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Miscellaneous - 111 GLENNCREST DRIVE 4/30/2018 (2)
111 GLENNCREST DRIVE ' 210/104.0-0057-0000.0 �. -..��. Location ' No., Date � t NORTH TOWN OF NORTH ANDOVER „ Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ sncHuse A Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ - Building Inspector Div. Public Works PER�IfT NG.-* APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. ✓ PAGE 1 ti MAP 440. LOT NO. 2 RECORD OF OWNERSHIP 'DATE BOOK 'PAGE V ZONE I SUB DIV. LOT NO. & F LOCAYION / PURPOSE OF BUILDING5J04 VEF 6;,Lev -VA y „r ,OWNER'S NAME ZWI �'o ,�' y1��J.�J1f NO. OF STORIES �CS•I�ZE /L/x `3 OWNER'S ADDRESS L' BASEMENT ARCHITECT'S NAME `� j�y{�.� 1/' _ SIZE OF FLOOR TIMBERS IST �J/0 2ND3RD'"+`�-- c t r�J���'V LTJ /� BUILDER'S NAME A,r!I� SPAN 1-21 DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS --- DISTANCE FROM STREET f_l / O P11 OSTS z- DISTANCE FROM LOT LINES C-SIDES J REAR GIRDER•SJ ��/i G�..�� 'AREA OF LOT � FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW :�6 (/^ ^f' SIZE OF FOOTING _/'L X IS BUILDING ADDITION / MATERIAL OF CHIMNEY _ (a IS UILDING ALTERATION /Zxi IS BUILDING ON SOLID OR FILLED LAND W k BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BI- I D OF APPEALS ACTION, IF ANY �3 �f„J IS BUILDING CONNECTED TO TOWN SEWER web -♦ IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST .14 SEE BOTH SIDESp.� EST. BLDG. COST // /Q Oic�.cyo� PAGE 1 FILL OUT SECTIONS i - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM �. PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY k{ ATTACI-W-D GARAGES MUST CONFORM TO STATE FIRE REGULATIONS r PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR I' � Ti �•f�v( l DAT FILED BOARD OF HEALTH O AU?WbRI5:C6 AbENr OWNFR Tat-66-1-- F E E -- CONTR.TEL.#56 PONTR.UCPLANNING BOARD ` PERMIT GRANTED �, ,( �f; TLeiu 195( r. C p4 40, 0 0,!R- ARD OF SELECTMEN OKTIY1 E PMffINSPECTOR `tb'tA f llr tp I k.+IVV;'='' t. ',g'F�; ---' -BUILDING RECORD 1 OCCUPANCY 12 iai i1d LIE'S. . »...,w..w«.wwY.�..w•.eX... SINGLE FAMILY SroulEs TI- U P-IOW-EX''AI DWE—NSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT IN S ' 16r 'DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. j CONSTRUCTION I 2 FOUNDATION I 8 INTERIOR FINISH - CONCRETE d t 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY VJALL UNFIN. "` •"""���� 3 BASEMENT AREA FULL _ FIN. B MJ: AREA - '/. FIN. ATTIC AREA I - NO BMT FIRE PLACES HEAD ROOM l; MODERN KITCHEN 4') WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOrPD SHINGLES EARTH _ - ASPHALT SIDING HARDW'D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE - STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME - CONC. OR CINDER BLK. STONE ON M ONRY WIRING STONE ON FR AE _ SUPERIOR I� POOR ADEQUATE NONE 5 R F A 10 PLUMBING GABLE I IP BATH (3 FIX.) — GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES V LAVATORY WOOD SHINGES KITCHEN SINK - SLATE NO PLUMBING TAR & GRAVEL STALL.SHOWER , ROLL ROOFING MODERN FIXTURES _ 'TILE FLOOR, TILE DADO 6 FRAMING ( 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. i MBER BMS. 8 COLS. STEAM 7.7 COLS. HOT W'T'R OR VAPOR1, WOOD RAFTERS _ AIR CONDITIONING RADIANT H',T'G ._ UNIT HEATERS 7 NO. OF ROOMS GAS. 011 tti B'M'T 2nd _ ELECTRIC %M, lard I NO'HEATING• I NORTiy Town of '�l 6 0 X10.� 266 o 0% ) K RIVEVAY ENTRY PERMIT — _ er, massoy •� ` C' M ME WICKV °oR O ss BOARD OF HEALTH U LLDV O THIS CERTIFIES THAT....... .1..� ....�.. t�: .. .....l:t............................... BUILDING INSPECTOR has permission to erect ......................... s on ...�.l.�..4�.�rtr .:!�.2 .�.....I,,�.�i�' r..... Rough 1 tt�� to be occupied as .�... �.�: �®�!l... `,�.6 1 I O Chimney ..& ......... ................................. • Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS CONSTRUCTION ST RTS . Service Final 16 ..... .... ......... ..................... .............. BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. . ®o Not Remove Burner No Lathing to Be ®one Until Inspected and Approved by Smoke STREET O. 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J. 4b ro N � Na rte; ,tis FEZ T NEE,e•D. PL/4W I hereby certify that the building on this property is located as shown on plan and complies with the Building and Zoning Laws of the i Toim of North Andover. CHARLES E. CYR CIVIL ENGIMM -+�� :.: ,iN Uj ` LAWREIICE, MASS. N.B. - Do not use offsets for :;'.I;,.• • •tea r; , establishing lot lines for the I MI(AW erection of fences, walls, hedges, etc. NOT APPLICABLE TO FLOOD PLANE ZONE. i " Date.......t. .............:'... 3� NoarM,hoG TOWN OF NORTH ANDOVER O p PERMIT FOR WIRING s`SACHU ....dt" This certifies that 1 has permission to perform . .Se..u -"C.. ........ . .:..` ---............................ wiringin the building of...........�... ........................................................................... at .....1.�...�......���nj@/10 ....................................North Andover,Mass. Fee... —............Lic.No3.&(JP.. !\ ELECTRICAL INSPECTOR W5 Check# /5 +e4 Commonwealth of Massachusetts OfficialtUOnly Use '' � • ��I'7 -/ Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/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 (PLEASE PRINT IN NK OR TYPE ALL INFORMATIOA9 Date: City or Town of. NORTH ANDOVER To the]'nspector of Wires: By this application the undersigned gives notice of his.Dr her intention to perform the electrical work described below. Location(Street& ber) ro Owner or Tenant FAV Liv e Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: T= Completion of the following table may be waived by the Inspector of Wires. No.of Recessed LuminairesMNo.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above El Elo.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No,of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "'"" "'" '"""""'"""""' 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 No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) r Work to Start �— Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover s in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) X certify,under thepaNvajdpena1fi s o fper' ,tha he i formation on s app 'cation is true and complete / FIRM NAME: . LIC.NO.: S Licensee: Signature LTC.NO.: (If applicable, t410010 er "ere t"iithe ' en a nu er lin Bus.Tel.No.• r© Address: T5A/ Q��� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department ofP blic Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PEtt1VlIT FEE:$ Signature _ Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed S- on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass N Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: -- Inspectors Signature: Date: 1 FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: ,,✓�--� Date: — —� DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Le0b Name(Business/Organization/Individual): Address: i' d City/State/Zip: Phone#: Are•you an employer?Check the appropriate box: Type of project(required): l.&Jll am.a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. i(Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 0 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no..employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also full out the section below showing their workers'compensation policy information. I Homeowners who subniif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'.Below is the policy and job site information. Insurance Company Name: _ f�X Policy#or Self-ins.Lie.#: Expiration Date: �. Job Site Address: /// City/State/Zip: AJ- , Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the ns enalties of perjury that the information provided above is true and correct Si natur 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#: r r � , 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,b6 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 Depaftment 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' compensatioii'policy,please call the Department at the number listed below. Self-insured companies should'enter their i 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia • x I €`:a COMMONWEALTH OF MASSACHl7SETTS ',BOARD OF ISSUES,: THE FOLLOW ING,L`I"CENS #4 A5,- REG "JOURNEYMAN ELE.@TRS! N #¢ SHAUN A MARTIN 61 BROOKbALE R0AD J SALEM" H 03079-19. 0 ' 38080"..., o /3:t/16 ; 77471 • •FA I r I ♦ Date.............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACHUS This certifies that ;............... .......................... has permission to perform ......4, ............... .. ...................... wiring in the building of......... at //-- AndoverTMass. I CIVI, Fee-7?, ? f............. Lic.N./-),:?d .......... . ... ....... ELECTRICAL INSP R Check 8855 'Y Commonwealth of Massachusetts Official Use Only 4p _ OM 0 Permit No. �iSJ Department of Fire Services Occupancy and Fee Checked C-15 i UV BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 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 ININK OR TYPE ALL INFORMATION) Date: � .—e2 9 6 9 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) / P 4� Owner or Tenant eIt 40Telephone No. Owner's Address Is this permit in conjunction with.a b 'ding per 't? Yes No ❑ (Check Appropriate Boz) Purpose of Building �jf/� r , 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: A / Completion of the followin table may be waived by the Inspector of Wires. No,of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming bove ggABattery Units — No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS N®.of Zones No.of Switches No.of Gas Burners No.of Detection and � Initiatin Devices No.of Ranges No.of Air Cond. TotTons No.of Alerting Devices No.of Waste Disposers Heat Pump Number. Tons KW No.of Self-Contained Totals: - " Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW LocalMunicipal ❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent No.of Heaters KWo.of Data Wiring; Si s Ballasts . No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to StartInspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of s to the permit issuing office. CHECK ONE: INSURANCE a BOND ❑ OTHER ❑ (Specify:) a ��,���,���,4��.% I certify,under the pains n penaltie of perjury, at the info mation on his application is true and complete. FIRM NAME: LIC.NO.: Licensee: Signature LIC.NO.: (If applicable, e+�ter"exempt 11 in the license number line.) Address: L, / &-; K,0,tk Q 3A Bus.Tel.No.:Co Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61, security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ f r ,; '�..,, �.. ���� �� • ; ►� II �, y The Commonwealth of Massachusetts kj 1 Department of Industrial Accidents Office of Investigations 600 Washington Street iU ! gto Boston, MA 02111 c www.nvus gov/dia . Workers' Compensation Imiurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legaibly Name(Business/Organization/[ndividuel):_ Addre,ss In Rr.),) city/State/Zip:_ �Q (Q Are you an employer?Check the appropriate box: 1 I am a employer with__ _ 4. F16 ❑New construcotion 1 am a general contractor and I Tye of project(required): d); employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am asole proprietor or partner- listed on the attached sheet I 7• Q Remodeling ship and have no employees These sib-contractors have 8. []Demoiition working for me.in any capacity, workers' comp.insurance. g ❑Building addition [No workers'comp,insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11,❑ Plumbing repairs or additions myself. [No-workers'comp, c. 152, §1(4),and we have no 12. Roof insurance required.]t employees. [No workers' ❑ repairs comp. insurance required_] 13•0.Other *Any applicant that checks bo)e#t must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new affidavit indicating such. Icoattactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. !am an employer that is providing:workers'compensation insurance for my employees; Below is the policy andjob site information. Insurance Company Name:_ z IcIle— (— 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er th airs d enalties of perjury that the information provided above is true and correct • Signature: - Date: Phone FEOther useonly. Do not write in this area,to be completed by city or town officio[ n: Permit/Lie ense# ority(circle one): ealth 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son• 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 shaU not because of sucb 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 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 numberlisted below. Self-insured companies should enter their self-insurance license number on theaPP p ro riate 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 pernit/Iicense 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 f dwe 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-QS www.mass.gov/dia Date...... ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ............. ....................................... has permission to perform ......4.. ........15�i2.... .>.......... wiring in the building of..........A ...................................................... - 7� ..... / at......./ ...............................................A......................,North Andover,Mass. Fee..��..... Lic.No.�&C;S37.........A-��e���n�. /. .....A.. ............ ......... ..... -4 L&ICAL IN Check # 8760 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 5 _1.7 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 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 W INK OR TYPE ALL INFORMATIOA9 Date: 0s:_ f/ — 0 9 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) �QAwr S 0 t•v� Owner or Tenant O� Telephone No. Owner's Address Rm 4�__ Is this permit in conjunction with a buildin ermit? Yes B No (Check Appropriate Box) Purpose of Building ` �' Utility Authorization No. Existing Service Amps / Volts Overea ❑ Und rd ---- hd g ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Sf / • NIS ,% J v� I�IYI Com letion of Lefollowing table may be waived by the Inspector of Wires. t No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.°f Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o, o mergency ig g Z rnd. ❑ Batte Units -- No.of Receptacle Outlets 3 No.of Oil BFIRE ALARMS No.of hones No.of Switches No.of Gas BNo,of Detection and InitiatingDevices No.of Ranges No.of Air Cotal ons No.of Alerting Devices No.of Waste Disposers Heat Pump s KW _ o.of Self-Contained Totals: _ Deteetion/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* _ No.of Water No.ofo. No.of Devices or E uivalent Heaters KW al of Data Wiring; Si Ball s Ball No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail tf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (� G`O (When required by municipal poIicy.) Work to Start:LS —09 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of sam to the permit issuing office. CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:) I cern under the pains d enaldes o '' P P fP�7ur1',that the inform °n on th application is true and complete FIRM NAME: Q v l e`er/ LIC.NO.: Licensee: Signature (If applicable, ep�ter "exnpt"in the license tuber 1, LIC. LIC.NO.: �D?Q Address: (n I3fD0lGD,Q/e JR�P.� `�9 8�s Tel.No.: "- 43?// 5 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt. L cl.No. VY 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 ❑o I am the(check one) wrier ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ ams ��� ��: � � � Z _o�o,� F r� -' The Commonwealth of Massachusetts k� t Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston, MA 02111 r' www.mass gov/dia . Workers' Compensation Imillrance Affidavit: Builders/Contractors/Eiectricians/pinmbers AnR icant Information Please Print Legibiv Nanie(Business/organization/Individual): ( Address: (� 36 City/State/Zig: q Phone #: . C1 Are you an employer?Cheek.the appropriate box: 1r�I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have bred the sub-contractors 6. ❑New construction 2.❑ I am asole proprietor or partner- listed on the attached sheet.x 7• Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity, workers' comp.insurance. g ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑ Plumbing repairs or additions >r myself.[No-workers'comp, c. 1.52, §1(4),and we have no 12.[] Roof repairs insurance required.]t employees. [No workers, comp. insurance required.] 131 TOther 'Any applicant that checks bortt�I must also fiat out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue 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'con , oli information. P P c}' am an employer that cs pxoviding:workerscompensation insurancefor or my employees: Below is the informapolicy and job site tion 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 t Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORD1=R and a fine of up to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der a pains pen of per_ that the information provided above is trice and correct Si tttr Date: —/ Q 9 `Phone#: is Official use only. Do not write in this area,to be completied by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. 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),addresses)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 requiredl to carry workers' cornpensation 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 tail 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 ace at the bottom P space 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 permittlicense number which will be used as a reference number. In addition,an appiicant 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 y (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: The Commonwealth of Massachusetts Department of Industrial Accidents Officeof Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 , www.mass.gov/dia Date..! ::... ... ./........... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING .0 C040S Thiscertifies that ...................... .... ................................. ................................ has permission to perform .......................................................... wiring in the building of ...... ..................................................... at.... ........ .. ... North Andover,Ma&q. ......................... ............... Fee ................ Lic.No. ............. .. . . ........ . i1c ELECTRICAL&SPECTOR Check Commonwealth of Massachusetts Official Use Only a' Department of Fire Services Permit No. �D g Occupancy and Fee Checked 1 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (]eaveblank 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 PMTW INK OR TYPE ALL INFORMATIOl9 Date: City or Town of: NORTH ANDOVERTo.ththe Inspector of Wires: By this application the undersigned gives notice of his or her intentionA;-'r—e rform the electrical work described below. Location(Street&Number) s Owner or Tenantr Telephone No. ,a q Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building � (Check Appropriate Box) Utility Authorization No. �j�s� Existing Service Avr� Amps 42 /o�// Volts Overhead / Undgrd❑ No.of Meters New Service ,�0 Amps 410 r-2414 Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: t^vft^p rJ��A-d F� Completion of the ollowirs table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp. (Paddle)Fans No.of Total No.of Luminaire Outlets No.of Hot Tubs Transformers ISA Generators KVA No.of Luminaires Swimming pool Above ❑ In- o,o mergency ig g d. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSINC.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges No.of Air Co d. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number ons KW No.of Self-Contained Totals: Deteetion/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑'Municipal • Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Heaters KW o.of Si s Ballasts Data Wiring: No.Hydromassage Bathtubs No.of Motors No.of Devices or E uivalent Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f Ele cal Work: (When required by municipal poIicy.) Work to StartInspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) � fjj///�OA/ �i At�'� J� I certify,under the pai and penalties o perjury, t the inf rmation on his application is true and complete. ` FIRM NAME: V Licensee: LIC.NO.: a (.f pp p Signature LIC.NO.: �d I a Izcable, nter"exem t"in the license number I* e.) Address: �atl-14d �/� 0 �� „v h! f7 9 Bus.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt L cl 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 11 owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: 0 Sew U C'e" ( t 6-tz -.61 � i 1 The Commonwealth of Massachusetts kj l Department of Industrial Accidents Office of Investigations 600 Washington Street V Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print LaQibly Name (Business/Organiration/Individual); Address: C l lgf e X1 .4-/� �.v o �a 1�.� r) City/State/Zip._ : 1e lyd 0 3d d Phone#* Are you an employer?Check the appropriate box: l.� I am a employer with .. ► _ 4. ❑ I am a general contractor and I Tye of project(requiret�: employees(frill and/or part-time).* have Lured the sub-contractors 6. ❑New construction 2.❑ I am a.sole proprietor or partner_ listed on the attached sheet.1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mei' any capacity. workers' comp.insurance. [No workers'comp, insurance 5. ❑ We are a corporation and its 9' ❑Building addition regmrecL] officers have el0. exercised their ❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I 14 Plumbing repairs or additions myself.[No-workers'comp, c. 152, §1(4),'and we have no 12. Roof insurance re uired t ❑ repairs q ] .employees. [No workers' COMP. insurance required.] "Z-Other am that checks bout#l m t Homeown ust also fill out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp•policy information, f a►n an empioyer that is providing workerscompensadon insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy#or Self4ris.Lie.#: + Expiration Date: Job Site Address:[ (� �p t'("�� �/�:v 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 required under Section 25A of MGL 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern n r the pains a enalties of perjury that thein nrmation Provided f P tiled above is true and correct. Si Lure• Date: Phone#: ,�Q — `� r ficial use only. Do not write in this area,to be completed by city or town offtciaL A City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Pinmbing Insptxtor 6.Other Contact Persom 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 iegal 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 thae 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 er 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 requiredto carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advisedthat 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,notthe Department of Industrial Accidents. Should you have any.questions,regardin the law or if you are required to obtain a workers' g. Y 9u � 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 i Please be sure that the affidavit is complete andprinted 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 Nvill 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 the city or town p may be provided to the by �' i. Y applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i.e. a do license or permit to bum leaves etc. said erson is N ( g p } p NOT,required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL.#617-727-4900 text 406 or 1-8.77-MASSAFE Revised 5-26-!15 Fax#617-727-7744 www.mass.gov/dia i Date. :: . .. . . . . ".O R7:'tio TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING . • ,SSACMUS� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . ... . .f`. . :: . . . . . . . has permission to perform . . .;.. . . .. .. `.'. . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . at .'. . . . . . . . . . . . . . . . .. .`. . , North Andover,.Mass. Fee. . . . . .Lic. No.Z. . . 3= . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING r (Type or print) NORTH ANDOVER,MASSACHUSETTS _ Date BuildingLocation //I 6- ji0cAesP Owners Name o`ff L- Permit 1# D Amount Type of Occupancy 0ueLt-) New ri Renovation Replacement Plans Submitted Yes 0 No F FIXTURES H C x O W a W V a w � 3 L as vx, w W Un x a t7 O ►�., W 3 O A S � w p° COD F-4 1 Z O Cn W O U W 3 a A a H a a SLRB Rk%MM BE FLOOR / M ILOOR y IM FLOOR 4M FLOOR 5M H1= t , 6M FLOOR ( - 7M F JXR 9M FLOOR (Print or type) Check one: Certificate Installing Company Name j AjA►V !4 C-J1 R w f ✓/cJ ❑ Corp. Address C-7 6 !9 ye'st- ST1z-r'k` - Partner. Z L T1-4Jcv✓ '44-oss Business Telephone 47,t G f-7 11,21-- Finn/Co. Name of Licensed Plumber: Dy U 1 J' f/9 C--TN ry S/�-� ►J Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma etts Stateumbin ode and Chapter 142 of the General Laws. By. J1gilalULG V1 L1(,el-�minder Title Type of Plumbing License City/Town Icense 1Num5er Master ❑ Journeyman r4Z;j t APPROVED(OFFICE USE ONLY The Commonwealth of Massachusetts �j 1! Department of Industrial Accidents t�� ! Office of Investigations r ,3 600 Njashind fon Street Boston, MA 02111 c� www_nwssgov/dia . Workers' Compensation Ias trance Affidavit: Builders/Contractors/Electricians/pinmbers Anolicant Information Please Print Legibly Name (Business/organization/individual):— 044; i Address: .3( /9.2 e;Z ('7,<t--2 City/State/Zip: wi.rs <<1' Phone A. 97t E&7 /f.3 Y Are you an employer?Check the appropriate box: -- 1.❑ I am a employer with 4, T�of Project(required): ❑ lam$general contractor and I employees(full and/or part-time).* have lured the sub-contractors 6• ❑New construction 2• I am.a-sole proprietor or partner- listed on the attached sheet.? 7• ❑F odeling ship and have no employees These sub-contractors have 8. Q olition working forme.in ay capacity, workers' comp.insurance.[No workers com , insurance 5. 9• r] ding addition p ❑.We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all worts right of exemption per MGL I I.❑ Plumbing repairs or additions myself, [No workers'comp. c, 152, §1(4),and we have no insurance uired. t 12.[] Roof repairs �J ] em . ployees. [No workers' comp• insurancerequired_] t3.❑.Other *Any applicant that t checks bot:#I must also fill out the section below showing their workers'compensation policy information, Homeowners who submit this aftitlavit indicating they are 8aing all work and then hila outside contractors must submit a new affidavit indicating such. ;Contractors that check this box mustettached an additional sheet showing.the name ofthesub-contractors and their workers'co affidavit policy isatin such. t am an employer that is providing:workerscompensation irmuranre for my employee Below is informthe policy and job site . ation. 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. !do hereby certify under the pat*7 and penalties of perjury that the information provided above is true and correct: Simi :IJ 0:1Date: / Phone#: 17e 6e7 /l3K OfJ`icial use only. Do not write in this area,to be completed by city or town.offciaL City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical inspector S. Plumbing inspector 6.Otber Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all emp l oyers 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 includirig 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 Cceusing 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.oir 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 workerscompensation•affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addrms(es).acid phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are 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,notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' oarnpertsatian policy;pleasecall the Department at the numberlisted 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 permittlicense number which vviIl 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 ofthe 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.When 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 as a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Iavestigntions 600 Washington Street Boston, MA 02111 TeL #617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-Q5 www-mass.gov/dia I Location l// No. Air Date .S 0 ys/ rM pf '40 , TOWN OF NORTH ANDOVEW Certificate of Occupancy $ Building/Frame Permit Fee $ 'SSAC14USE<� Foundation Permit F,ee $ ---- Other Perm Fee/ $ ; s- Sewer Connection Fee $ �i Water Connection Fee $ TOTAL Building Inspector �`�� Div. Public Works f PERMIT Nc. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. �GE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE ZONE I SUB DIV. LOT NO. I I i LOCATION / C PURPOSE OF BUILDING OWNER'S NAME lCl+_ NO. OF STORIES -•Qj OWNER'S ADDRESS ! AML - BASEMENT OR SLAB v ARCHITECT'S NAME 7 SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME _/ RFgAt SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR "' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST f SEE BOTH SIDES - �i EST. BLDG. COST L PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST POUR SQ. FT. - PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY �I ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS - PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH SIGNATURE F OR AUTH R ED GE T F E E p OWNER TEL.# 8 7-1 �� -PLANNING BOARD PERMIT GRANTED CONTR.TEL.# 19 -: -�- CONTR.LIC.# �7� 9 BOARD OF SELECTMEN BUILDING INSPECTOR i a-6/ BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILYST TORIES HIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS I AGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW-D PIERS PLASTER DRY WALLUNFIN. 3 BASEMENT 11 AREA FULL FIN. BM'TAREA _ 1/ 1/1 '/. FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS , CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH.71LE . STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING 't STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING { GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR 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 GAs O B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING A t4ORT_ . own of over Q No. Z ` op o ��-A E o dover, Mass., 19 l COCWCME WICK �qO Q�\\1 5 A7ED P BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT......... . .... I ......... ..I.1 .. . . ...... .................................................................. � Foundation has permission to erect..49.4141". . buildings on ...�* ..`.A. . ... .. s * ough to be occupied as.....494!. .....0. .�.....`...&Of A�.................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .......... ....eo ........................ .......... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. (ZMA/1:0 MIATM FINIAI nRIVFWAY FNITRY PFR BAIT Smoke Det. Date 4055 AORT#q +ac TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING « � . •. ,SSACMUSE� , "lam This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . .U. F . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of .. at. . . F.-( . . . . . . . . ., North Andover, Mass. r Fee. . t.C . .Lie. No.. . . ::. :+ . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MAP PARCEL QU J 7 FORWARD 6-7,57 S SETTS UP' s FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location // moi.�r<rr' Owners Name �—[�.,.!( .._ Permit#_3261 Amount �,G Type of Occupancy 12ui-��� �� New o_'*�' Renovation Replacement ❑ Plans Submitted Yes No FIXTURES z w a zZ Ln C7 C4 Ln a W H w z F a x � d �a a a a A a " Cn r SZ EMM &ASEVENT M HIM r,D RIM 3M FIDCR 4IH F10CR 5M FlaR 6M RjaR 71H FLOQ2 SII3 FLO(R (Print or type) nn '7 Check one: Certificate Installing Company Name Corp. Address �� (�J u ` ` ) Partner. Business Telephone Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy L..J 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(or entered)in above applicat n are true and accurate to the best of my knowledge and that all plumbing work and ins ons p ormed under Permit Issued this app' tion will be in compliance with all pertinent provisions of the Mass us Sta u g Codeland Chapte 2 of General Laws. By: Signatureor Licenseaum er Type of Plumbing License Title City/Town icen um er Master Journeyman El APPROVED(OFFICE USE ONLY