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HomeMy WebLinkAboutMiscellaneous - 124 COVENTRY LANE 4/30/2018 i / 124 COVENTRY LANE 210/104.C-0121-0000.0 I � I i i Date . . . . . . ..... NORTIy pf a.ao 41 o? °� TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION SAcHUSES . t This certifies that . . !�' has permission for gas installation . in the buildings of . .L� �-+`1�. . � G'ol . . . . . . . . . . . . . . at + /f,7. ?:Y':. .4/7. . . . . . . . , N rth,Andover, Mass. Fee,A,,? . Lic. No.!�W'S22 . . . / . . . . . . . . . . . GAS INSPECTOR Check# 7884 r • 4J 1�- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: b r 9 � jnj0Vt,— , MA. Date: /Ihb/ Permit# . - 11 f` Building Location:�2 y C V t1 Yrs * ry Owners Name: ro Po r rg e (-)o Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New: ❑ Alteration:❑ Renovation: ❑ Replacement: ® Plans Submitted: Yes❑ No❑ FIXTURES CO WW Y 2 Cd Z w O _ m x O W w 0 0) H 0 W W O z z m 0� hW- n W R 0 Q F=— W w W Q a I— o ILLI X > w — z W Q = � N V u) � L7 N O u. W V W Q UW' J W z N = W ~ (0 = Z Lu > W z P P 0 z --1 0 L- W H W W v o o u=. z z 0 a F > > w Q > 0 o SUB BSMT. BASEMENT I I I I �. 1 FLOOR 2 FLOOR 3RIF— FLOOR Iddress: mpany Name: C�'Gv� /``cam PI r h �,n ����/ Check One Only Certificate# ,�/1 ❑Corporation Lt tr/`K City/Town:_ /7//�r"*�U— State:�/ ❑Partnership Business Tel: �i 7 S� Z 7�5 7 Fax: (�0� 3 6 Z s YYZ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ( No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ 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 Signature of Owner or Owner's Agent Owner El Agent E] By checking this box❑;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. 17 , ByType of License:_ ❑Plumber Title�/7//& H Mast fiGas tter tignature of Licensed Plumber/Gas Fitter City/Town ❑Journeyman License Number: APPROVED OFFICE USE UN—Lyj ❑LP Installer The Commonwealth of Massachusetts Department of lnd'ustrial 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 Leaffily Name(Business/Organization/Individual): Q/ /ll Address: S Lc^moi Q C,-L City/State/Zip:_ �J l t�=,.t c / /�03S Phone#: 7 S i�L 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 employees(full and/or part-time).* have hired the sub-contractors 6. F1 New construction 2. I am a sole proprietor or partner listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demblition working for me in any capacity. workers'comp,insurance. g• E]Building addition [No workers'comp.insurance 5. ❑ We aie a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11-E1 Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 1211 Roof repairs insurance required.]t employees.[No workers' comp,insurance required.] 13.0 Other *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 are 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. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: f Policy#or Self-ins.Lie.#: 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). 'I Failure to secure coverage as required under Section 25A ofMGL 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. Ido hereby certify under the pains and penalties ofperjury that the information provided above is/tr/ue and correct. Signature: ?hone FT�ssulnug only. Do not write in this area,to be completed by city or town official. n: PermitUcense# hority(circle one): I.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I I Information and Instructions coons 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 an contract express or implied,oral or written." Y of hire, An employer is defined as"an individual,partnership,association,corporation or other legal ent' ` Of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the g ity,or any two or more receiver a trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartinents and who resides therein,or the occupant Hof owever 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 sh wp yer." the i renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any r applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the,commonwealth any of its political subdivisions shall enter into any contract for the performance of public work requirements of this chapter have been presuntil acceptable evidence of compliance with the insurance ented to the contracting authority." Applicants Please fill out the workers',compensation affidavit completely,by checking the boxes that apply to our situation a necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of and,if insurance. Limited Liatility Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than t members or partners,are not required to carry workers'compensation insuranceIf an LLC or LLP does have . he 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 compensation policy;please call the Department at the numb listed below. Self-insured companies�wu" ente'self-insurance license number on the appropriate line. r their pity or Town Officials Please be sure that the affidavit is complete and printed legibly. The De of the affidavit for you to fill out in the event the Office of Investigations hates to contaent has ct provided regarding thetapplicant.' e ro Please be sure to fill in the permit/license number which will be used as a referencd number. In addition,an applicant that must submit multiple pemut/license applications in an PP y given year;need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been'officially stamped or marked by the city or town,may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each Year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NmTrequired to complete this affidavit. The Office of Investigations would no to thank you in advance for your cooperation and should you have any questions, 1 please do not hesitate to give us a call. The Department's address,telephone and fax number: xlZe Oahu Irweatd-1 of Massaclaosetts Depaftent of J dustrial Accidents Office Of InveSblgallons 600 Washington Street Boston;MA,0211 X Tel.#61.7.7274900 ext 406 ox 1..877-M-ASS.A.FE Revised 5-26-05 Fax#617-727-7749 WWW-massg-av/dia r r' CO—MM�NWEA-LTFrOFl9WSSACHUSEM �V; IN PLUMBERS AND GASFITTERS &jqjfAGPL-u:mBER PETER,�;G. ASHMOR-TH I LE-RO=Y. AVENUE QsTKINSON N.H 0381.1 25.1.1 1 Date HORTN TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ,SSACNUSE� This certifies that . . l-r /./.9 . . . . . . . . . . . . . . . . . . . has permission to perform . . . .tA. . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of 41-1.s. . . . . . . . . . . . . . . at. . /). �/. .(�.G: North Andover, Mass. Fee .Lic. No../U2r !. PLUMBING INSPECTOR Check # E C + 8656 •• of N° •. u all -0 — J i • � 7 •• .o d '---tMMM-.-t.t..s..... �m ®�N�����i���siONE WE ME .....-.-.--�....-Mmmommm ME MINE -.-..-. MEN! WONMINE mmmmmmm --.-Elm = -.--..�-MmmMMM ....-. - 1 1 1/' I ' ■ • n/ s oil , 4 1 I 1 • _ 1. V: 7/ i •• • 11 1 :,V' V. • h1� ..11� 1- •i 1• hills � �•/i X11 ■ !yyr•,• :,• ell•F'-. • q "f • , .6• .1•, •- / JI. 1 - ♦ �V'i • •I 111 1•h � •'- 1 •APPROVED(OFFICE USE ONLY 111• . . 1 "/ �City/Town PAP r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 w•ww.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnWicant Information Please Print Le ibl Name (Business/Organization/Individual): Address:__E• 6"4_ k--) City/State/Zip: A i . A rly o Phone#: � �� �p (�'�'-- �336 Are you an employer?Check,the appropriate bore; am a employer with—C j 4. Type of project(required): I T ❑ I am a general contractor and I employees(full and/orpart-tune).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition required.] officers have exercised their 10.7 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑Plumbing repairs or additions myself.[No workers' comp. C. 152,§1(4),and we have no insurance required.] t mPto ees. [No workers' 12•0 Roof repairs comp.insurance required.] 13.7 Other Any applicant that checks box r1 must also 6I1 out the section beler wing their eir we 1:,='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 workerscompensation insurance information. for my employees Below,is the policy and job site Insurance Company Name: Policy#or Self-ins.-Lic.M Expiration Date: Job Site Address: /-H Gy7 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 $250.00 a amstthe violator. Be ad ' e t a copy of this statement may be forwarded to the Office of vestigations of the DIA r' ce covers verific I eby certify unde a pen ties of rj that the information provided above is true and correct Si Am v. Date: Phone#: Official use only. Do , of 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#: 3r . Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of coinpliance 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 phone number(s)along with their certificate(s)of J 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 mtumed 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 permiVhcense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Sob Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 wwu7.rnass.gov/dna Date.. .C�,/�1�,/�® . ... .. f ,AORT1y 1 O ° I.. l� o� ° 0 11 TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION s • 9SSACHUSES pp ! This certifies that . . . .G. . ./. .moi+ . � - . .t . . . . . . . . . . . . . has permission for,gas installation . . . . . . . . . . . . . . . . . in the buildings of . . .7 C. .o. `?. . . . . . . . . . . . . . . . . . . . . . . . . . at . 12.�l. . �� :. �!�yl. . �.� . . . . . ., North Andover, Mass. Fee. .2 Lic. No. A.w i. . .� � ,-. . . . AS INSPECTOR Check# 5 , 7259 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, ASSACHUSETTS Building Locations • Permit# �^Zw Owner's Name Amount$ New❑ Renovation Replacement Plans Submitted ❑ U z z H Ci W d W W Qp O a p w FW. Q W O Q a z E" ? v� z O Z o x 3 ° a° > o °a o SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR s 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR ' 18-T H . FLOOR (Print or Check one: Certificate Installing Company Name W a 4-4 ❑ Corp. Adds 44� p P�Artner. Zf ss Te ep one — ��Firm/Co. Name of Licensed Plumber or Gas Fitter l - INSURANCE COVERAGE Check one: I have a current liability Insurance olicy or it's substantial equivalent. Yes No� If you have checkedYes,please' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the-licensee does not have the Insurance coverage re ed by Chapter 142 of the Mass. General Laws,and that my signa on this perm lication waives this requirement Chec ne: Signature of Owner or Owner's Agent wner 0 I hereby certify that all of the details and information su tted r tete ove is tion are true and accurate to the best of my knowledge and that all plumbing work and install ion o ed d Pe ' for this application will be in compliance with all pertinent provisions of the Massach tate Co Cha er 1 2 the General Laws. C-1 Of By. Signature f Licensed P nber Or Gas Fitter Title Plumber U ' City/Town as Fitt cense umber Master APPROVED(OFFICE USE ONLY) Journeyman r 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 Le�bly Name(Business/Organization/Individual): u Address: V City/State/Zip:A\R, A_ Phone Are you n employer?Chee the appropriate box: 1 I am a employer with- 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have fi. New construction p ) hued the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet7• Remodeling ❑ g ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of � g gh exemption per MGL .11.7 Plumbing repairs or additions myself [No workers' comp. c. 152,§1(4),and we have no insurance required.] t employees. 12.❑Roof repairs em Y [No workers' comp.insurance required.] 13.0 Other 'Any applicant that checks-box#1 must also fill out the section below-hoar:_^+ha� .., t Homeowners who submit this affidavit indicating they are doing all work and then hire outside ontractors 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 worker;'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �--• r Insurance Company Name: `.G Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:-/�f0( G��r/ 1. � 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, ell c' of a to$250.0 P ties in the form of a STOP WORK ORDER and a fine P y against the violator. Be adv' ed tha copy o this statement may be forwarded to the Office of Investigati of the for insur cc co rage eiifi o . Ido here pe allies t the information provided above is true and correct Si atur Date.: Phone#: Official use only. Do n 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.PIumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),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 i" be retried to the city or town that the applicatidz 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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 LavestigatiFons 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 6.17-727-7749 www.mass._aov/dia N°„ 2667 Date..:.!...... o.. NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �SSAcHusE� This certifies that ...� ......... ... ... 1// ............................................................ has permission to perform �%S Y��, �r f W. 1 o�'°/ perm' p ,,l...................................................................... wiling in the building of........ ............................................. / ✓� COU4`1f'1� ... / .......... ,No' h Andover,M u . ......./...:....J.................. .. / .............. �5 v 6 Fee..................... Lic.No.:�.'....... ................... .............. ......,�......... r ECTRICALINS ECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer THECOMMONWE4UTIOFARMCH SMS Office Use only DEPARTMFNTOFPUBLIC&4FM Permit No. BOMRDOFFIREPREV©V170NffkMT10NS527CMR 12.00 lop Occupancy&Fees Checked PPUCATION FOR PERW TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date�/1 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location Street&Number /.,21 �6y fW li Owner or Tenant K,rd Owner's Address Sd?r''-e- Is this permit in conjunction with a building permit: Yes Ljj No (Check Appropriate Box) Purpose of Building p�Ak �'a Utility Authorization No, Existing Service Amps//b--- Volts Overhead Q Underground M No.of Meters --�—+�— New Service Amps Volts Overhead Underground No.of Meters Number of Feeders and Ampacity " Locatiait and Nature of Proposed Electrical Work I No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.ofZighting Fixtures / Swimming Pool Above Below Generators KVA ground eround No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of ryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.H dro Massage Tubs No.of Motors Total HP I OTHER i lra==Cvvaa Ptmarttote m mmvW dMmmidusiAls Ga',aaiLaws Iha,.eaarnuitLiabkhuatoePb*ymchrdrtgCm#Ak CoraageordSSLhUttdacFalad YES F1 NO a Ihaw abnftdvaWptoofofsaretotheOffoerYES n NO F-1 ff}cuhmedwcWYES,plemmk*the%pecfwyaawbydudd<gthe INSURANCE a BOND � OTHER a (Pt aseSpaffy) Expiry im Date Estimated VahtedUedrical Work$ WorkiDStart lD �3 Z%6 hspectionDateRawestod Rough FM Signed utxkr"&Rr4ltks ofpajuty. FIRM NAME LimnseNa i / r/� 9J Lica�see he0� .��e/a �.f LroaseNo 2,2- aisiressTei Na 9 bS Y' 799/ AdAw, tel/_ .Gly�6r/�✓ All.T&Na OWMI: 'SPWRANCEWANER,Ianawa¢e#AtheLioffwdoesrt theirrstxarneoaaageordsRhUlde asm*mWbyNbssact zftCatedLaws and dvtmysignataeait%pamitwai,Cs fismWiffmiat (Please check one) Owner M Agent M Telephone No. PERMIT FEE$ 6 rn htCliitJtr-� Location No. /-/9Z— v Date01 ,.ORTiy TOWN OF NORTH ANDOVER 3 °t F w Certificate of Occupancy $ NQS ,� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 16 Check # N 1 c. 1 O Building Inspector v 1 TOWN OF NORTH ANDOVER e BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATF4 OR DEMOLISH A ONE OR TWO FAMILY DWELLING OR BUILDING PERMIT NUMBER. DATE ISSUED: SIGNATURE: 11n/ ''C 6-t,� Building Commissioner/I for of Buildings Date , Z SECTION 1-SITE INFORMATION + 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: log ( r2- 1 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning DistriQ Pr osed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqLlired Provided v � 1.7 Water Simply M.G L.C.40. 54) 1.5. Flood Zone Infomurtioa: 1.8 Sewerage Disposal System: Public Private ❑ Zone Outside Flood Zone ,g' Municipal Q-- On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record �Pq Uf ry jJ AJ Name rin Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ -i '=* IRA N&:5 n Licensed Construction Supervisor: V�.S � r?O O ` 0� ,.(-b(I a ��_y t License Number Add s \ A�j �( / " �\ � 7 6 (� ?0 1 D � Z uC3tZ) Expiration bate Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name M Registration Number r Address r Z Expiration Date ^ Signature Telephone Y/ SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. + Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Dt W, VaLa V i'D 6w� -.16 -172 ro�'A^5 01 5 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �teikwe Uo *��i as Owner/Authorized Agent of subject property Hereby authorize to act on n�2� relMO �k authorized by this building permit application. _ n Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, Top- ' C as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief� Prim"N >, / Si ature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS 1 2ND 3RD SPAN DM ENSIONS OF SILLS DIMENSIONS OF POSTS DEVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUIL DING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Vozeolas Basement" 124 Coventry Ln, North Andover, A A" dimensions approximate I r 4 Hez ing, Hot hater Flea_ Storage i I ��p 5� J) l,0 Louvered door 00 411 00 iz— CF3 N N N 0) b C') Storage a under stair t�1 4enchseat-built in U bo tV o " -Up-to N CAP--� F12o main, set GLOSLN ` 4.11 a n NR*A?L a: Closets Closets CID r 1tiA-�F�e2 r I T6 13'4 _ _ 14'3 �. .. .................._......... I 35'1^-. REA 1011 sq ft �v�5 K.Vt Arc r A yr The Commonwealth of 9Vlassachusetts Department of Indust7ialAccidew Office ofInvestigations :600 washington Street 1. Boston, 9KA 02111 Workers'Compensation Insurance Affidavit APPLICANT INFORMATION Please PRINT Le0bly - Name: 7X�2 Pete S Location: ri Ct City: Al y rC&-, o'LJLf_ Telephone#: 7 6P2— — So ( O I am a homeowner performing all work myself. G4� I am sole proprietor and have no one working in my capacity 13 lam an employer providing workers' compensation for my employees working on this job Company Name: Address: City: Telephone#: Insurance Company: Policy M O I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City: Telephone#: Insurance Company: Policy#: C ,Corimpany Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to 51,500,00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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. I do hereby certify under the pains and penalties of perjury that the information above is true and correct. —� Signature: I�`— Date: �3 Vo Print Name: 1 L �5 s Phone# Official e t write in this area tial Us ONLY-Do no D Building Department City or Town: Permit/License#: D Licensing Board D Selectmen's Office D Health Department o Check if Immediate response is required 0 Other INFORMATION&INSTRUCTIONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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 section 25 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,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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confnmation 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. 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 Fax# (617) 727-7749 Telephone # (617) 727-4900 ext. 406, 409, or 375 NORTH Town . of _ R over No. 4 9L == o` y dover, Mass.; COCNIC MEWICK ADRATED S H E BOARD OF HEALTH PERMIT T Food/Kitchen Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT...... . ?0rf.U...at '0 �1/� iVy. �V Z''0114 S ..... I............... ,/ A ....................... ..................................... Foundation has permission to erect.....t�NIWA!....... buildings on ....�! a ..eV'w�� tv ..... ...... Rough to be occupied as....A3 4&90�0� � AC ADO .................................................. Chimney ...... . . . ............................................................. .. . . . provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. r* /m y P $ ` SO PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS � M UNLESS CONSTRUCTION ST S ELECTRICAL INSPECTOR e Rough . .... , . .. ...... ......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner J Street No. s ? SEE REVERSE SIDE Smoke Det. -Te 1�ammanucal� ref�l�cFutxcluse� ., BOARD OF BUILDING REGULATIONS : License: CONSTRUCTION SUPERVISOR Number: CS 067016 Birthdate: 06/1911962 Expires: 06/19/2001 Tr.no: 10253 Restricted To: 00 I THOMAS C BARNES • 19 TOLLAND RDx % , I N ANDOVER, MA O1E45 Administrator l ' ,j I