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HomeMy WebLinkAboutMiscellaneous - 110 WAVERLY ROAD 4/30/2018"'t Date ... &. - '. - .. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........................................... has permission for gas installation .......... in the buildings of ......................... at North Andover, Mass. Fee�--.,-� ..... Lic. No ........... ......... -GAS INSPEQR� Check # 4360 MASSACHUSEM UNNORM APPLICATON FOR PERMIlT TO D0 GAS G (Type or print) Date U 3 NORTH ANDOVER, MASSACHUSETTS r Building Locations 010 (AJA U8`2 L '� RI) Permit# 4 3 6 0 Amount $ 110 Owner's Name S vU S4 - New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or type)one• Certificate Installing Company NameLG/ /� ^ i�Ir� <drvi� l'i'-%� ,_.�—� . X C Address I l 3 F Lh Our S1777 •---- ❑ Parhuer. .. r ❑ Firm/Co. Name ofLicensed Plumber or Gas Fitter J-U�c c ALL14-111 b INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [3— No[—] Ifyou:-have decked yM please indi tate type coverage by decking the appropriate back. Inability insurance policy Othertype 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 Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owna ❑ Agent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code anfl hapter 142 of the General Laws. (OFFICE USE ONLY) of Licensed Plumber Or Gas Fitter 3496 r License Number Joumeyman 4 �i��iiii�iiiiii�■■�iii�ai�i' (Print or type)one• Certificate Installing Company NameLG/ /� ^ i�Ir� <drvi� l'i'-%� ,_.�—� . X C Address I l 3 F Lh Our S1777 •---- ❑ Parhuer. .. r ❑ Firm/Co. Name ofLicensed Plumber or Gas Fitter J-U�c c ALL14-111 b INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [3— No[—] Ifyou:-have decked yM please indi tate type coverage by decking the appropriate back. Inability insurance policy Othertype 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 Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owna ❑ Agent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code anfl hapter 142 of the General Laws. (OFFICE USE ONLY) of Licensed Plumber Or Gas Fitter 3496 r License Number Joumeyman Location Wq ut t2 L 1?d No. qC0 Date Z) 3 ,LORT#q TOWN OF NORTH ANDOVER 41 Certificate of Occupancy $ Building/Frame Permit Fee $ HU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 163'11 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . .., i: �^ >'�,'e"�,�y��`'ry°S `.i.'�k`e rOj�H 1`Q�e��Ri.��.Ql�i &4;� x'?'✓.x � $sR .p. .py. . ............ BUILDING PERMIT NUMBER: ,c.,( (�/ DATE ISSUED: SIGNATURE: Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RaIltired Provide ReqWred Provided R 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record nn �I� Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Klo\11 A (N � �,-�, Qt C _ �11�• C C ` Signature Telephone / �AVCM r (4 7 �2 6r ?(-�- Not Applicable ❑ License Number Expiration Date 3.2 Regi tered Home Improvemen Co-nn-rracto Not Applicable ❑ Company Name } Registration Number (6< v Addre c� S 1 �� t �� `may/ Expiration Date f Signature Telephone 00 M X Z O O O z M 90 r SECTION 4 - WORKERS COMPENSATION (XG.L. C 152 4 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant 0FFICIALVSEx9NLY I. Building � a V�v L (a) Building Permit Fee Multiplier 2 Electrical , F3 CSU G'C (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) J 6 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �C_Ld %' . , as Owmer/Authorized Agent of subject property t Hereby authorize to �i e to act on My bel cfll{i all matt s relat v o work authorized by this building permit application. Si nature of Owner J-11 Date SECTION 7b O((WNER/AUTHORIZ D AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief, Print N f Signature 40 ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlVIBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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,S.150A. The debris will be disposed o in: (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 AC®RD. CERTIFICATE OF LIABILITY INSURANCE DATE 04/14/2003 PRODUCER NORTH ANDOVER INSURANCE AGENCY INC 9 WAVERLY ROAD NORTH ANDOVER MA 01845-2415 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED Michael Rodden 47 Prescott Street North Andover MA 01845- INSURER A: NATIONAL GRANGE MUTUAL INSURER B: TRAVELERS PROPERTY & CASUALTY INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DDNY POLICY EXPIRATION DATE MM/DD/YY LIMITS A GENERAL LIABILITY North Andover MA 01845- EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 500,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FXI OCCUR MPP37395 02/01/2003 02/01/2004 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY JE LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY ALL OWNED AUTOS / / SCHEDULED AUTOS (Per person) $ BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE / / / / (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO / / / / AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ EMPLOY RSOMABILSTf ION AND X TORY LIMITS OER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 $ 849K419 01/01/2003 01/01/2004 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER I I ADDITIONAL INSURED: INSURER LETTER: CANCELLATION ACORD 25-S (7/97) _ © ACORD CORPORATION 1988 VWT�- INS025S (9910).01 ELECTRONIC LASER FORMS, INC. - (600)327-0545 Page 1 of 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REP SENTA E North Andover MA 01845- ACORD 25-S (7/97) _ © ACORD CORPORATION 1988 VWT�- INS025S (9910).01 ELECTRONIC LASER FORMS, INC. - (600)327-0545 Page 1 of 2 0 z M a x w A a d v x w° � In cn w° o V) Z z � A or. to U ca w 0 C7 w�' w a o a w tw a�' cn w a p a z � to 1:4 w z w w w A w w w' z U) 0 cn ., 0 1 .. o ..� m� o .�5 16, p h � C O C3 V V •dam O !O 3�= o �c m U H Ea m �mo 33Eyo mo: is n c z Z cm l- v E vni �mm�a. m O � y�t cm c m y = m 4m. c c O O O cmO CC = o o� 10cf l i COi O O . Z O O r: O C d O C i CD C •O a. c N W C �L� O ® w •�GL=E ev LU C ci ®ti Z LU cm m> ao _yCL 0:5 J2 N .� O _ A v O j-CL�m � ., 0 1 "ORT 0 S US Date. Y-.i:� 3. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ................... has permission to perform .... � , . I .............. plumbing in the buildings of .................... at - - /./ f!� . .1-A- /0 - A- r. /4. ................. North, Andover, Mass. Fee. ..... Lic. No..',�.'.) . ... ...... ........... PLUMBING INSPECTOR Check # 5589 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS !' Date U3 Building Location /10 W4 LIO2I-Y Owners Name Soo -.2-APermit # -�F5 Amount Type of Occupancy/? es i oeutm- V New Renovation Replacement .� Plans Submitted Yes No (Printor type) / I f ;Check one: Certificate Installing Company Name H (l�/U f �- �Ll (� t?T Corp. Address Q 7L Ou Partner. Business Telephone i 1 13 Firm/Co. Name of Licensed Plumber: V EF HuTm VT Insurance Coverne: Indicate.the 'type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnityj- rBond Insurance Waive. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work andin lens performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massac e tate Plumbing Code and Chapter 142 of the General Laws. Plumbing I D (OFFICE USE ONLY Master D Journeyman ......... ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ....................... ................................................................ has permission to perform ..... ......... I ......................................................... wiring in the building of ...... .. i� ........................................ at ...... Xe��' ........ ........ .......... /.�. & .............. . North Andover, Mass. Fee"�� ... 6� ......... Lic. No" ................... C� ...................... Check # 7�� 4� — ELECTRICAL INSPECTOR 4491 �L Commonwealth of Massachusetts UIVDepartment of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No: yy Ql Occupancy and Fee Checked_ Zev. 11/991 (leave hlankl 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 RV M OR TYPE ALL INFORMATI01N9 Date: ,� � - O 3 City or Town of: pf/ „yLy �� ,,� To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the ele9trical work described below. Location (Street & Number) //a W 13t f ,r /-ti Owner or Tenant C"/fa., ,/, , ,, S 'xze Telephone No. Owner's Address { �;-�_ t Is this permit in conjunction with a building permit? Yes ®', No ❑ (Check Appropriate Bos) Purpose of Building Existing Service _ZCjll Amps / Volts Utility Authorization No. Overhead [ -/tndgrd ❑ No. of Meters % New Service Amps / . Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �v.- r -s ('mmnlatinn of iha rnfln—i. , r ,hla .. , 1, ;_-1 h.. /1. No. of Recessed Fixtures 7 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 2 Swimming Pool Above ❑ In- ❑ rnd. Qrnd. i o. o mergency igFit rig Battery Units No. of Receptacle Outlets a% 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 Waste Disposers � No. of Air Coad. Total Tons eat Pump I _umber _, ons KW Totals: �� '� �..........._. _.................... No. of Alerting Devices'I No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of i o. of Si ns Ballasts Data Wiring: 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 Fires. 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 ®OND ❑ OTHER ❑ (Specify:) % — G 3 (Expiration Date) Estimated Value of Electrical Work: (When required by municipalpolicy.) Work to Start: ,j ' % a Inspections to be requested in accordance with MEC Rule 10, and upon completion. 1 certify, under the pains andpenalties ofperjury, that the information on this application is trite and complete. FIRM NAME: All - 1 z l /�� LIC. NO.: %,z -/may J__� Licensee: Apo,.i A,' Signature � LIgqC.. NO.: -T � (If applicable,a er exempt 'in the license number line.) Bus. Te1.�1 S;'7 — / �� L Address: - — Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/AgentPERMIT FEE: S Signature reTelenhone Nn.