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Miscellaneous - 115 JOHNNY CAKE STREET 4/30/2018 (2)
115 JONNf 2101 OH_ 7_ A-0185-0000'0- T Locations D11,t1U 04 No. c?, 3 Date D a u MORTq TOWN OF NORTH ANDOVER . .Go Of�..�° , 11.0 3? c Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector i •a TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED: =00—� Q 2 SIGNATURE: � ( Building Commissioner/1or of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number AarcelNumber 1.3 Zoning Information: l J�? 1.4 Property Dimensions: Zonis District Proposed Use Lot Area Frontage(ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number on Address CJ 1 /-//13/2 6--> :3 v4i, 0go�ivt / ��"/ J �S 3� Expiration Date ic Signa a Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name 1"317rn 30I/1�J /',�/n)t ��ne�Lj� �5( Registration Number Address 1" < J o/Z Q J r L4-1 qv- S �� `�` Expiration Date n� Si re Telephone "/ F- ti SECTION 4-WORKERS COMPENSATION(XG.L. C 152 § 25c(6) 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 OFFICIAL USE ONLY Completed by permit applicant I. Building g,S'00,O O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 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 I> as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. —Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Name Signature of Owner/Agent Date NO. OF STORIES SIZE ` BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3RD 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 N o rc r Iy Town of And No. Z3 � OSA COCHICt-LCTIdover, Mass., x.95 RATED 1 H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System /► lfiv#.444.4 . BUILDING INSPECTOR THIS CERTIFIES THAT... fi ..........#14.................... ... .......... . .................................................... Foundation IC has permission to erect....... � ... .......... buildings on .j..tv-...�._...�. !. !.. „.., �� Rough .... to be occupied as........Op..� � / �4 Yet I'` 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-La s relating to the ns ection, Alteration and Construction of Buildings in the Town of North Andover. /0 4)� '& � 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 Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. W CmnrrtatrweaFth orNiassacfiu��tts (Dep= rw�1n�uszrial Accidems VC 600 Washi'V=Street . Boston,� 02111 . Workers'Compensation Insurance Affidavit APPLICANT LNFORM-AT'ION Please PRINT Leagibiy Nam-.:- Location: ameLocation; Telephone M 9W - '7/7/7 2//o Ex 7— I I am a homeowner performing aIl work myself ❑ I am sole proprietor and have no one working in my capacity ❑ i am an employer proviaing worker' compensation for m/yr e mpl oy ees working on this job Company Name, ,.(!` CL U17 Address; City; �%`'' `�IGSy ( -S Telephoner Insurance Company: ,1�✓►7t/14ti1 Z7`'S ��'`� Policy f: (i`) ❑I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following. workers' compensation policies: Compal Name: Address: City: Telephone�: - Insurance Company: Policy f: Company Name: Address: -- Telephone W: City: Insurance Company Policy'-': Armzh additio=d sheet if necessary raiiuse to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to "D1.500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a une of 5100.00 a day against m. I understand that.a copy of this statement maybe forwarded to the office of Investigations of the DIA for coverage verification. 1 do hereby certrjy under the p 'ns and penalties of perjury that the information above is true and coo rest. 5i�ature tri 6 °/ 21 Print Name: &vl l-3 Phone 0 Ozncial Use ONI Y-Do not write in this area ❑Buildino Department* D Licensing Board Ciry or i own: Permit/License r: p Selectmen's Ocoee n Health Deoartment D Check if immediate response is required 0 Other ROO MOIL €IISMUCTI0NS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted aom the "law" an employee is deisned 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, andincluding 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, con eruct' on 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 section 25 also-states that every state or local licensing agency shallwithhold 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, 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 beeupresented fo.the contracting authority. 1�pplicants Please fill in the workers' compensation affidavit completely,by checking the.box that applies to your situation and supplyimgcompany names, address and phone numbers as all affidavits may be submitted to the. Department of Industrial Accidents for,connzmation of insurance coverage. Also be sure to sign and.elate the affidavit. The affidavit should.be returned to the city ortown 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. Wiry or Towns Please be sure that the affidavit is complete and panted 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. .Pleast.be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the DeparIIment by mail or FA_X.unless other arrangements have been made, The Office of lnvestigations would aceto thank you inadvance 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 Fax# (617) 727-7749 Telephone# (617) 727-4900 ext. 406,409, or 375 . Oar An TypeOf • ,mqs IIGr T-6�">M�° Escp uoer�e > L rr »n MR UWX*WO@34M ow gas Tio Fr'" � � '• • 1]11! - __ ♦3 01I +M�_�nq �.��• grt J`„�.. c,Kur NA JobPbM 11i iraarlaA p�gre L Zip Cole to jWo sad hba�r�,rccordw�wt�spsCi��"es below,ta►�the sMo ot: J va DdINm , , 1 yolk aee �W. be. 1po1� i1 a VnMgW'Am al"tofm 4W I y�{rrW deole�e 1n WAMW 4=9yrs w111 be salor� .X01 �W"aooi0o� Nps Itds gopowl my 40Msit a� � —-- � Y ANXIM& wM&vm by VA if Momftwvow or~bnYWA ow ow VOW amMY N umdby 'sC O° We hcrebY submit VWificariais wd C$tiMWS for. LAS oycot CQt440oL4J>zx SOW ice and water barrier Protet�or►along all bottom edges Of { Eave water of ice and �nstaN 3 feet specl8 we wNl ems►conventional ff roof is tom• . shiWd MW fop to bottom 1n e� p ly d and tar paper wll cover the k high in the same boards wet be repulsed at( )Per Omar ft. remakft bare wood. Any Mftd or dema9ed or( )per sheet of plywood. Winstaa heavy 9Au94 Sluourom drip edges along every edge sud bM of each roofiine• Cover entire roof(s)with ttf4 26 year all Whatt, non-fiberglass. Promm grade shwq*e (Color of choice). �;Mepbm an pq*boots where possible• QrSeat as flashings with dear Geo-Cai se aM_ No Wade tar unless previously appWd- CM%emve all work-related debris• roof against aY{eaks due to defects in his unship fOr 92 years under normal CkWff stances. D'�ocal current references and proof of workman's cwnpensebn insurance gWen. r.� tv /Jtw�i �W� Q Remarks: �groc et lrsp�d -The abuvw per• ificBdOw alss sMWkcwy md am ' mon so do the wO*a Spedfie&Psymm � will be mads a outlined abo DoW of Act= p 9 . Date�G /Cf% .?... .. NORTH Y 41 0 °` ` TOWN OF NORT/HAiiDOVER . o ' PERMIT FOR G�►S INSTALLATION 9 � �SSACHUSEt This certifies that . . . : . .>�{. . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . in the buildings of !': t. . . . . . . . . . . . . . . . . . . . . . . . . at . .�./,�: . .� �. �' ` . . . . . . . . . . ., North Andover, Mass. Fee. . P. . . . Lic. No..`7 . . V . �.«.},41.. . . . . . . . ,+GAS INSPECTOR Check# 2 c S C 'i 9 2 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: - ���/� .. Dat e: G % 9 Permit# .k.. s� Building Locatio„, f �� Owners Name:C Type of Occupancy: Commercial Educational Industrial Institutional Residential New:; Alteration: Renovation Replacement:�� Plans Submitted: Yes No FIXTURES w w U �,” D o w w Ov v7 N = W '_ W O (7 J_ >. W W W (� tY w W W m 0 Q~ 0. F— 0 W OJ d )( . > N U W N C7 u] to O O = U a U. w > W W z J P i- O z J () LL Fes— W W W OU O O O w W > O Z O w z W Q Q Q A// BASEMENT 1 FLOOR 2 u FLOOR ' 3RD FLOOR H E-11 4 TH FLOOR 5 FLOOR r. . - I 61N FLOOR _. - 71 H FLOOR 8 R—F L_O.O R Check One Only Certificate # Installing Company Name:., ✓� Corporationqv Address: joo ��o.�c City/Town: �State:LMA Partnership Ll .....µ. Business Tel: o�y Fax ' Firm/Company Name of Licensed Plumber/Gas Fitter:l,„ m$ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Bond L OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent b- By checking this box❑; I hereby certify that all of the details and Information I have sub�eSdun�derthe red) garding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations pert per it Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code; d Ct eneral Laws. ---Type of License: By 'J Plumber Gas Fitter -- Title i ,. , Signature of L mber1( as r. Master !. cnyi o•:, Journeyman j License Number _ µ I APPROVED OFFICE USE ONLY4 LP Installer FINAL IIVSPE( PION BELOW FOR OFFICE USE ONLY PROGRESS FNSPFC"I IONS) FEE: S PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH ---------------- PLUMBER PASEUTTER LP INSTALLER LICENSE NUMBER; PERMIT GRANTED EJ DATE: GAS FITTING INSPECTIOR Vct j D1�FQ t1j, Ca� a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass.gov/clia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmization/Individual): \7_0S ff 00l1 ICO G FV1 Address: s�°A2�o�►„J Si City/State/Zip: A/• 02 0KOM/--/ wt4 OZ 1=hone#: 4/7 - 7.S-G - 7f 7 � Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2,KI am a sole proprietor or partner- listed on the attached sheet. ? E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. El We 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 1 dumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no. 12.❑Roof repairs insurance required.]t employees.[No workers' 13.1-1 Other comp.insurance required.] *Any applicant that checks box#I 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: //,I'- V-1lJ1aNN Y e fA e- City/State/Zip: N• 677 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby cer ' nder thepains andpenalties ofperjury that the information provided above is true and correct. SiLmatur . Date: 2 - Z S- /S Phone#• 4/-7 715-4- 79�? Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: r. C®IUiIVIOi�WEALT�f®F il(MASSACWUS�T I S .I ® .e R'LU,MBERS AND GASFITT_ERS. . ,L CE,NS`ED AS A MASTER PLUNIyBER.: I 1SSUES THE ABOVE LICENSE T03' ,., .. .$EpH:,.N1 FDLEY '%p►.' q ::SPA:RROW STREET RDXBURY MA 0213..2;.-35;3.1 . . ..: i; 1708 05/01/14 185453 `_,.I �I 0 ' o��P��roi�tyo°�ash��9 �a o (P`ov aeskco�5 e,t� yo bo e� sof \ o � e<yl se a90ee0 \o �P �°es�ele0� ° \ sue 9o &e \Oias o � sss5 \o\, toy \ he ,o aLei�sce0�a° tsCtoseo OCot °. h �m g Vo � t\ �� co so . aC�Pal' 1a�N Re�e\\°e\sed\os ry otih vdedby l . \r�amend ea s as ass�9oc P°s�e PecSO\ 1 , J1 1' 1 1 Dated 10' .�-'. . . . C `ytoTOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . C1`�P T . 2 has permission forgas installation . ..? . . .w in the buildings C p y-. . LLL. . . . . . . . . . . . . at . .��. Sv��ti�n�,.Iu .. . . . . . . . . . . . .North Andover, Mass. A . . . Lic. No.l2-.7CX. . . .C.!J,a. . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# 6605 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I�• A�tlOo d ( MA DATE PERMIT# t) JOBSITE ADDRESS /S� ! !!�xz AK .SJ=T OWNER'S NAME / �i�IIV CiG ST. LL GOWNER ADDRESS - _ TE y 33 _j� 1 SJ FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALM PRINT CLEARLY NEW:J RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES F--j1 NO 5a APPLIANCES 7 FLOORS- BSM 1 2 3 1 4 5 6 7 8 9 10 1 11 12 13 14 BOILER �I -- _--� .-- BOOSTER CONVERSION BURNER -1 �.. 1.{�, �I __! ,_ I __.-_I _i:__. _ :►. _ _ __t , _� _ -_1 _ _.. COOK STOVE DIRECT VENT HEATER _- DRYER FIREPLACE --_I�,_- i - 1( ...J L .__ I 1-rr-.a __-1(J I _—I[ -1�r�.{ II -- . FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER [-�(� I _-.. (�!I-- 1- �- - --I _ --- LABORATORY COCKS .I( - I I_ -J .__s I T I _I ,-_ .( --_ I {_ . ;�f _._J ------ MAKEUP AIR UNIT 1— T�- IT-l l.- r_ C -1_- { I -: _-- OVEN POOL HEATER ROOM/SPACE HEATER - ROOF TOP UNIT t__ j i UNIT HEATER la. •UNVENTED ROOM HEATER WATER HEATER I I --11__. .�i�_w1 I' -- L- I 1 ?�-I L:.-__�J= -._,.f --_J 7-� OTHER I I I II I {. x1 �L -( - .Y L_._.J I_ F--j F INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ANO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY JA OTHER TYPE INDEMNITY D BOND I__! 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 -_J AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accur the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance all P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C9 PLUM BER-GASF ITTER NAMED _. -' LICENSE#094 SIGNATURE MP�3 MGF E] JP11 JGF LPGI�_I CORPORATION[I]# PARTNERSHI I# LLC # COMPANY NAME: ADDRESS CITY Gf• 2llu -- _ _{ STATE jtT (ZIP 1. 2.T. TEL -4,17 FAX —�CELL[—d ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES L 0 : 8 19 Date a ,1 . . .�. . . . . . r TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . . has permission to perform . 2 . . .`! �. - **** !�5 _ J plumbing in the buildings of��'� � ti . �.�c;e, , (.—� . , , , , , , , � at . . . . �7. .- �? Nc�.y.l. ��c�. ,North Andover, Mass. Fee W. . Li 1) o PLUMBING INSPECTOR Check#�(p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ DATE 2 Z 'r- MA /3 PERMIT# JOBSITE ADDRESS OWNER'S NAME //,s 07/! N ewlee- POWNER ADDRESS SAS'_ TEL G/7 233-857.__I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0E EDUCATIONAL ® RESIDENTIAL Id PRINT CLEARLY NEW: Ej RENOVATION: REPLACEMENT:J9 PLANS SUBMITTED: YES 0 N0§d 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I ! ..__.._._.I f ._... i ...._.._._( ( ! __...-_i DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER __f FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ( E ___--.__I ..___ _1 ._._ ! _ I __.___1 ____._E .-..__.__,- _..___E ____._._1 ..__.__. _E f _.._._..i KITCHEN SINK LAVATORY I _._.-._ ._.....__! ( , -__-_-- f ) � ! _' E _.__._..I 11 i ROOF DRAIN i __.._._E E E _� [ _ ..__f .__ SHOWER STALL SERVICE/MOP SINK TOILET E _-_._.._E ._.-_-- �_.l ___.. _._� .____...{ _. _--- f --j== -- I RAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _11 WATER PIPING _ _I . i _ _..._ E i . _ f 1 _ ._ _i _-! _ _-__E OTHER _._.------ -1 ._-1 ____._.! INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO M IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY D BOND 0 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 .f AGENT SIGNATURE OF OWNER OR AGENT � ! hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc u to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ith Pertinent provision of the p Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �3• PLUMBER'S NAME LICENSE# /Z 7ar I SIGNATURE MP if JP EJ CORPORATION #=PARTNERSHIP LLC COMPANY NAME rOC ADDRESS CITY 0. - ......._.._..._.;STATE /tiff 11 ZIP [Z137,-�.-----I TEL FAX CELL[4;j-Xf L= r EMAIL 3 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No 7rTHIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I ZZldlv_m � e dllai( a4n z/ s ,� J A ` r The Commonwealth of Massachusetts DI Department of Industria Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��s��P/1 /rnD L r Address: City/State/Zip: A/• 2 v xQN!!!-t rK,4 a?- i.3ZRhone#: is/ 7 - 7 SG - -7f 71� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.KI am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship andhave no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 1 dumbing 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. 1 Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit anew 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:-//I" v-17)YN14JY eofAe City/State/Zip: N• .Q.JDOvtn. 67 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 cer ' nder the pains and penalties of perjury that the information provided above is true and correct. Si afar . Date: - - Z S - /S Phone# Gid - -767&- 7/c? 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#: 1 p . W 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 employeiis 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 producedacceptable 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston,MA.02111 Tek.#617-727-4.900 ext 406 or 1-877MMASSA.FB Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia :COMMONWEALTH OF MASSACHUSETTS'., PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO;' J. DLEY 1-P,H, M. , F -+ ' ' 9 SPA,RRDW STREET t WEST'.RD,XBURY MA 02132 3531 05/01/14 1854.53 12708 I , O�D 6oa�d\or 5t•, # �o�PN�r°it\yam°�asr�r9 a 'qty \M oyed, e,�0 a°at colt, of des\cersuOO• o0rJ y°rC of a- \00 ra\V \8,6� ed,a at\tag °�rbe - ` s o cp a s t 1 v� s� p9 < e ease res PAZ cra rope eas a\La d ` \s Ctc \pyo r,M a is top C\tc east ape \�N\5`°1�O,6osto dress srss°tetet\°5°0\hUs rokoe oay°ut awe of sot addo\tlm PtO�tsteaard Nos Ctcers \\yottt °\aam\Gadoa G\tO\h\ptNt\eg�eeP °\c°�Via\ Peps 5o ets°aa ets°a•�. �eae\tcease \\\s a o\ret.\edby\a arts ended <o any \eqv as 02 •\aped s<ed as °pe soa of P° I� J f „ • J r - ( I 0 el 5 9 • bF,'1"SLRb 7y�' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING L This certifies that . . .Aaau/.n has permission to perform . . plumbing in the buildings of. . T- , (,✓�� _ d at . . .��� . /�n,ns �?��. �North Andover, Mass. Fee .67Z,.S.Q . Lic. No. .�J.0.�Y . . . . . . . . . . . . . . . . . . . ` . . . PLUMBING INSPECTOR Check 4 7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS ._11 OWNER'S NAME POWNER ADDRESS _6 TEL _ - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL hl EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES Q N012/ 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 GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM .__._.___1 ____._f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY .__.-_._. .......__._.__I ROOF DRAIN _J .._.__f _____.J _..._._J ___-_J -------- SHOWER ---._JSHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i _. i .__.._{ _ 6 I — _ f I=_..._._f _ _ E OTHIrR ._( ..._.._J _......_.J INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[if NO MJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1A OTHER TYPE OF INDEMNITY DI BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [- AGENT f 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. PLUMBER'S NAME / LICENSE# SIGNATURE MP JP CORPORATION 0# __ PARTNERSHIPP#=LLC E COMPANY NAME ¢ v { ADDRESS / j CITY �jy� STATE / ZIP �Q � TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �► J� /��l/ �� FEE: $ PERMIT# PLAN REVIEW NOTES n s The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/El Please Print Legibly Applicant InformationYA Y,� � Name(Business/Organizatiou/Individual): I f� Address: � � ' City/State/Zip: Phone#: _Z Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. []New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling 2.[JI am a sole proprietor or partner- listed on the attached sheet.# E] ship and'have no employees These sub-contractors have 8. [JDemolition working for me in any capacity. workers' comp.insurance. 9, []Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their of exemption per MGL 1 LgPlumbing repairs or additions 3.Elriht I am a homeowner doing all work g p p12,�]Roof repairs myself. [No workers comp. c. 152,§1(4),and we have no insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. ctors and their workers'comp.policy information. tContractors that check this box must attached an additional sheet showing the name of the sub-contra I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. t Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: pity/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/ox one-year�tor S Be advised that a copy of this statement may be forwprionment,as well as civil penalties in the form of a 0P.a ded�O the ffiEe of RK ORDR d a fine of up to$250.00 a day against the Investigations of the DIA for insurance coverage verification. Ido hereby ce.tify der hep ins andpenalties of perjury that the information provided ab ve is tr and correct: Date: Si ature: 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#: s 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 r 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: The Gomux ORWOalth of Massachusetts Department of Industrial Accidents Office ofluvestigatlons 600 Washington Street Boston.,MMA 0211.1 TO,#617-727-4900 exJ 406 or 1-877,7MASSAFE Revised 5-26-05 Fax#617-727-7749 WWW-Mass.govldia 4 • r COMMONWEALTH OF MASSACHUSETTS . PLUMBERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUMB Jl ISSUES THE ABOVE LICENSE TO: i I i DANIEL J BROWN � 171 CENTRAL ST NORTH READJNG MA 01864-1701 26,384 05/01/14 164590 Fold,Then Detach Along All Perforations • �z i' i i Date. �..�.�. .................. � NOarh oa; x TOWN OF NORTH ANDOVER PERMIT FOR WIRING t i J _ is • This certifies that .. ..U„ .5. Re.z..p 41% 0............................................. has permission to perform .................................c'Jov�J. r�. l e--.� ... ............................,. ......... L^I W wiring kk in the building of... p.�.................................................. a at ......l.�.��� .......' 1..��� �...........n.....!! -.�. ............�............ forth An dover, ... s..s... Fee55.C—o..........Lic.No. ............ ...... Check# 6 2-0 ELE SPEC .. commonwealth ol/i/ab9ac4uiettd Offic@ Use Only ' 2epartmen1 of,7ire S wicej Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: „3 Z� 13 City or Town of: /��/f-1,�;l,�re,�. To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) - Owner or Tenant (�� � - �; ,- Telephone No. (,t om o233 - b%d'75 Owner's Address -Z 71IL-4 leek • 50,4t„ 1'v✓t i fZ7. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building C-0Je,, 4-a.. an , 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: N©�.�� Completion o thefibllowing table mgy be waived by the Inspector o Wires. No.of Recessed Luminaires Z No.of Ceil.-Susp.(Paddle)Fans No.of otal Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above n- o.o Emergency Lighting No.of Luminaires Swimming Pool ❑ ❑ g y g g rnd. rnd. Batte Units No.of Receptacle Outlets r j, No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches o.o etection and $. No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alert Devices Tons g No.of Waste Disposers eat Pump .....umber.. Tons ...... No.o Se - on amed Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: �. No.of Water Nf o.of No.of Devices or Equivalent No.o Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices or Equivalent � OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 600 - O0• (When required by municipal policy.) r Work to Start: OI ZI13 , 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 same to the permit issuing office. CHECK ONE: INSURANCI:�4 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: �-(cam_( } �„ LIC.NO.: Licensee: TILS � Signature , LIC.NO.: �y� I applicable,enter "ezem t" (/ pP p to the license number 1'ne.) Bus.Tel.No. - Address: 07 �a57` 6"�' 54 . 5.10 H 0a 1 a7 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: 1 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: $ r �Y`T�� _ ^�� �� N� �-p��c �.`��%� .-, J � � �� z � ' t3 � � 1 i s i r Commonwealth ot`M9 , , setts Div%sion c`RegisL ati Board or Electn a l A JAMES J'f, N f 5 JASON l PLYMOUTi _ ' r Joumeymarr;ale 14630-B 07131,'2013 ry!~ 007711 Ex iration Date. Serial No P. •