �e LOCATION: Assessor's Map Number 11 -20F Subdivision WO C �- �-� Street _CL r=h.� RECOMMENDATIONS OF TO /AGENTS: Conservation Adm1n'iLtrator Phone is '�- O �-7 0 Parcel Lots) St. Number �l Use Only*********************** Comments ��'C�1Nc�ln - W" Town Planner Comments Food Inspector -Health Septi - ns; or -Health Comments z�>� SG- E=r" Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected 9/0L Date Approved /8 7 Date Rejected Public Works - sewer/water connections g - driveway permit F ' re Departmentvtid Received by ilding Inspector Date s ' Y n ' 1 CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number YQ— 748 Date cZ .23 j cl cl THIS.CERTIFIES THAT, I / THE BUILDING LOCATED ON �� C'4%1Il W oopa-X R MAY BE OCCUPIED AS SS) Nit h FA m I1 y R*S14+V"IN ACCORDANCE MW WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 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