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Miscellaneous - 12 MIDDLESEX STREET 4/30/2018 (2)
/ 12 MIDDLESEX STREET 210/043.0-0003-0000.0 Date l�.�,;-11-1 .......... &ORY#4 oF. ,9D 1* TOWN OF NORTH ANDOVER 0 PERMIT.FOR PLUMBING Hu This certifies that PA c,� C4 c,-j e- -�Q'S ......I......................................................./.................................................I has permission to perform....V�........�... ................... plumbing i the b 'Idings of....0 C� P.V-�u -, 2 g m, e iii ........................................................................................ at ...... North Andover, Mass. Fee .......................................................... "ri PLUMBING INSPECTOR Check# 2-64 - ks 17';-11`� t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK b CITY K=F�-- MA. DATE ll�i�f"I PERMIT# D JOSSITE ADDRESS mi t ¢J OWNER'S NAME Scoff�j h p OWNER ADDRESS !� _ r� TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:F-1RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO F-1 FIXTURES 1 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER , 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws,-and that my signature on this permit application waives this requirement. 00 CHECK ONE BOX ONLY: OWNER El AGENT ❑ Signature of Owner or Owner's A Brit 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 NAME Peter J. Crane SIGNATURE_/ 21805 # MP❑ JP E] CORPORATION ❑# PARTNERSHIP ❑#__ LLC ❑# "ANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street Haverhill STATE 11A ZIP 01830 EMAIL annacrane.ac@verizon.net' 978.771. 1155 CELL 978.771. 1155 � FAX �j l 1 `�. �' �� � -�_ �-. r ' I i q ....�. ' i �Honrh TOWN OF NORTH ANDOVER q"= PERMIT FOR GAS INSTALLATION gs�cMuss 1 This certifies that ............:....... �....................... . ................................. has permission for gas installation .... cit >c in the buildings of..Cc, v)�.�, at....... . ....r"}. .Q. ............:V.............................., North Andover, Mass. Fee..-30250. Lic. No. . . . .. ................................................... GASINSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A, /4n4)C f f===� MA. DATE ��� _ I PERMIT# U JOBSITE ADDRESS' / tQt OWNER'S NAME < G OWNER ADDRESS: tag TEL: 1 -1 FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT. CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ i FIXUTRES 7 FLOOR- Bsmt 1 2 3 4 5 6 7 8 1 9 1 10 11 1 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i INSURANCE COVERAGE rl have a current liabili 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. LIABILITY INSURANCE POLICY ] OTHER TYPE INDEMNITY ❑ 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 ❑ 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 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/GASFITTER NAME: Peter J . Crane LICENSE# 21805 1 IG�RE COMPANY NAME: Crane's Plumbing & Heating ADDRESS: 70 Douglas Street CITY: Haverhill STATE: 71A ZIP: 01830 FAX TEL: 1 978.771.1155 CELLI 978.771.115 EMAIL: I__annacrane.ac@verizon.net MASTER❑ JOURNEYMAN ® LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#� i6 a �r� r 4 1 WwCOMMONWEALTH OF MAS US Il 13-1 oki • • • • :w PLUMBf'1t`5''AND GASF>I> . .... RS S.SU>E;SHE FOLLOWING LICENSE.* L I CEN5EI1 AS A JQIiRNE:YMAN:�PLUMB a I #'ETk:R J CRANE x 0 DOUGLAS ST HAdERH ILL. » ;;MA O l$3076741 111161:10 MA Ell jjlll:[,�_ wrinfa..,'.. The Commonwealth of.M•assachusetts , - - Department of IndtfsfrjgI Aeeidents Office ofInvestigations 600 Washington Sheet Boston,MA 02111 Uf wwm mass gov/dia Workers' Compensation bsurance Affidavit:Builders/Contrc°actors/BlectriciansfPlumbers Applicant Xn£ormafion Please Prim Le�itbly Name(Business/Organization/fndividual): ����Q Address: City/State/Zip: Phone#: ��/f Z-1 f , Are you an employer?Check the appropriate box: Type o£project(required): 1.❑ I am a employer with ___ d'• ❑ I am a general contractor and I 6• E]New construction employees(fail an.(Voxpart-time)* have hired the sub-contractors 7. 0 Remodeling 2.Q�I am a sole proprietor or partner listed on the attached sheet.r These sub-contractors have 8. El Demolition ship and'have no employees working for me in any capacity. workers'comp.insurance. 9• F1 Building addition [No workers' comp.insr�rance 5• El We are a corporation and its 10 E]Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑Plumbing,repairs or additions 3.❑ I am a homeowner doing all work c 52 1(4),and we have no myself.[No workers comp. ,§ 4( ) 12.QRoofrepairs insurance required.]t employees.[No workers' nXI Other comp.insurance required.] ''`Any applicant that checks box#1 must also fill outthe section below showingtheir workers'compensation policy information. I-Homeowners who submit this affidavit indicating they sre doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that cheekthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. f am an employer that isproviding worrcers'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 xequiredunder 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. X do merely certj9under the gins and penalties ofperjury tliat tree information provided above is true and correct. Si ature:� Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tows.Clerk 4.EIectrical In 5.Plumbing Inspector 6.Other - - Contact Person: phone#: L Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees, Pursuant to this statute,an,employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or lobal lie-ensing 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 cgntracting 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 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. fu 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 shouldwrite"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 us on file for futureexmits ox licenses, Anew affidavit must be filled out each h 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 aiud fax number: Tho Go 4RwealthofMUssa.,rhme-M Dep.attm,ent of Indusidal.A coldauts (, iWe ofla-Vestxgatiom 600 Waftg(ox.Stxe�t Boston,MA 041111 Tei, 617-72.7-4900 ext 406 ox 1-$77-MA.SSA'F Revised 5-26-05 FaY.#617-727-7749 749 WWW-M1Ms,g4vfcha Date...q./..�..��V.................... 4 ` OF NOR7h,� TOWN OF NORTH ANDOVER * PERMIT FOR WIRING ,SSgCHU56 This certifies thatArk . /1'I.,./ � �{ ....... has permission to performA/ rt ,, ,,,.,/'K.c�. na wring in the building of..//............... .�s^-r.................................................. �x .. .......'......!!..f........., X... ..........................North Andover,Mass. &e..... �!... ...1...,�.......Lic. No. ........... .. ......... �'�y�' EPCTR*]C�AL INSPECTOR Check# 14 /20 li. Commonwealth of Massachusetts official Use only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT MINK OR TYPE ALL.INFORMATION) Date: Mj/ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant seM Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes V1 No ❑ (Check Appropriate Box) Purpose of Building POIY I eAe—hj%) Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters j Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: MA) + 1006C °1 6>Vr-1 bSvP/ Completion of the following table may be waived by the Inspector of Wires. 1-44— No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In E] No.o Emergency Lighting c.s rnd. rnd. Battery Units No.of Receptacle Outlets U No.of Oil Burners FIRE ALARMS No. of Zones No.of Switclies No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number I Tons I KW No.of Self-Contained Totals:I I • ••••••••• '••'••••••••••'•••'' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other ` Connection No.of Dryers Heating Appliances / jar Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters — Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs---JNo.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: _ Ip Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electri al Work: (When required by municipal policy.) Work to Start: ?� / t;/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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 V BOND ❑ OTHER ❑ (Specify:) X certify, tinder the gins and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: _ �[ LIC.NO.: 76!� Licensee: .&DeM O-z&lg6 Signature LIC. •NO. 1&d?616 (If applicable,enter "exempt"in the license number 1 ne.) us.Tel.No.: . - —13C, Address: 0Alt.Tel.No.: ` 3374/ *Per M.G.L c. 147,s.57-61,security work requires hepartment of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature e PERMIT F g Telephone hone No. WE:P $ Q ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit.application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an by electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. �. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP Pass ? Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: �� fes.-. q Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com P /1 l The Commonwealth oflMlassachusetts 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 Leizibly Name(Business/Organization/Individual): MMD", Y /`'/AZ'L` J� Address: G0 6e - City/State/Zip: &/'� C9911 Phone#: �' �9 /✓� Are you an employer?Check the appropriate box: Type of project(required): 1.1�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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ,Wmodeling 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. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance -required.) employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box41 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 fhe policy and job site information. Insurance Company Name: 14MPA Policy#or Self ins.Lic.M 800gog0 c/o4- rZ ExpirationDate: 0 Job Site Address: 12 %�/'� City/State/Zip: Attach a copy of the workers'compensation-policy ileclaration page(showing the policy number and expiration date). Failure to secure coverage as required-under Section 25A of MGL 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 ofup 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 DTA for insurance coverage verification. at' ro ided above is true and correct. - enalties o er'u that thein orm ton v Xdo hereby cert undertliepatns andp fp J ry f p Sim ature: � � Date: Phone#: 3 t 30 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.written." An employd 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 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicahts Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired 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 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. 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 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: `rho CoinMo>«w a o£Massacliusetts Department of fadustdat.Accidents Office of Tntyestigatioms 600 Washingtoa Street Boston?MA 021 X Z Tell,#617-727-4900 ort 406 ox 1-877-MASSAFF Revised 5-26-05 Fax#617-727-7749 _. _ __ TFFCFF{TF YYfnnn rrnTs��i.. !J I Ol COMMONWEALTH OF MASSACHUSETTS ® ® • - o s B0AF#1?-OF ELECTRICIANS ISSUES THE FOLLOWINGLiCEN'SE AS A RE:G .JOURNEYMAN ELECTRISC.IiAN c` ANOREW G .LITZENBERG 22 WENOEI_L Rb EXT tiff NAHANT; MA 01908-1129 l 1496 B 07'/31</< 6:::. .; ' 39633 r lif`' { Date.................................. f NaR7M q 3:;•,;�`` " TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING SACMUSEt This certifies that ... ............................................................................................. has permission to perform t .................................................................... wiring in the building of.....2 ....n-n . ..... ............................................... at.Z2....... �'� -�-�-F•L �' ........... ,North Andover,Mass. Fee........ ......... Lic.No/2etrh' ELECTRICAL INSPECTOR Check # -? 7 l° 8078 "' Commonwealth of Massachusetts official Use Only IMMM Department of Fire Services Permit No._ ?6 7F Occupancy and Fee Checked -lj�S—c' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice ofd er intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address s Is this permit in conjunction with a building permit? Yes tv l No 1 ( ❑ (Check Appropriate Box) Purpose of Building /. Z 1'/ eol C r Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans N0.0 Total Transformers KVA y No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o mergency ig g d. rid. Batte Units No.of Receptacle Outlets No.of Oil Burners EIRE ALARMS No. of Zones 4 No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices i No,of Ranges No.of Air Cond. Ton' No.of Alerting Devices No.of Waste Disposers .Heat Pump Number Tons KVV No,of Self-Contained Totals: __......_..............._._.__. D ection/Alerting Devices No.of Dishwashers Space/Area Heating K Local 11Municipal W . Connection 0 Oma' No.of Dryers Heating Appliances KW Security Systems:* No.of Water o.of No.of Devices or Equivalent Heaters KW No.of Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total gp Telecommunications firing; OTHER: No,of Devices or E uivalent ' Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under th ains rid a tie o p ��) P ofperjury,that the information on this application is true and complete. FIRM NAME:i�C LIC.NO.: 3 Licensee: t C�,r�.^ �tayP Signature LIC.NO.:/16 (If applicable, enter"exempt n the license number li e.) Address: f a f C'2 ,0,_, 5'T �,ytes�v�„�� ^,14 p/Ick Bus'TeL No.:q U_ 7 *Per M.G.L c. 147,s.57 61,security work requu•es „ „ Alt.Tel.No.: 'J 3 epw ent of Public Safety S License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the( Owner/Agent check one) ED owner ❑owner's agent. Signature Telephone No. PERMIT FEE.S �,6 . 'ZS-.,' •� ��� � - - _ Y � 4 M The Common wealth of Massachusetts s~3 I Department of Industrial Accidents Office of Investigations 600 Washington Street ,a % Boston, MA 0211 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectrlcians/Plambers AnoEicant Information Please Print Legbly Name(Business/Organization/Individual); —� Address: City/State/Zip: Phone Are you an employer?Check the appropriate box: 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I Type of project(required): employ=(full and/or part-time).* have hired the sab-cotmactors 6. ❑New construction 2.❑ I am.asoie proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sins-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp,insurance 5. El We are a corporation and its 9 �Building addition Electrical❑ required.) officers have exercised their 10. repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions 1 myself[No-workers'comp. c. 152, §1(4),and we have no insurance required.]t 12.❑Roof repairs t req ] ._ .employees. [No workers' ❑ ' comp. insurance required_] 13- Other 'Any applicant that checks bottiE 1 moat also Tilt out the section below showing their workers'oompensetion policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4Contraetors that check this box must attached an alditioaal sheer showing the aamc of the sub-contractors and their workers'comp.policy information. 1 am an employer that.is providing workers'compensation insurance for ray.employees: information. Ilelow is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: / Expiration Date: Job Site Address: � (�CP 1,— S T City/State/ZipW Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date), Failure to secure coverage as requited 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. 1 do hereby cerdA under the pains andpen�wz ofpe at the information provided above is true and correct signafore: _ Date.- Phone ate:Phone FBoard only. Do not"write in this area,to be completed by city or town official Town: Permit/License# hority(circle one): Health 2. Building Department 3.City/Town Cierk 4. Electrical Inspector 5.Plumbing Inspector son: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe'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 evidenceao 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/iicense 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 ormarked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fima•e permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ' please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 6I7-7274900 Ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia Location No. Date C-1?- � 61 NORTFTOWN OF NORTH ANDOVER ?0•,1`1O I•,MO 9 + ; . Certificate of Occupancy $ °'` c�' Building/Frame/Frame Permit Fee $ j s�cHusE 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # / Building In Wtor v PERMIT NO. O .S8 APPLICATION FOR PERMIT TO BUILD'" NORTH ANDOVER, MA APAP NO. L- LOT NO. J3 2. RECORD OF OWNERSHIP DATE BOOK PAG E ZONE f, SUB Dri'. LOT NO. LOCATION DI -JCP tese� 4— PURPOSE OF BUILDING ' M - O\VNER'SNAAIE 11 r� / r� a /�p G NO-OF STORIES S SIZE OWNER'S ADDRESS 12,: 8 BASEMENT OR SLAB ARCHFfECT'S NAME tj alSIZE OF FLOOR TIAIBERS f, ] 2N 3 RD BUILDER'S NAME U IC4o r, J-10 o? fSCO SPAN #I CLJ n DISTANCE TO NEAREST BUILDING v(OG l DIMENSIONS OF SILLS ACLJ n DISTANCE FROM STREET DIMENSIONS OF POSTS O4� DISTANCE FROM LOT LINES-SIDES �L REAR ti Sv DIMENSIONS OF GIRDERS AREA,OF LOT , Dd FRONTAGE , f HEIGHT OF FOUNDATION THICKNESS ESS BtADING NEW v SIZE OF FOOTING x W BUILDING ADDITIONye MATERIAL OF CIIIAINEY r 1 ,iS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND y .t:r � U/ f co WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Lp IS BUILDING CONNECTED TO TOWN WATER •e-5 BOARD OF APPEALS ACTION,IF ANY U IS BUILDING CONNECTED TO TOWN SEWER �0 5 IS BUILDING CONNECTED TO NATURAL GAS LINE INSTUCTIONS 3. PROPERTY INFORMATION LAND COST P-44 0a I,,r�1 EST. BLDG.COST OO PAGE i FILL OUT SECTIONS I-3 EST.BLDG.COST PER SQ. FT. EST.BLDG.COST PER ROOM B-LECTRIC METERS MUST BE ON OUTSWE OF BUILDING �I c` SEPTIC PERMIT NO. f) lt/ ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS I)1 4. APPROVEI)BY: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR Cie BUILDING INSPECTOR DATE FILED OWNERS TEL# CONTR.TEL# CON IR.LIC# SIGNATURE OF OWNER OR AUTHORIZED AGENT' EE %3910 PERSIIT GRANTED j b Vlo2l D DO Revised 5/5/99 JAI If r ! t NORTIr 1 . O F D ' RECEIVED +, JOYCE 8RAOSHAW —• ` TOWN CLERK 'sSAG1U5�` NORTH ANDOVER NORTH ANDCOVER 2000 JAN 20 P 1: 3 b THE ZONING BOARD OF APPEALS 27 Cl-DkRLES STREET NORTHA�00VER. MASSACHUSETTS()13_45 Any appeals shall be filed NOTICE OF DECISION ATITA' 73)633-9542 44 TfW, CM within(20)days after the Year 2000 date of filing of this notice Property at: 12 Middlesex Street in the office of the Town Clerk. 1 NAN E: Bradford B. & Wendv D. Wakeman DATE: 1/12/2000 ADDRESS: 12 Middlesex Street PETITION: 016-99 _ North Andover,MA 013. 5 HEARING: 1/11/3000 i The Board of Appeals held a regular meeting on Tuesday evening, January 11. 2000, at 7:30 PM upon the application of Bradford B. & Wendy D. Wakeman. 12 Middlesex Street, North Andover, MA. Petitioner is $ requesting a variance from Section 7, Paragraph 7.3 for a front setback and for a Special Permit of Sectiona 9, Paragraph 9.1 to reconstruct a proposed addition of a front porch on a pre-existing non-conforming structure and lot within the R-4 Zoning District. The following members were present: Walter F. Soule, George Earley, Ellen McInn're, Scott Karpinsid. Upon a motion made by George Earley and seconded by Ellen McIntyre. the Board voted to GRANT a � dimensional variance from the requirements of Section 7, Paragraph 7.3 for relief of 17'3" for a front r�a setback, in order to construct a front porch and to GRANT a Special Permit in order to construct the front porch on a pre-existing,non-conforming structure. In accordance with the elevation drawing and the Plan of Land by: Gregory L. Bowden, P.L.S.. Professional Land Surveyor. #31610. Northpoint Survey Senices, m I ISO Water Street. Haverhill. MA 01330. Voting in favor: Walter F. Soule, George Earley, Ellen McIntyre. Scott Karpinski. Y L-3-1 LV VV 10.4 Variances and ADAeals: The'Zoning Board of Appeals shall have power upon appeal to grant variances from the terms of this Zoning Bylaw where the Board finds that owning to circumstances relating to soil conditions,shape,or topography of the land or structure and especially affecting such land or structures but not affecting generally the zoning district in general,a literal enforcement of the provisions of this Bylaw will involve substantial hardship,financial or otherwise,to the petitioner or applicant,and that desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of this Bylaw. Special Permit: The Board finds that the applicant has satisfied the provision of Section 9,paragraph 9.1 of the Zoning Bylaw and that such change,extension or alteration shall not be substantially more detrimental than the existing non-conforming structure to the neighborhood. Furthermore,ifthe rights authorized by the variance are not exercised within one(1)year of the date of the grant.they shall lapse,and may be re-established only after notice,and a new hearing. Furthermore,if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed atter a two(Z)year period from the date on which the Special Permit was granted unless substantial use or construction has commenced.they shall lapse and may be re-established only after notice,and a new hearing. By order of the Zoning Board of Appeals. �`L�. Walter F. Soule, Acting Chairman ml/decisions,1000/3 BOARD OF APPEALS 688-9541 BUILDINGS 688-9545 CONSERVA'T'ION 688-9530 HEALTH 688-9540 PL.-\N LING 688-9535 Registry of Deeds Northern District of Essex County Lawrence, 11A01840 02/10/00 BRADFORD WAKEMAN AN # 92 Rec: Type FLAN 16.00 # 93 Rec: Copies 1.50 Inst: _;; I Type DECSN 10.00 Total 27.50 # 94 Payment Cash # 95 J0.00 THANK. YOU! Thomas J. Burke Register of Deeds North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number' is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: IN lam! v �` i5 d5 r I 4CT- (OA (Locatiorfbf Facility) Signat e of Permit Applicant / IIJJ Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations c� ;~ Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name 1/ Please Print Name: //��� � T(/b)S ry Location: 7— City City Phone # 0 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address City: Phone#: Insurance Co. Policv# Company name Address V S City /1/" KI(M/Q C Phone#: / �� 3 Insurance Co&L/-/, w G��� Policv# 6 �161Z % Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition m criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. t do hereby certify under the pains and pen of perjury that the information provided above is true and correct. , r Signature Date Print name 0 701( s v S C Phone# T Official use only do not write in this area to be.completed by city or town official' City or Town Permit/Licensing ❑ Building Dept ❑Check d immediate response is required ❑ licensing Eoard ❑ Selectman's Office Contact person: Phone:: ❑ Health Department ❑ Other a . 0 357 DEPARTMENT OF PUBLIC SAFETY 108357 ONE ASHBURTON PLACE, RM 1301 BOSTON, MA 02108-1618 Q. 0 DO CONSTRUCTION SUPERVISOR LICENSE i 19911 Number: Expires: Birthdate: CS 069595 07/25/2000 07/25/1961 LTJ� Restricted To: 00 VICTOR J TUDISCO 4 SPRING ST MERRIMAC, MA 01860 Keep top for receipt and change of address notification. 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 or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT aX nn G )L-1LrnCd'*-, PHONE 3,34 LOCATION: Assessor's Map Number 3 PARCEL SUBDIVISIONN/� (� LOT (S) STREET 7Y I �fSC�C �! ST. NUMBER ) * ** **********k*******O F F IC IAL USE O N LY**t* REC DATIONS OF TOWN AGENTS: it CONStRVATION ADMINISTRATOR DATE APPROVED g-111 01 Quo DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER.CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR M DATE Revised 9197 jm ,AORTH ovm Of Andover O No. 0� � Zo o +hover, mass., 000 IN COC^+iCnE wiCK 1 S ti BOARD OF HEALTH i PERMIT T j Foodi Kitchen Septic System i � I �� IWA ke A I BUILDING INSPECTOR THIS CERTIFIES THAT....... ..�..............I.. ...........................................I........... ...... ....... j Foundation Q i Q has permission to erect...... VC;..1D ........... buildings on .......'A.............................'t �.......5.......'...... I Rough to be occupied as ...FfO N+..... . .. ................................................................... .... i Chimnev ................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in ; Final i this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. ; PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. I, Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR i P UNLESS CONSTRUC S T ..V000* 600 C Rough Service BUILDING INSPECTOR Fina( Occupancy Permit Required to Ocaipy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry 'Niall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. burner Sweet No. SEE REVERSE SIDE Smoke l)et. I PROPOSED EX18ANG. PORCH . :. DWELLING ,Y FIRST FLOOR a ELEVATION 1/4" i 110.0' PARCEL 3 AREA=11.000 S.F. SHED. 0 o • %;%j; �,jj.. �:;ij/!.'/, � � ji'l/iii 28.2 EXISTING. DWELLING 1 1/2 STORY AREA = 1,343 S.F. f 10.0 -N •Lo PROPOSED.,8'x26' PORCH cv r: I AREA = 192 S.F. EXISTING 8'x6' PORCH MIDDLESEX - STREET TO BE REPLACED SITE PLAN 1 - - 40 Town Of North Andover Project: Building Department °f M0RT#1 d 114ED .4 27 ? >° `' �° Proposed front porch extension 27 CHARLES ST F A 1? -,P . 978-688-9545 _ 12 Middlesex'St No Andover MA 01845 APPLICANT : Brad Wakeman cs�t : f= 12 Middlesex St. ......_....,,_. .. .... , ..... ........ ... ,.� :r, ... _. _ No Andover, MA. 01845 -DATE: 10/28/99s Title of Plans arid Documents as above Please be advised that after review of.your Building Permit Application and Plans that your Application`is DENIED for the following reasons: Zoning Use not allowed in District Not in conformance with Phased Development Violation of Height Limitations Sign exceeds requirements X Violation of Setback FrontX Side Rear X Insufficient Lot Area Insufficient Parking Violation of Building Coverage Insufficient Open Space Use requires permits prior to Building Permit Sign requires permits prior to Building Permit Form U not complete by other departments Not in conformance with Growth By-Law Other insufficient frontage Remedy for the above is checked below. X Dimensional VarianceSpecial Permit for Watershed Review Special Permit for Site Plan Review Special Permit for sign Complete Form U sign-offsCo of Recorded Variance Information indicatingNon-conforming Co of Recorded S ecial Permit Other Other Special permit/extension of non-conforming lot Plan Review The plans and documentation submitted have the following inadequacies : 1.Information Is not provided,2.Requires additional information, 3.Information requires more clarification,4. Information is incorrect. 5.All of the above. Foundation Plan Plumbing Plans . Subsurface investigation Certified Plot Plan with proposed structure Construction Plans 116 Affidavit Mechanical Plans and or details Plans Stamped by proper discipline Electrical Plans and or details Framing Plan Fire Sprinkler and Alarm Plan Roofing Footing Plan Plans to scale Utilities Site Plan Water Supply Sewa a Disposal Waste Disposal Other see reverse ADA and or ABBA requirements Administration The documentation submitted has the following inadequacies : 1.Information Is not provided.2.Requires additional information. 3.Information requires more clarification.4. Information is incorrect.5.All of the above. # # Water Fee State Builders License Sewer Fee - Workman's Compensation-' Building Permit Fee Homeowners Improvement Registration Building Permit Application Homeowners Exemption Form Other Other The above review and attached explanation of such is based on the plans and information submitted. No definitive review and i or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies,misleading information,or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department.The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file.You must file a new building permit appliG�f2orm d began the permitting process. 13uilding Department Official Signature Application Received Application Denied ' If faxed: Denial Sent Referral recommended: Fire Health Police X Zoning Board Conservation Department of Public Works Planning Historical Commission Other BUILDING DEPT cc: William Scott 0-1—A 1 Plan Review Narrative The following narrative is provided to-further explain the reasons for denial for the building permit for the property indicated on the reve'rse,side: %- � �^� �,, .� ,.w3.�r. ate,�}� s^r` �' �- F s i• a^ fi ae� �"'� ��N v 'y l z a+r t 'g} .�j 7',.5rssS k a'r va<s yy. ys,+:, }'� '"".. " '�'a�'�¢�33YY r N S ; ��� *, 4 WIN! or� *' �,. rq�"'hf •r�4 �Jr� 1'; "6\t�� .��W.tFZ �"z r'a j�z ,3tYR-r 4RYc��i gp .>iiSt.tiv' z ti S .r- r x '� .t&' 1 S 1 „�' '� _. „s y7-'r' .,,.• "aEt `'�.`z ka>,....w. ti.s.,r..aY'� '"t�:Y�'iS' ^a +n�...-#„ �:wr.+iJ•dp nY#,,h" la''- �„+.tc Section 7 Dimensional Requirements/R4 District requires 30'front and rear setbacks,15' foot side setbacks, 100' of frontage and-12,500 square foot lot size... Section 9 Extension of a non-conforming lot. t q s: Lai r 1 s r • _..� — i. p : �i�, ii ;!j111j�111 t;ii131;1I Itil1'j� + :j';r ij+' f•'j``•`i I,F�k i,\ ``, C s. t7ft Mi ��; � i 1. f�� '!mss � - 1 . �i �" r Y m� .^+ � �. t• �� r.- ! .+ •t j wA IFq,.'F•!�' ay ,..Yy,'w+c�.'s•YV�siMl'._•.�°•.. -An yA I - ..` "Ye .�+Y �Aix @/`L 7. Ila ''': w•.;��11t{r � „ ,jam/. - �('•��:; "�.�•�►• 2."',;"' e- __. -� ,�.� `i 1. ''•-'. � `.: •�, '�. - =lr��r„C -�ea• f�` � r�, � �..� jS'�"'.. a 'r �'+ 1 'r "* �' - �.....-., _ ���' i; �' \'. r`�a��� yam` �� ' � fi-j fr � ._r��•. .. 't• .� •�e a`rc .�_•Cr.<�•�. � •r'�-i, i? �� � i ' ��. ,;,� •tri r ,• � �4 .:i•��i 31er..'•r - +; - •r-. � � - 'mow .r � � f.'Sisf F.J,�.r=tr¢ ~f - .;��� � ., `�iA f�••1��1����'< •Y• ate. � t 1 iS1� .�e� •IIS .<r �'� '.. x. '�' -,RJ`.i'. �/'!�'ti i M• sit r'r� _ r• _,.• '*� .aa •wrt. �• ��r t � s r I i T•. 1.2 • •a �'4 ..s.a�•s � 7 ♦V`4. ,.f ��'}Ztit►�F� 1: �� rte '" `r�.\ � �!� � , ..�.� � � ' ��t\:. ��ae�•irs� a.'.•.��Y � ',�� k u y � ,;.P�®�,� .`\ 4 �/,,9����-_ _ : t�� ��`- ��� mss. . 7iH�i*'••,+�,��'�\ b. � .•� �... ti 4,•`� � S��` ,�.0����' `y,• �"'� Y�s .-N�•• �_ - � _ �:`tea �. .�\f'.'i:�'��i��e�.. `;i ��•�+ 1 ��� L� ,\y�~�r, '�!' i� 'w•,J r1 ��'•{! ,`�t�r*.��11 A \ �yi �, I�•A -a�Kg � {. M�"Z jk: t' !.+�M1:\> �+t� '•���,ttt� •� 9 ,s \� I ' SB 100-0 N I? + I � t m to - � �wiltnq N Z � ° N81 0 _ o `d \ AGer,4�H . 9 ara,sEu« o 'C Date.�j/.A).�. . TOWN OF NORTH AND R PERMIT FOR PL U ING ,SSACMUSE� This certifies that . . . ://�. rx2. e Al. . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . !l C u� /. plumbing in the buildings of . . at . .J1.2. . .//,,. E�r(."t/.. t y . . . . . . . . . . . .. North Andover, Mass. Fee. . �.�' . . .Lic. No.. . . . . . . . . . .-!. ''�:`� . . . . . . . . PLUMBING INSPECTOR Check # 1 U 3 G 7267 CA MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Date . 20 0 T Permit # Z� 7 Building _ � Owner's AT: Location_/,,2- Name 4,1, wfv Type of Occupancy: New ❑ Renovation Replacement ❑ Plans FIXTURES Submitted: Yes ❑ No z 2 N z Y a h N J �, (� 4 z W W W Y J N W n t7 tt N z_ N Q 0. Q ~ _z O z N 0. O J N W N rA x y h 0 W N Y a N lw Z 0. z 3 X Ir z m a a s 6 ° z ac m to W �- h V) ° a N Z ¢ a m O aL W I- h W 4 N ° j N a ice- 4 Y ° a ° LL cc W x Q O z z Y 0. 0 Q W ¢ Y W F' O V z A \° a a a x° v a a o a ° ° d it Q O a h SUB-BSMT. / BASEMENT J 1ST FLOOR 2ND FLOOR a• 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR (Print or Type) Check One: Certificate Installing Company Name Uptack Plumbing & Heating, Inc [2 Corp 1415 Address 32 Rochambault Street ❑ Partnership Haverhill , MA 01832 ❑ Firm/Company Business Telephone 978 372-8503 Name of Licensed Plumber or Gasfitter Leonard A. Hall I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. 1 have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. By Signature of Licensed Plumber Title Type of Plumbing License City/Town 8678 APPROVED (OFFICE USE ONLY) License Number JV Master ❑ Journeyman Date.. .,. .. .?.... .... MORTN 3� TOWN OF NORTH AND R O i•, p 4 PERMIT FOR GAS IN LLATION SACMUSEt This certifies that . . _/?./�Y. l�. . . . .r has permission for gas installation . . . . -. . /. . . . . . . . . . in the buildings of . Z// ... . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ,/ . . . .�.?�.� .�: .c� :i. . . . . .��` . . , North Andover, Mass. Fee.��"� Lic. No.. �--�./rG . . � �-� . . . . AS INSPECT Check# t 6009 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) U,kvAtJ 6 SL —. Mass. Date le7 Permit# p Building Location 4a K Q S l Owner's Name_ JA h E S p�H Eh rnC1J - NOON �1fJDbUE� MA Type of Occupancy f2ESI O�Off )FL- New ❑ Renovation ❑ Replacements Plans Submitted: Yes[] No ❑ N N Y W N N N V Z Q N N M O ? N F- OC 0 Ul W = V m F S Vl Z O W H 4 Cc Z 0 r W C1 N H 3QIl W O d to F' W d 1- N O W W W 0 0 cc J Z d S a cc W C W W h I 4 W J 4 C F. r N O z 0 z W J �H. y�j W > W O Z, Q Q Z O Z O ���yyQ = 0 O tl Y W 3 C tl � 0 Y G a F O SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET HCl Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 9 71B-68,7-1105 ❑ Firm/Co Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes I$( No ❑ If you have checked Yes. please indicate the type coverage by checking the appropriate box. A liability Insurance policy P< 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 waives this requirement. Check one: Signature of Owner or Owner's Agent owner[] Agent ❑ hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and accur to to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. Te of Ucense: Title Plumber Signature of cen Plumber or Gas Gourneyman asfitter City/Town Master Ucense Number 374'5 O C S O J BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO,DO GASFITTING NAME !E TYPE OF BUILDING r LOCATION OF BUILDING PLUMBER OR GASFITTER UG NO. PERMIT GRANTED DATE.�.-....�9 GAS INSPECTOR "O RT:1�o TOWN OF NO H ANDOVER 3? �a,� .., �• CL PER IT OR PLUMBING SgACMUSE� This certifies that . . . . . . . . . . . . has permission to perform . . . . .1: 1 . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . ... . /b `^. . . . . . . . . . . . . . . . . . at . . . ,/�f . . .A.V<..G . .'r. . .C.e.0 .. . . . . . . . . . , North Andover, Mass. Fee., Lic. No..5.69 .':�.? //' . :. . . . . PLUMBING INSPECTOR Check # / 3 Y. ' 7390" �v� .:;.y t � ....".......+."✓i:,ud..... !. _ ... -. .• i+hW .,.. -. .--vr .�.. � _ _a+ .rte ". sw`4,wuYnrwn.-.=.�._ _ MASSACHUSETTS UNIFORM-APPLICATION FOR PERMIT TO DO PLUMBING. (Print or Type) NO• A�J LOLA Mass. Date S Permit #_72i_6 Building Location i(, P?Dn✓/ �I Owner's Name JAMES (�'HEA6J tj0kV1 A QLVEk. 11k Type of Occupancy_SM2LI.STI fl - New Renovation O Replacement p Plans Submitted: Yes [] No O (X . B.P.# SEWER# FIXTURESSEPTIC# ' z Z 'X N to O Z } y r $o-t N ! V a 1 N = W N z 0 a s a r- z O _z w ox a.► .N 1 V� O W_ r� W N F� x IT y N W z T. N x . tu` V y tr W Ox cc N f• F- y Z G 0. d Q a c E •rl W O 7 u d Q a W N O cc J Z a 4 ¢ 44w x f. F, w o ° 0 ra IL x z x X 4. 0x x •i " u ,� ° ar t Y N O In. .O .N Z O O N 4! F O V "d G < J 4 ¢ OC 'z Y J la N D O J 3 H to U. a O a a 3 C1 A3 sue—BSMT. J BASEMENT 1ST FLOOR 2NO FLOOR c 3RO FLOOR 4TH FLOOR STH FLOOR "p, } 6TH FLOOR 7TH FLOOR r STH FLOOR installing Company Name BA\/ STATE GAS Check one: Certificate # Address 5.5 F7 A 12ST n t.i ST O Corporation L AAA- M CK H p Partnership Business Telephone-c 78 G97- 1105 O hrm/Co. _ Name of Licensed Plumber _F P-A, N CIS X CO R K EP-Y INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial.equivalent which meets the requirements of MGL Ch. 142. Yes O No O If you have checked,ves, please indicate the type coverage by checking the appropriate box. A liabilihr insurance policy ❑ Other type of indemnity El Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the aMass. General Laws, and that my signature on this permit appitcation waives this requirement. ' Check one: Signature of Owner.O ° er's Agent Owner p Agent O. y I hereby certify that all of the details and Information I have submitted(or enter above application are e d accurate to the,best of my knowledge and that aD�pfumbing work and Installations performed under the forthis appl be in compliance with all Pertinent provisions of the Massachusetts State Plumbing Code and Chapter en BY Title_ Signature of Ucensedum r City/Irovm Type of license:Master ��' Journeyman C)--- C license Number d�pP - v BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS 't FEE r: y APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING..: : .- !' 3 LOCATION OF BUILDING_~- r D . ? PLUMBER �0 ` PERMIT GRANTED f _: ' I• DATE - 2.0 :. PLUMBING INSPECTOR Date s ............. NORTH °ft °:•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACHUS� This certifies that ......................:.........................:....... ..............�......... has permission to perform {v. ............................/............................................. wiring in the building of..(e!- s......... ................................................. at./-'.........���1.:.::' .. v . ....,.................... ,North Andover,Mass. Fee ... .... Lic.No:��V&.....%.... !........ ...1..�....�-....✓....... u T ELECTRICAL INSPECr6R Check # 7204 Commonwealth of Massachusetts Official) Use only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( ),527 CMR 12.00 MSC (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 'Q] 7? ® 17 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or h r intention to perform the electrical work described below. Location(Street& Number) a yC 1 �x -35-{- Owner or Tenant /'q GcJ lephone No. Owner's Address S P/ Is this permit in conjunction wit a building permit? Yes No EJ (Check Appropriate Box) Purpose of Building ijateS,e, 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: � s Completion of the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In o.o Emergency Lighting No.of Luminaires Z f Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.o Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mun'c'pal ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems: No.of Devices or Equivalent x No.o Water KW No.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E ect710 'cal Work: (When required by municipal policy.) Work to Start: .z r7 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: INSURANCE M BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and pnalties of perjury,that the information on this application is true and complete. FIRM NAME: i'G Gr's o G -I Z LIC. NO.: 30$93 4' Licensee: X S/1j(, ig ature LIC. NO.: pv (If applicable, enter "exempt"in the lic nse number line.) u Bus.Tel. No.: 3 YJO 1 Address: C, Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: 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, 1 hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ��; .� II i 4 I r !� 0 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/Electricians/Plumbers Applicant Information Please Print Legibly i Name(Business/Organization/Individual): � tf / Address:-- ' City/State/Zip: Phone#: 92A 3�0 3V9 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors , 1 2.WXam a sole proprietor or partner- listed on the attached sheet. I 7. [44emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ur Policy#or Self-ins.Lic. #: v CP :3 3(71 Expiration Date: f Job Site Address: SQ,,(� jr C 44y4rcity/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 ins rance coverage verification. I do hereby certi / er hep ins a enalties o perjury that the information provided above is true and correct Si nature. Date: a Phone#: �� 3b(7v14 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#: Date..... .�.�. ®. .... f NOR71{, 3?°•_tom`` :•_�."�O� TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that .......1....!.!�qll ....�t�� ��.!�!—Y � c/ )... 2... ..... . l...... has permission to perform « SF /��t /� Gl/A•,r .. .io/................ wiring in the building of......6........ .AA-.j................................ at...Lz- IPA4.E=5e.X.........5% '............... .North Andover,Mass. Fee.... Lic.No 3 ......... .�.r. f-!... ...�/'�: ! ELECTRICAL INSPECTOR Check # 22. 7422 Commonwealth of Massachusetts Official Use only Permit No. 7 7 Z Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (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 INFORMATION) Date: 3 % Q " City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of h' er intention to erform the electrical work described below. Location(Street& Number) 1 a- /11),,Me's ems' S� Owner or Tenant 13, I 6V e"11 Telephone No. Owner's Address AA-,'' A AOL vu" Is this permit in conjunction with a building permit? Yes ❑ No 21, (Check Appropriate Box) Purpose of Building Utility Authorization No. as 9 �1.2 9 Existing Service I a° Amps / Volts Overhead d Undgrd ❑ No.of Meters New Service100� Amps / Volts Overhead EP--' Undgrd [JNo.of Meters Number of Feeders and Ampacity Location and Nature ofoposedE lerical Work: CIS,q�; � S&rV, Ce- npd •' Completion of the following table ma be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. � rnd. El Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS [No.of Zones No.of Switches No.of Gas Burners o.of Detection and InitiatingTotaDevices No.of Ranges No.of Air Cond. Tons �© o.of Alerting Devices No. of Waste Disposers Heat Pump I Number Tons KW No.oSelf-Contained Totals: IDetection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local❑ Mun'c'pal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Water o.o No.of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: S� J 13'`� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [g BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of erjury,that the information on this application is true and complete. FIRM NAME: / ,Q,h J 5r>e LIC. NO.: " 3019 3 Licensee: j'SnIx, Signature LIC. NO.: (If applicable, enter "exem//��t"in the i ense number line.) Bus.Tel. No.: Address: %c�- 0'',/It � /107,erot-;j.7 C � Alt.Tel. No.: )7S 340 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ �._ �� �" �� d� - �� � � 7 �� R l i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 S° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): n q2 4 Address: 0- I/1e City/State/Zip: Phone #: 7 rn 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.F1' I am a sole proprietor or partner- listed on the attached sheet. + ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y9. E] Building addition [No workers' comp. insurance 5. ❑ 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 I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other U �4 comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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. SCP 33 S— �33 Expiration Date: /c 3,o Job Site Address: j c�- J d �� �'c �� N kLyt,""_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 tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u r the ain and penl les of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this Alto 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#•