HomeMy WebLinkAboutMiscellaneous - 115 WEYLAND CIRCLE 4/30/201829,11
ME
TOWN OF NORTH ANDOVER
Building Department
1600 Osgood Street
Building 2- Suite 2-36 Building Dept
North Andover MA 01845
Tel: (978) 688-9545 Fax (978) 688-9542
COMPLAINT FOR INVESTIGATION
DATE:,. h a-0 TEL#: Lj -7
NAME OF COMPLAINTANT:
ADDRESS: `�C> � Pte, I a -J v CQe /V try
COMPLAINT TYPE:
Electrical:
Plumbing:
Gas:
Building: bbo,k d-, vLC
Property Owner: •1 C'_.� Z— k dl-, OL t A \ PA y�C�
Address:
1
Other: -SGL.r e—
LL -�
b lti S t 1�s
Signed:
Complaint Form - Revised 6.2007
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Several neighbors are concerned that the owners of 115 Weyland Circle, North Andover are running a
boarding house in connection with their business as follows:
1) In December, 2013, Liwei Zhou and Weinan Qui purchased the home at 115 Weyland Circle.
2) In December, 2013, Liwei Zhou founded a business known as Chinese in New England Education,
Inc. with an address of 21 High Street, North Andover, MA
3) The Company specializes in coaching children from the high net -worth families in China to
prepare them for overseas education over a multi-year program of trips, summer classes and
the like.
4) During the entire summer of 2014, the couple boarded students at their home in connection
with their business.
5) An average of 15 students and upward resided in the home during the entire summer.
6) The neighbors believe that the internal structure of the home was altered to accommodate an
in law suite for the mother in law, and for housing the students.
7) The neighbors believe that the operation of a boardinghouse is detrimental to the residential
character of the neighborhood and is objectionable for the following reasons:
a. The amount of traffic in the neighborhood has been increased. A van transports the
students to and from their daily activities and is frequently in the neighborhood.
b. The students impose increased foot traffic in the neighborhood.
c. The students are dining on "take out" food regularly, increasing deliveries to the
neighborhood.
d. Airport transportation for the students to accommodate their trips increases traffic in
the neighborhood.
8) The owners of the home have approached other neighbors and have suggested that they could
make money by housing some of the students.
9) One neighbor has housed some of the students. The students carried mattresses through the
neighborhood to the other home.
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This certifies that _ J
Date .!.. l
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
has permission to perform .. a,.�!.ie c�r'1 .T / �?`t�,.!�J,.,'i5r�*.
.........................................................
wiring in the building of........,�eA v�-
.........................................................................
. ...........at ...// �" ��,,,,..P„.........- PE�-CnUCAL
, North Andover, Mass.
Fee �� �i-
.''......... Lic. No ��!.I�l`..... � ......... ........ .......... .............
E INSPECTOR
Check # �.'
.. Commonwealth of Massachusetts Official 'Use only
tPermit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONSev. 1199
� /j(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL, INFO TIOA9 Date: 4 I j - 2 r
City or Town of: �j�-� An aW To the Inspector of Wires:
By this application the undersigned gives notice ofs or h intention t perform the electrical work described below.
Location (Street & Number) �� tj W O of' or Cj r1✓Q
Owner or Tenant Z 2 Telephone No. A 1F 2
Owner's Address
Is .this permit in conjunction with ^building permit?
Purpose of Building "_/3 G�
Existing. Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed EIectrical Work:
1, q �,v 4 0 U,A-t 04` -
Yes V No El (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
CA
ComDletion of the follnwinc tahlp mnv hp wnivpd by the ?7 ectnr of Kres
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑In- E]
grnd. grnd.
No. of Emergency Lig-EM-9
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
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal El Other
Connection
No. of Dryers
Heating AppliancesKW
Security Systems:
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force., and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:)
Estimated Value of Electrical Work: bb (When required by municipal policy.) (Expiration Date)
Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete
A
FIRM NAME: LIC.
Licensee: '77A , C+Vou) Signature LIC. NO.: 11&14
(Ifapplicable, enter "exempt'�iin the �iceense`num er line .) p r,� MO) Bus. Tel. No.
Address: ' tiir�'/�Q/�' ►n i� 1{ri� 0� a Zi L,AIi Z�
1 Tel. No.: V
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. PERAHT FEE. $ ��
ELECTRICAL PERMIT FEES
Statutory reference(s): Mass. Gen.L.c143 a. K., 527 CMR 1200, Ordinances of the City of Chelsea, 3.4-50
c
**Fee for total estimated value of Electrical Work: 3% of $5,000 • $10,000; 2'/z% of $10,000 • $20,000; 2% of $20,000 - over
Residential Electrical Permit Fees Commercial and Industrial Electrical Permit Fees
Permit Fee Permit Fee
Basic wiring -with 100 amp service
(including meter) $50.00 Services
Each Additional 25-100 amps $20.00 Upgrading per 100 amps $40,00
Each additional meter $20.00 101-200 amps $60.00
Underground trench inspection $20.00 201-400 amps $75.00
Basic wiring - 2 inspections $40.00 401-600 amps $100.00
(sub -panel - additional charge) 601-1200 amps $200.00
1200 amps and over (per 100 amps) $25.00
Services
Temporary service (Panel & Meter) $75.00 Meter $25,00
Service change (relocation) $25.00 Sub Panels
(with meter) 691199 amps (each) $25.00
Each additional 100 amps $15.00
Service Upgrade 240 volt machine
Per 100 amps $25.00 AIC unit - heat cool unit (each) $85,00
Each additional 100 amps ' $20.00 Window air conditioner $25,00
Add public panel $25.00 Lighting - outlets - devices
Add public meter $25,00 1 -10 $15.00
11- 25 $30.00
Alterations - remodeling - miscellaneous 26 -10D $40.00
Sub -panel $20.00 101 and over (each device) $ 1,00
Signs $55,00 Transformers I Generators
Siding $30.00 0 -10 KVA $40.00
11.- 50 KVA $60.00
Electrical Outlets - devices - fixtures, etc. 51 and over $75.00
1-10 $10.00 Vaults and equipment $75.00
11-25 $20.00 Alarms, fire and burglar (2 inspections.
25 - Over $50.00 with panel) plus devices $55.00
Camivals, fairs, circus, etc. $100.00
Major Electrical Appliances
Dryer - electric range - hot water heater - disposal Annual continuous maintenance permit $150.00
Dishwasher - window air conditioner - other $15.00 (exception: major renovation)
Electric heat per KW $ 5.00
Central air conditioning or heat pumps $55.00 Demolition $40.00
Gas or oil burner $30.00
Alarms, fire and burglar (2 inspections) Explanatory Notes
(with panel) plus devices $55.00 1. If work is started and a permit is not obtained on or
Motors - each horsepower or fractional $ 2.00 within (5) days or without the consent of the wire inspector,
Generator $25.00 the fee will be doubled,
Low voltage wiring - per device $ 2.00 2. Tenant wiring in a commercial, mixed use building
requires a separate permit.
Swimming Pool Wiring 3. Minimum wiring permit shall be $40.00
Above ground $55.00
In ground $100.00
Take - over permit - rough - service - final (each) $25.00 y�
Reinspection permit for defective work $25.00
Renewal Permit $25.00 L
Demolition Permit $40.00
Explanatory Notes
1. Minimum wiring permit fee shall be $30.00 b
2, Permits Expiration dates are; New work -one (1) year
Remodeling - six (6) months
Pool - three (3) months
3. Minimum 200 amp service required for three family residences
J
I
a
The Commonwealth of Massachusetts , -
Department of Industrial Accie%nts
Office of Invesfigations
600 Washington Street
.Boston, MA 02111
www.massgov/dza
Workers' Compensation Insurance Affidavit: Builders/Cont°actors/Electricians/.Pliimbevs
Applieant Information Please Print Le�ably
Name (Business/Organizaiionftdividual): % L<, 1— l
Address:
City/Siatelzip: IV k en o 'Z 1 �—! ( Phone #;
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. 0 New construction.
employees (full and/or part time) * have hired the sub -contractors
IV 1 am a sole proprietor or partner- listed on the attached sheet. 7� E] Remodeling
ship and'have no -employees These sub -contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance•g. Building addition
[No workers' comp. insurance 5. El We are a corporation and its
required.] officers have exercised.their IO.KElectrical repairs or additions
3.E1 I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §I(4), andwehaveno 12.❑ Roofrepairs
insurancere ed. v employees. [No workers'
] 1311 Other
comp. insurance required.]
xAny applicant that checks box#I must also fill out the section beldw showing their workers' comp ens ation policy information.
T -Homeowners who submit this affidavit indicating they tie 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 o£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 anal job site
information.
Insurance Company
Policy # or Self ins. Lic. #: Expiration Date:
Job Site Address. Citylstate/Zip: /V C7 j e r
Attach, a copy oldie workers' compensation p olicy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL o. 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 liereby cert& under the pains and penalties of perjury that the information provided above is true and correct.
�-.Is .2--o(,�_
official use only, Do not write in this area, to be completed by city or town official.
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,-
express or implied, oral or wxitien."
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 tnistee 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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be, advised that this affidavit maybe submitted to the Department of Industrial
Accidents for con& anon 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 *orkers'
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 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 will be used as a reference number. Th addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) 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 ox permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho GoUIMoawealth of M-ass4ehvset s -
Department ofladwtdal Accidents
0 -toe ofTnvestigations
• 6Q� Vi�a$i�ag�o�. S1�oet
Boston, MA. 021. X x
TeJ. # 617-7.2'x_4.900 at 406 or. 1-877-:1V1ASS.AFE
Revised 5-26-05 Far, # 617"727'7749
v WW-Maagovfdaa
f-
1057;)
Date .GJ'411'-.-'.
TOWN OF NORTH ANDOVER
I I
This certifies that ? ...............................
has permission to perform -
plumbing in the buildings of ........ Z,6� ............................................................
at ..... 15 w .1
-,b— ., North Andover, Mass.
.....................................C`..(4k ........
.......... ..... ......
FeejLO..Lic. No. .........................................................................
PLUMBING INSPECTOR
Check
PERMIT FOR PLUMBING
WATER HEATER ALL TYPES
WATER PIPING
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
INSURANCE COVERAGE:
CITY
111616
LIABILITY INSURANCE POLICY 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.
MA DATE ( PERMIT #
SIGNATURE OF OWNER OR AGENT
JOBSITE ADDRESS
and that all plumbing work and installations performed under the permit issued for this application will be in compliance YA6hl Pertinent provision of the
A
OWN R'S NAME 'WCl
P
OWNER ADDRESS
COMPANY NAMEr/�. ADDRESS ( G ► C_v t
TEL —1FAX
TYPE OR
OCCUPANCY TYPE
COMMERCIAL
EDUCATIONAL D RESIDENTIAL 0l
PRINT
CLEARLY
NEW: RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES D NODI
FIXTURES Z FLOOR-
BSM 1
2 3
4 5 6
7
8
9
10
11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
(
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
�. I __._.. _._ _I P
l _._I..____J __-- (__..___ ___..__ 4 –_..i
DRINKING FOUNTAIN
! ..._.____1 ._.._ !
._._..._! _f I ! ..__..._.J ...__...J .-- .__.1 .__..._1
FOOD DISPOSER
FLOOR AREA DRAIN
T_I
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
I _Ill 1711 _.__ 111111
_.-..i _..-__6 _....._ ____...1 _..
WATER HEATER ALL TYPES
WATER PIPING
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E] NO El
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 [I AGENT D
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 acc 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 compliance YA6hl Pertinent provision of the
(Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L.— _�3 I't LICENSE # , �i o i ( SIGNATURE
iVIPd JP DI CORPORATIOND# PARTNERSHIP D#®LLC DItI
COMPANY NAMEr/�. ADDRESS ( G ► C_v t
CITY STATE ZIP (}Z(7 TEL A�AA
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ry The Commonwealth of Massachusetts
Department oflndustriglAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name (Business/Organi'zation/lndividual): G
Address: eo
City/Stale/Zip: Phone #:
Are you an employer? Check flip 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).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7• F1 Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.9,
5. [J' We are a corporation and its
❑Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10.[] Electrical repairs or additions
3. ❑ I am a homeowner, doing allwork
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.❑ Roof repairs
insurance . re uired
required.)
employees. [No workers'
13.❑ Other
comp. insurance required.]
I Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they ire 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 anal job site
information.
Insurance Company
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: Vim C� C/ City/State/Zip:
�'
Attach a copy of the workers' compen tionpolicy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP -WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA. for insurance coverage verification.
Y do hereby certify u tla pains and penalties ofperjury that the information provided above is true and correct.
--�
Date: b �F
c;o„afi„-P• ,. --' � -
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License U.
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 #:
M
Information and nstru.ctiolms
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 em
ployer'is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be. an employer."
MGL chapter 152, §25C(6) also states.that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phonenumber(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 LL C or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 retum.ed 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 GaxumoawDalth of Massacbmetts
DepartMeut of fadusWal Accidents
Office o£Xuvestigatious
600 Washington Street
Boston} MA 021 X Z
Tel # 617-727-4900 eyt 406- oz 1-87MASSAk'B
Revised 5-26-05 Bax# 617"727-7749
vt€��v_mace antxfrTia
v
JN W
9387 Date. . �//XA .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SSA U
This certifies that Xeres ...........
has permission to perform
plumbing in the buildings f Z? rliq r
at .... 11-5 ...... ". rc Z, A*-*d,ov*e,t';, Mass.
Fee Lic. No. /A .
PLUMBING INSKtCTOR
Check #
MASSACHUSETT$ UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�• .
CITY MA DATE �% 7— /Z PERMIT It
JOBSITEADDRESS!�S WCy-�qfv i� C 12� . OWNER`$NAMEJ b&Aikjc- /e14*t10"- :CX4 -1 i
r
OWNERADDRESS l/ TEL IFAXI I
TY.P --0k
OCCUPANCY TYPE COMMERCIAL J I EDUCATIONAL (I RESIDENTIAL
PRINT
CLEARLY
NEW: I RENg11AT149: ] I REPLACEMENT: f PLANS SUBMITTED: YES( I NO.j I
FIXTURES 1 FL06R-+
13SM
1
2
3
4
5
ti
7
a
9.
10-
11
12
13
14
BATHTUB-
....._
......_
...
..
...
...
..
..._
..._..
__....- -,
CROSS CONNECTION; DEVICE
DEDICATED SPECIALtNASTE'SYSTEhi
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
....
. ......:
....._..
:...:..
I .:.
DEDICATED GRAY WATER SYSTEM
j
DEDICATED WATER RECYCLE SYSTEM
_
DISHWASHER
DRINIONG FOUNTAIN
l;
FOOD DISPOSER
FLOOR IAREA DRAIN
j
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
I
i
.
—.—'
I
....
......
_-......
....
ROOF DRAIN
_
--
SHOWER STALL
SERVICE/MOP SINK
TOILET
-
URINAL
WASHING MACHINE CONNECTION
—
WATER. HEATER ALL TYPES.
-----
- --
W/ITER PIPING
..OTHER
_.._
INSURANCE COVERAGE:
1 have a ctirrent•liabilit iilsitratice policyor its substantial equivalent wilich meets the fequiraments of MGL Ch. 142. YES 1 I No
IF YOU CHECKED YES, PLEASE INDICATE THE TYeE OF COVERAGE BY CHECKING THE APPROPRIATE13OX BELOW
IIIABILITYINSURANCEPOYCYJ 1 OTHER TYPE OF INDEMNITY I ( BOND I. i
OWNER`S INSURANCE :WAIVER: I and aware that the licensee.>does not have the insurance coverage required by Chaplet 142 of the
Massachusetts General Laws, and thatiq signature on this era it application vuaives this retittireinent.
_ I;HECK'ONEONLY:. OWNER AGENT.
SIGNATURE OF OWNER OR AGENT
1 hereby certify Thal all of [lie details and information I have subAliited ot enlered recdarding:this application are true and accurate to the best of my knoerlddye
and that all plumbing work and Installations performed under the permit issued for this application %trill be in c ompliance VAlli al[ P ' trent prgvision of'the
Massachusetts State 'Plumbing Cale and Chapter 142 of Hie General Lams.
PLUMBER'S NAME[- 120 t,(.'T ILICENSE11IIZ_o�f1 NATURE
MP]af JPI 1 CORPORATION] .It/j 'PARTNERSHIP -!#f LLC I ]0I
COMPANY NAME + IADDRESSI /ii�r6 SC,4J)cii,, S'T-
CITYI OLA CCILe - STATE 1 4 1 ZIP !EL C 4- Yp I
FAX CELL I I EMAIL I
Vl
LU ld
d
F
u
� C)
V
J
Q,
a �
LU
a
g
a
ry The Commonwealth of Massachusetts -
Department of IndustriglAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov1dia
Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ?1C,^(.r P j4�
Address:_
City/State/Zip: b" U- MR U 152 f Phone #: '?;T -57z—,901
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 1
6. ❑ New construction
employees (full and/or part-time).*
2. 91 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7• ❑ Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance,g,
5. El We are a corporation and its
❑Building addition
required.]
officers have exercised their
10.C1 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing. repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roof repairs
insurance required.)
employees. [No workers'
13.❑ Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they hire 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.
X 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: 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.
X do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
P. 1, Date- y' /% - t Z-
91 >e-
%>e f-a—
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
6. Other - -
Contact Person:
4. Electrical Inspector 5. PIumbing Inspector
Phone
Inform.ati®n 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 employes."
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 maybe 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 retumed 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. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of investigations would like to thank you in advance. for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Mossacliv..setts
De.p.artment of Zndustdal ,Accidents
Offioe of'Investigatxons
600Wa.shingto>a. Street
Boston, MA 02111.
TO, # 61.7-7274900 ext 406 or 1.-877,MSSAFE
Revised 5-26-05 Fax 0 617;,727-7749
WwwW-mass.govfclia
w
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) I I S Y la"td C14-4- L
NORTH ANDOVER, MASSACHUSETTS
11AA � /! "� ^ ,, Date
Building Location 5 VVP,G/ C G! ae_ Owners Name I �1�+�G-� / Penn it #
(` Amount
Type of Occupancy k4e—� +C
New Renovation Replacement Plans Submitted Yes No
FIXTURES
(Print or type) i Check one: Certificate
Installing Company NameLi�iClYi �(�rft� Corp.
Address` If6 SPartner.
DA /1 AC'A� �1 4C► i F Z fo
Business Telephone V]k7 S'7Z — Firm/Co.
Name of Licensed Plumber: 'Ro6c— sJ (-:-j
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 11 Other type of indemnity n 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 ins nce
Signa ur Owner Agent F1
I hereby certify that all of the details and information 1 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 Massachus to P bin Code an hapter 142 of the General Laws.
By: Signature ure o icense a Piumoer
Tvoe of Plumbing License
Title 70 YY"- ,...,/
City/Town License um er Master I V� Journeyman
E
APPROVED (OFFICE USE ONLY
J
i ilk ■■■■■■■■■■■■■■■■■■■■■■■■■
(Print or type) i Check one: Certificate
Installing Company NameLi�iClYi �(�rft� Corp.
Address` If6 SPartner.
DA /1 AC'A� �1 4C► i F Z fo
Business Telephone V]k7 S'7Z — Firm/Co.
Name of Licensed Plumber: 'Ro6c— sJ (-:-j
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 11 Other type of indemnity n 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 ins nce
Signa ur Owner Agent F1
I hereby certify that all of the details and information 1 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 Massachus to P bin Code an hapter 142 of the General Laws.
By: Signature ure o icense a Piumoer
Tvoe of Plumbing License
Title 70 YY"- ,...,/
City/Town License um er Master I V� Journeyman
E
APPROVED (OFFICE USE ONLY
. ..
- �
0
r
��
Location J w
I
No. "7/ Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ () — p
Building/Frame Permit Fee $ Z 9 Z
Foundation Permit Fee $ T
-Otbar- Permit Fee $ Z S
C`w Sewer Connection Fee $
o
Water Connection Fee $ u i
TOTAL $ L I L
Building Inspector .�
9599 Div. Public Works
t
/� 2
Location �� �, C � � l D 2
No. `71 Date 2 - 7-7- 4t�4 .
� R
TOV ,N -OF NORTH ANDOVEFV
p Certificate of Occupancy $
i'
Building/Frame Permit Fee $
,3 ACMUSE� Foundation Permit Fee
Other Permit Fee $
/0 Sewer Connection Fee" C-
Water Connection Fee $ lD77.C7
d TOTAL $ U
AI S«
Ins for
�'
9026
j Div. P6bi c Works
PERMIT NO. "IL
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
V
PAGE 1
MAP d40.
LOT NO.
2 RECORD OF OWNERSHIP (DATE
BOOK 'PAGE
ZONE P;e SUB DIV. LOT NO 7") tZ2-7
I
LOCATION//s_ ��/La.�d' �'irc!>� �a3C�oad
—
�4-e L, e --e—
OWNER'S NAME 6 O� a S /, r
f C
NO. OF STORIES SIZE
T T tG
OWNER'S ADDRESS �� l
BASEMENT OR SLAB is%e iii -e N7
ARCHITECT'S NAME CA Z 'l .[A f
L 6 L
SIZE OF FLOOR TIMBERS IST r7 1! 2ND �x f 0 3RD
BUILDER'S NAME�a %�--� a l d � � '
�— 12 xL6
SPAN
l
--111 ,��
DISTANCE TO NEAREST BUILDINGa / T
---
DIMENSIONS OF SILLSY --
POSTS 3��1r2
DISTANCE FROM STREET 'j �, /
DISTANCE FROM LOT LINES - SIDES ` REAR 20+
" GIRDERS
T
AREA OF LOT 1� S�cT'�7- FRONTAGE /�e�1�f
` vV
HEIGHT OF FOUNDATION �/ I THICKNESS
O
IS BUILDING NEW YP s
SIZE OF FOOTING f/ X �� r
IS BUILDING ADDITION �f i �.
'/vJ
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
0
IS BUILDING ON SOLID OR FILLED LAND �� J
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Yes
l
IS BUILDING CONNECTED TO TOWN WATER p tS
BOARD OF APPEALS ACTION. IF ANY `1/
/V
IS BUILDING CONNECTED TO TOWN SEWER -e S
IS BUILDING CONNECTED TO NATURAL GAS LINE -eS
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGN REO OWE N 7OR AUT RI D AGENT
FE��+�1
-G-0 '"
PERMIT GRANTED /
_! 19
PERMIT FOR FRAMUBUILDING
DATE: 3"tq"q 6 FEE PAID; 3/
ek;.
3 PROPERTY INFORMATION
LAND COST 2r &ate
-EST. BLDG. COST / 0 ^ d-z,y
EST. BLDG. COST PER SQ. FT. 5-y
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO. 1✓11A
4 APPROVED BY
OWNER TEL.#
CONTR. TEL. #
CONTR. LIC. # /6 L v
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY
ISTORIES
MULTI. FAMILY
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 ' INTERIOR
FINISH
CONCRETE
PINE
d
T
1
2 13
q "
CONCRETE BL'K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY WALL
UNFIN.
_
3 BASEMENT,,
AREA FULL
FIN. B'M'T' AREA
_
14 7/7 7/,
-'FIN. ATTIC AREA
O
NO B M
FIRE PLACES
HEAD ROOM
_
MODERN -KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
_
1
2
�_
__
3
_
_
DROP SIDING —
CONCRETE
WOOD SHINGLES
EARTH
HARD'✓'D
COMMON
ASPH. TILE
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
STUCCO ON MASONRY
STUCCO ON FRAME:
BRICK UN MAS N Y ,
BRICK ON FRAME
ATTIC STRS. 6 FLOOR
_
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE OW FRAME
SUPERIOR I� POOR
ADEOUATE NONE
5 ROOF
10 PLUMBING
GABLE
HIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. 12 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
A
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. h COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
GAS
7 NO. OF ROOMS
L
B'M'T 2nd
tatI 3rd
ECTRIC
rNLO
HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONSOFLOTrAND DISTANCE -FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
t"
a
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: �O X GU o d cy �,� �1 /T� �o r� Phone
LOCATION: Assessor's Map Number
�,
Subdivision L o R W,),n
Street �/(% 2 �/ �� v� c� C/
Parcel
Lots) .2;2
St. Number/�
************************Official Use Only************************
RECO ATIONS OF AG S:
Date Approved
Conservation Administrator Date Rejected
Comments
Town Planner
Comments
Food Inspe��t
c/lor-Health
�
Septic Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections -.7 -Y6
- driveway pe it = i -J 7 - 77 -y�E
Fire Department %
Received by Building Inspector
Date
KAREN H.?. NELe0`
anvor
Bi ILDI%G
l:OX5c3t:aTiU\
HE AL: H
In
--_ =-=Town-of - --
-' :
NORTH ASN -DOVER
'14 OF
PL ti'.Zti G CO3Ll, UNT= DEVELOP -NMN- T
Mc Alm?r• ; CATMON AND
120 Main Street- OIC
(S08) 682-6433 -
Dea� � PE� i�ql i T
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BL__l._R' S N;`�
;- =.S o N IS N2LM:
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Date. .
Tn 2641
M
,0RTFi TOWN 01
t VORTH ANDOVER
L CTI�10U;L
PERMIT FOR =1B INSTALLATION
SA
This certifies that....
wl rw#JG
has permission for gin installation ..FqA'.4°"'4.
in the buildings of . .....fV.Um Q -
at ......... North Andover, Mass.
Fee.:0.3 :0 Lic. No. //72/j ..........................
(- � it GM INSPECTOR
WHITE: Applica& 7w �CANARY: Building Dept. PINK: Treasurer GOLD: File
r
Office Use Only G(
tm u4t �lJmmnnwratt4 of �n*unEi� Perrnit No.
lepartmttrt of public hafttq Occupancy A Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMA 12:00 3190 peave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 �C-M% 12::00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date .
(M)Q or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform th electrical work described below.:-
Location
elow-Location (Street & Number) Lci?--
Owner or Tenant Fox- in cyo 12e,
Owner's Address ')33 _TL/&On! i',- s A/. ✓)
Is this permit in conjunction with a building permit: Yes er� No C (Check Appropriate 0x)go
Purpose of Buiidina Siq a%I� -%� I-q�e Utility Authorization No. R 0
Existing Service Amos _J Volts Overhead EllUndgrnd ,[ No. of Meters
New Service ? (K) Amps � Volts Overhead E Undgrnd UL No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work V -e- W We_ //I &V
OV 4,— 100 u✓11-e7S
No. of Li un Outlets I No. of Hot .ucs I Total
1-:9hung No. of Transformers KVA
ISwimming PcoiAbove— in- IGenerators KVANo. of Lighting Fixtures grno. -- grna.
No. of Emergency Lighting
No. of Receotacie Outlets No. of Oil Burners I Battery Units
No. of Switch Outlets I
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Total
No. of Ranges
No. of Air Core.
tons
Initiatina Devices
Devices
No. Disposals Heat I Noor Heat Total Total
of
Tons
KW
No. of Sounding
No. of Self Contained
No. of Dishwashers /
I SoaceiArea Heating
KW
Detect:onrSounding Devices
— Municipal =i Other
Local _ Connection
No. of Orvers
I Heating Devices KW
No. of No. of
Low Voltage
No. of `Nater Heaters KW
I Signs Sailasm
Wiring
No. Hvdro Massage Tubs
I No. of Motcrs Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the recuvements of Massacnusetts general Laws . /
I have a current Liability Insurance Policy including Comoi c Operations Coverage or its substantial ecuivaient. YE5 L� NO = I
have suomitteo valid proof of same to the Office. YES VNO = It you have checked YES. please indicate the type of coverage by
checxing the aopr priate box.
INSURANCE J BOND = OTHER = (Please Specify)
(Expuanon Datet
Estimatea Value of iectn al Work S
Worx to Stan S � � Inspection Date Recuested: Rough
fwd 1 G,411 Final
Signed unser t e Penalties ofPu erI r _ `
Al�
FIRM NAMEL 19 W gA Ge G74/ 9 LIC. NO. -19q 7/1
Licensee r L tt.ai I G.a C r Signature �� -LIC. NO.C,
,I Bus. Tei. No. (^ rT o - �d
Address �� /�i;� sh�r� t=f Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee Ices not have the insurance coverage or its substantial equivalent as re-
quirea by Massachusetts General Laws. and that my signature on tuts permit application waives this reoutrement. Own gr Agent
(Please checx one)
Telephone No. PERMIT FE. 5
(Signa,, of Owner or Agent) x�i5o5
T32192
Date ...� ..�. ".#?... .
NORTH TOWN OF NORTH ANDOVER
OFt�,,Eo ,egq.0
0 y� � PERMIT FOR GAS INSTALLATION A
p �
This certifies that . ... ... , �l.... ". .... .
has permission for gas installation . ; a
in the buildings of ... .............
.. ........
at// p
. :f.�i1�,�.,�...t�. •. . , North Andover, Mag.
Fee ...7d. Lic. o. ,/U. �.! . ....................... �.
(kit -3 ,► GAS INSPECTOfl
WHITE: Applicant CANARABuilding Dept. PINK: Treasurer GOLD: File
t:.
1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
G
iiXt Ety C- , Mass. Date
Building Location 1' 4 22 f6'4-/-10,'
New Ly' Renovation O Replacement ❑
_ 19 Permit # OC114
Owner's Name
Type of Occupancy SINGLE FAMILY
FIXTURES
Plans Submitted: Yes ❑ No ❑
Installing Company Name GALINSKY PLUMBING & HEATING INC.
Address P.O.BOX 1701
HAVERHILL, MA 01831
Business Telephone 508-374-1743
Name of Licensed Plumber or Gas Fitter STEPHEN C. GALINSKY
Check one:
n Corporation
❑ Partnership
❑ Firm/Co.
Certificate
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes)e No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application walves this requirement.
Check one:
Owner ❑ Agent
Signature of Owner or Owner's Agent
I hereto certify that all of the details and information 1 have submitted for entered) in the above 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 al! pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General laws.
Ts oe of license
Title Cr master Signature of Lic sed Plumberor Gas Fitter (/
C - journeyman License Numk 10348
or
■■■■■D■�■■■■■■■■■■■■■■■■■
IrM.".T.T.2■■■■■■■■a■■a■■■■■■a■■■■■
176TI M.
Installing Company Name GALINSKY PLUMBING & HEATING INC.
Address P.O.BOX 1701
HAVERHILL, MA 01831
Business Telephone 508-374-1743
Name of Licensed Plumber or Gas Fitter STEPHEN C. GALINSKY
Check one:
n Corporation
❑ Partnership
❑ Firm/Co.
Certificate
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes)e No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application walves this requirement.
Check one:
Owner ❑ Agent
Signature of Owner or Owner's Agent
I hereto certify that all of the details and information 1 have submitted for entered) in the above 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 al! pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General laws.
Ts oe of license
Title Cr master Signature of Lic sed Plumberor Gas Fitter (/
C - journeyman License Numk 10348
r - ,z
Date.... I
....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ /�
..................................................................................
" — ': ,/ ... (4 ................................
has permission to perform �I�� ....................
wiring in the building of
. . ....... ...........................................................
at ...... ....... . . ..... .. .. .... . North Andover, Mass.
..........
e I I- . 1�
Fee..�O ............. Lic. No No.............. ............. . .. .. .......... . . . .......
...........
Check ELECTRICAL.
NSPE R
4
CcorrvsonwaaLlh o��c�a�ar�affs
4 �aParfirtsn� o�}ira �arvika.9
BOARD,OF FIRE PREVENTION REGULATIONS
Or;icial UseOnl- y --�
Permit No. 7y U
Occupancy and Fee Checked
(Rev. I/07J leave blank) I
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (bI, 527 CMR 12.00
IN
(PLEASE PRTNINKORTYPE ALL INFOR�idATIOA9 Date:
EC (j
City or Town of: 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) _ _ _ _ % S LU %r/Z%2�Qo
Owner or Tenant B'�t _ TelephVY
n o. B ? l g Cp
Owner's Address
/ / S_ 11(J_
Is this permit in conjunction with a building
perm-it?
Purpose of Building
Yes ❑ No E (Check Appropriate Box)
Utility Authorization No.
Existing Service s Amps / Volts Overhead ❑ Undgrd ❑ No. of N-tters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:y-��p„�� CL�-t er, o P-Gu.r i a r� tri 14 Lar rn
' - S L{ S -rem
Comoletion ofthe following table may Ge waived 5v the 1nsvector of Wires.
No. of Recessed Luminaires
ector
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above n- EJ
Swimming Pool-rnd. grnd.
19-6.76F.Effiergericy ;g.aung
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Cas Burners
No. o etecUon an
c :..iating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
o
No. of Waste Disposers
eat umpum
Totals:
er
ons
i
o. oSelf-Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P a
Local ❑ 1 untcipal E] Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
i o. of Water KW
%seaters
o• o Bo. of
Signs
Data Wiring:
No. of Devices cr E uivsl:nt
No. Hydromassage Bathtubs
No. of Motors Total HP
e ecommuntcattons tr;ng: -
No. of Devices' or Equivalent
OTH E R: db l of Wires
Attach additionaldetarl rf desnred oras require y e tup
Estimated Value of Electrical Work: �� (When required by municipal policy.)
Work to Start:0,-44ZAnspcctions to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit foe the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, thatthe information on this application is true and .complete-
16-33
omplet ! 53 3 .
FIRM NAME: LIC. S�Curt'R-� Scr�t LIC. NO.:
Licensee:LSign ature's—�_ LIC. NO.:
(Ifopplicable enter "e a pt" in th�Iiken,=nber line j Bus. Tel. No.: 5_iK9-9
Address: i � e� L / /11T-G� �Ij�_ t� /�(S , 'UH ? Alt: Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. s CC- G l9 /5
OWNER'S INSURANCE WAIVER: I am aware that the Licenser 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 ❑)wner's agent.
Owner/Agent$
Signature Telephone PERMIT' FEE: No. �— .
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