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Home My WebLink AboutMiscellaneous - 125 COVENTRY LANE 4/30/2018 -------------- 125 COVENTRY LANE / l� 210/104.0-0139-0000.0 f U i i i BUILD"' ING FILE a Date '2�� 11.7,. . . . r TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . '. . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . Q . I . . . . . . . . . . . . . . . . wiring in the building of `.- . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . rth Andover, Mass. r &--7---' .b�.l�'m�. Fee . . . . . . Lic. No. . EL CTRICAL INSPECTOR i Check# _ 11280 C(2) L-7t,;7 A_) North Asidover MIMAP December 5, 2012 g� Jif i w . w - I r . ' . e ;v k - S YlaT4 I A r l y " f ,i y .i.:,"`� •� �'� r. ?� �• it 't k � r r Interstates Interstate Major Roads - Horizontal Datum:MA Slateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack �►ORTq Valley Planning Commission(MVPC)using data provided by the Town of - Cr Easements Of «ae '1 North Andover.Additional data provided by the Executive Office of ❑MVPC Boundaryr�.1 CD Environmental Affairs/MassGIS.The information depicted on this map is L7 Parcels3' L for planning purposes only.It may not be adequate for legal boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING # �l fy� # THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY #."s y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT #of ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF .�,bA THIS INFORMATION SSACHUs� 1"=65ft + ° 4 .�tx-°,, - �-� i V -- --. .ate^ �c:- - �-� e.(�-fid � ate'- C�c�-�-�-- �� .. ,..:. �z �. �- � �� ._r_ — .�. ._. ......._._�....._.., �S __ �� .� �•.� - F - _jtil�--,�-----�-----� .` 1 _n/ Commonwealth of Massachusetts Official Use Only Permit No. ' Department of Fire Services 0 anc ccu and Fee Checked 1 Occupancy t `f� BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 oeaveblanic . R PERMIT TO PERFORM ELECTRICAL WORK APPLICATION FOR All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT.WINK OR TYPE ALL INFORMATI0A9 Date: /02— 7—/ 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) a?S- ay?:�A� ell�� Owner or Tenant s*,e _ jmo e,� Telephone No. Owner's Address ^ 5q. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters .' / Volts Overhead❑ Undgrd ❑ No.of Meters e 'ce Amps New S rvx p Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Al/W Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Gen:rators �KV�Ay,�4jo. gAbove Ei In- No. of Luminaires Swimming Pool rnd. grnd. ❑ Batte Units t No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burgers Initiating Devices ,a No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices No.of Waste Disposers HeaTrum Number Tons KW „., No.Detection/AlertingDevices Self-contained ota Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ ❑ Connection Heating Applicurity Systems` No.of Dryers No.of Devices or E uances KW Seivalent No.of Water KW No.of No.of Data Wiring: l Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: I No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent In OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work:A49e)r r-0*6 (When required by municipal policy.) e requested in accordance with MEC Rule 10,and upon completion. �- �.— Inspections to b r Work to Start:t'� /7- / p q 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 co, rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ! 0 1� Lel C LIC.NO.: R Licensee: pdLCe -aySignatu LIC.NO.: /cf63 bK !e (If applicable,enter "exemp "in the Jicensp number li e.) Bus.Tel.No.:/ !n a? RY7 Address: vv i wN IN ` qt- 4� t�SS{e*/� N� :Coo3 �!o _ Alt.Tel.No. o�GOSy *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 cove age normally required,by la By my ' nature bel ereby waive this requirement. I am the(check one)❑owner owner's agent. Oxvrier/Ag (�03— 16 - /'[PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for they 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 f. application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written l 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 t 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 1fl Failed Re-Inspection Required($.) ❑ Inspectors Comments: I Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: . Y. Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL SPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: 7 Inspectors Signature. Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 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):_ /-P( Address: City/State/Zip: & Phone A e ou an employer?Check the appropriate box: Type of project(required): 1. m a employer with�� 4. ❑ I am a general contractor and I � have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 7. Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet.T ❑ g 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 lO�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 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑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 a new affidavit indicating such. " Dontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site aformation. isurance Company Name: 2 olicy#or Self-ins.Lic.#: � � 3 Expiration Date: S h-// )b Site Address: City/State/Zip: 6je_jr /` ttach a copy of the workers'compensate n policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 C up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ►vestigations of the DIA for insurance coverage verification. do hereby certify under th a s and pen,0&9s , perjccry that the information provided above is trace and correct. i afore: Date: ione# clo 3 o% acX�l 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#: 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 local licensing agency shall withhold the issuance or ti 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." t Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall A� 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 insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' , compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city of 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 WWW evised 5-26-OS mac.,gnv/rlia r 1 4 � 1 1 3' f GENERATOR APPLICATION `. DATE: LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: � �Ec` Z LbC PHONE NUMBER: ��` 860 ELECTRICAL GAS RESIDENTI L COMMERCIAL TEMPORARY Se - o �2vS LOCATION OF GENERATOR: *ZONING DISTRICT: i *CONSERVATION APPROVAL V Go O� c� vsP / ` �� .� 3 r � r � � � � . �� a I -cam� �-� � -- � � Date • TOWN OF NORTH ANDOVER ! PERMIT FOR GAS INSTALLATION This certifies that . . f• •i• • r 69 ' '' has permission for gas installation . . � ��- f--. , , , , , , , , , , in the buildings of. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . .f•� • • ,.�). �, . . . . . . . . North Andover, Mass. Fee .,,vG; Lic. No. .?c{. '-(�- � GAS l SPECTOR Check# 2S 8513 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ MA DATE E �PERMIT# JOBSITE ADDRESS �OWNER'S NAME L �p GOWNER ADDRESSTE 92y`�7_ - FAX ( TYPE OR OCCUPANCY TYPE COMMERCIALOJ EDUCATIONAL ® RESIDENTIAL[ PRINT CLEARLY NEW:0' RENOVATION: REPLACEMENT:El PLANS SUBMITTED: YES Q NOE] APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 19 10 11 12 13 14 BOILER BOOSTER --J===== ---- CONVERSION BURNER COOK STOVE —1 DIRECT VENT HEATER L_I DRYER 1 1 FIREPLACE FRYOLATOR FURNACE -- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT -- - - OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNI HEATER aJ UNVENTED ROOM HEATER I WATER HEATER OTAIER I --- -- --- -- - -�I---I - - ( INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO [] IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW v LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND F OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F___11 AGENT SIGNATURE OF OWNER OR AGENT 1 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-GASFITTERNAME j LICENSE# SIGNATURE MP U!fMGF[D JP JGF QLPGI Q CORPORATION 0'#=PARTNERSHIP[I#=LLC[I# COMPANY NAME: ____)ADDRESS _._ _ ldl _ :5 - I JAI �!I CITY W_ STATE li;azlp Q TEL FAXCELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# L /2/12-0//-Z, PLAN REVIEW NOTES 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 Name (Business/Organizatidn/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 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 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 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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.❑Other comp.insurance required.] 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 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site !formation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: )b Site Address: City/State/Zip: Atach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 F.up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of rvestigations of the DIA for insurance coverage verification. do hereby cert under the pains a d penalties of perjury that the information provided above is true and correct. i nature: r Date: h rl4—e2- lone#: 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#: a 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-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 not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city of 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 Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-$77-MASSAFE evised 5-26-05 Fax#617-727-7749 - www,mass.Rov/dia ,a pq `t,,,7s��7 pT t r! 1 It i > r 511'{1 a ' A "t i1 tint Its r, 1i • DIVISION OF PROFESSIONAL LICENSURE-BOARD OF � t _ ■ 4 :• S a I 1 LICENSE NO. EXPIRATION DATE SERIAL NO. Date . .77 5f' �s•, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . .�44014*-141zle / 40 T has permission to perform . . �� . . . wiring in the uilding of . . . . .4f: 5.R 16.!! . , , , , , , , , , , , , , , , , , , 1 � � L at . • • • • . . . . orth Andover, Mass. Fee s� . Lic. No. . ELECTRICAL INSPECTOR Check# 3 f fy'3 10960 a Massachusetts Official Use Only Commonwealth of Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: /'7 2 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) 125— ry ae n 4,-Cz Owner or Tenant p r 9c u e n n,b e n Telephone No. Owner's Address /.2 5- Cvvv ¢, /,he Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building res l 0 to C C 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: All ries e jsa, A, Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] No.o Emergency Lighting rnd. rnd. Batteryits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners �' No.of Detection andInitiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances Kir Security Systems:* Y No.of Devices or Equivalent 3 No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /O D O (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC 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-3 e ism force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the infolrmati n on this application is true and complete. FIRM NAME /r C r fie z 7 LIC.NO.: 0 1 5 2 6lddx� A Licensee: AoUll, 11 16'�,d Signature ' LIC.NO.: (If applicable,enter "exem t"in the license number line.) Bus.Tel.No.. Address: �� Alt.Tel.No.: b / *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 PERMIT FEE: Signature Telephone No. Y , ._ �JJ1Lttil.rS,i�,�.r�E�.!'�_•t�t�[-(.lrp�J'a.]L0.�lpF".�L-Aj.d�•��y®�'(��y�.j`p�t,r�+� '�•� .+-Lll��.l3t�SCl.�.l�{.1f.�L��®�1.� .- • _ .lr.C4O U►,7f�F7J..�21-.J1�0,RQt �• •• - 32�ssei�--,� � -•�'aileQ-�[ ] �e-ins�iectzox�xequxxec7'(��O.DD)�� ns to S., coxvzne�nfs: ' (Xnspecuxsyzgnatuze��otiaTs) .r Pate 3?assea:- aiSe[ -r ate fnspectzo�xeo�uixe ( O.OD)-•[ ��ecto 'co enfs: pspectoxslgignatuze iowfl ) Pate 'assetl--� � �+'a4Iet�•-j � ate-fn.s�eetZo��ec�unre��4.OD)N[ � asectoXs'comments: , ��nspectoxe' ignatuxe-�o fnitaTs) Pate . ssea.--[ I �'ailec�•-j � �e-xnspectionxegnixe�(�50.OD)�j � ' �,�ectbxs'coxnm.e�,fs: r {ttspecforalolgaatuxe-ioWfials) safe e r�� ;aiier�--•� �• 'l::te�nsp ection zec�uiz'etl 050.0 D)•-[ � ectoye cwhm.ents: , Vitus ectoxs° zgnature azo xnifials) Pate t n'rn re r JS er 1s n rn rsin c�e�7�,YY 7 C 71 ,t lY7rP A r'arY►'�r��n s fT7ai!;TrnL�77G� A'DVA Ira*n w vnv 1 M. 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 /l Please Print Legibly Name (Business/Organization)Individual): CC, l ( � ��n /�/r le-e, Address: City/State/Zip: 910,44 Alier #4: Phone 9 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.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. w kers' comp.insurance. Y P tY• 9. F1 Building addition [No workers' comp.insurance 5. DIVe are a corporation and its irequired.] officers have exercised their 10.EJ Electrical repairs or additions 3.E:] I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13. Other 6,0 .. �.l 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. rr Insurance Company Name: T / v,1-P r _/, k, c-k C_ e Scz ; Policy#or Self-ins.Lic.#:- - C61,1 6 P* /6 15-y Expiration Date: 2sL,2o t2 ` Jdb Site Address: j 2 � 61✓(14 e City/State/Zip: Ari 141-a-0c IYA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. d do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: r Date: 7/7; a Phone#: 97,? .509' /7 // 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#: i 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." a 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 insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-$77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date. Iry. . . . ...... . _ 9 i NORTH 4,0 of '` TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION SS,%CHUQ. SE This certifies that . . . . . . . . .4 "�. has permission for gas in the buildings of . . lt�!�??� a at . . . . . . 0o � . . . Fee.3�:-' . . Lic. NoZ..� U. . . . . t ' . . . GAS INSPECTOR Check# t 1� 8241 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE,07/11/12 PERMIT# JOBSITE ADDRESS 125 COVENTRY LN OWNER'S NAME CORBEN GOWNERADDRESS TE _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:L1 REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER (� E BOOSTER x CONVERSION BURNER COOK STOVE 1 g DIRECT VENT HEATER DRYER I 1 FIREPLACE - FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER ; _ LABORATORY COCKS MAKEUP AIR UNIT :... �. _ _ I. . ; r.r.. ... �.... .€ t OVEN POOL HEATER ROOM/SPACE HEATER , i ROOF TOP UNIT l TEST UNIT HEATER J.iE UNVENTED ROOM HEATER WATER HEATER ' S I OTHER m..... INSURANCE COVERAGE I have a current liability-insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _51 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 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 complia with all Pertin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JEFFREY HUTNICKLICENSE# 15212 GNATURE MP El MGF 0 JP JGF!j LPGI CORPORATION # 2840 PARTNERSHIP E]#=LLC 0#= COMPANY NAME: CALLAHAN AC&HTG ADDRESS±BELMONT ST .� CITY NORTH ANDOVER STATEMA ZIP 01845 x TEL 978-689-9233 FAX 3 CELL. EMAIL PLUMBING@CALLAHANAC.COM Date 9476 TOWN OF NORTH ANDOVER t �'s PERMIT .FOR PLUMBING ,SSACMUS� r G � 1. . . .�. . 1.��- . . . . . . . . . . . This certifies that � . .�f.�-. . . . . 1 has permission to perform . '!a`^�?`�. . .�'~�'`� kl b� plumbin in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . at . . . . . . .Z-��. . . �!p � . . . No And er, Mass. Fee X04 .Lic. No..1'57-1-r. . �D- PLUMBING I PECTOR Check tl 11, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I,_NORTH ANDOVERMA DATE 07111/12 : PERMIT# JOBSITE ADDRESS 125 COVENTRY LN OWNER'S NAMEJ CORBEN POWNER ADDRESS ._ _....._ TEL — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL RESIDENTIAL El PRINT CLEARLY NEW:F1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ ...._ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _..I KITCHEN SINK LAVATORY ROOF DRAIN f SHOWER STALL __. —j_._ _-------- SERVICE -SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION w. WATER HEATER ALL TYPES WATER PIPING OTHER BACKFLOW PREVENTOR FOR BOILER ? INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY E] BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El AGENT E] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true nd 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 compl' with all Partin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME JEFFREY HUTNICK LICENSE# __15212Irl SIGNATURE MPE] ip El CORPORATION# 2840.,.,_ --IPARTNERSHIP[ # LLCEI# COMPANY NAME CALLAHAN AC&HTG ADDRESS 121PELENT ST CITY NORTHyANDO 'ER STATE MA ZIP 01845 TEL 978-689-9233 FAX CELL EMAIL PLUMBING@CALLAHANAC.COM FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139 , SEC. 3B TO: BUILDING COMMISSIONEF ARD OF HEALTH OR INSPECTOR OF BUILDIbG 1 5 Mul North Andover Town allTHANnOVER North Andover Fire Department OFFICE OF TONIN MANAGEk ' 120 Main Street SES-124 Main Street North Andover, MA 01845 North Andover, MA 01845 ATTENTION: FIRE PREVENTION RE: INSURED: CORBEN, Steven and Sharon R. PROPERTY ADDRESS: 125 Coventry Lane North Andover, MA 01845 POLICY NO. 75127400000 LOSS OF Jewelry on July 21, 2002 FILE OR CLAIM NO. DA0208047F CLAIM HAS BEEN MADE INVOLVING LOSS, DAMAGE OR DESTRUCTION OF THE ABOVE CAPTIONED PROPERTY, WHICH MAY EITHER EXCEED $1,000.00 OR CAUSE MASS. GEN. LAWS CHAPTER 143, SECTION 6, TO BE APPLICABLE. IF ANY NOTICE UNDER MASS. GEN. LAWS CHAPTER 139, SECTION 3B IS APPROPRIATE, PLEASE DIRECT IT TO THE ATTENTION OF THE WRITER AND INCLUDE A REFERENCE TO THE CAPTIONED INSURED, LOCATION, POLICY NUMBER ATE OF LOSS AND CLAIM OR FILE NUMBER. C SIGNAT Terry M. Seger i T.M. SEGER CLAIM SERVICE, INC. 459 Washington St - PO Box 277 - Duxbury, MA 02331 Telephone (781) 934-9770 Fax No. (781) 934-9194 ON THIS DATE, I CAUSED COPIES OF THIS NOTICE TO BE SENT TO THE PERSONS NAMED ABOVE AT THE ADDRESSES INDICATED ABOVE BY FIRST CLASS MAIL. 09/03/2002 GNATURE & DA E Catherine M. Hepburn, Secretary FORK{ 13 (5-1999) I Location d I No. Date j b j TOWN OF NORTH ANDOVER o p Certificate of Occupancy $ i Building/Frame Permit Fee $ 1 's "CHU <� Foundation Permit Fee $ s�cHust , -A Permit Fee $ <) Sewer Connection Fee $ i Water Connection Fee $ TOTAL $ ? Building Inspector 130.00 PAID ' Div. Public Works PiR11IT NO. c APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ✓ PAGE 1 �4AP 4d0LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK PAGE ZONE SUB DIV. LOT NO. � LOCATION/2 S CfOL1, //�., yJ9 1� C9C� URPOSE OF BUILDING e�� /' W1722 L NER'S NAME { j� �� NO. OF STORIES iG!/C SIZE 7/V OWNER'S ADDRESS /V 1 / BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD vBGILDER'S NAME ,,1/I/C SPAN DISTANCE TO NEAREST BUILDING �•�//V,/ DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS ISTANCE FROM LOT LINES —SIDES �� REARL1,("� ./L •' GIRDERS AREA OF LOT FRONTAGE�7� HEIGHT OF FOUNDATION THICKNESS S BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND ILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES ST. BLDG. COST x,000 PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS ''PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 4 TE FILED �<< / LAUILDING INGrUCTOR Sl-GNA-fU OF OWNER THORIZED AGENT F E E OWNER TEL.k �` < PERMIT GRANTED CONTR.TEL.# � 338 :7-:�--f� CONTR.LIC.# ®�Q.Z•1 H.I.C.# Jl�. BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY JS.OWIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL K. PINE _ BRICK OR STONE HARDW PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B TAREA _ 1/ % l/ FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS ( 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD114'D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE —{I_ STUCCO ON MASONRY �— STUCCO ON FRAME BRICK ON—MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. )2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER j ROLL ROOFING MODERN FIXTURES ' TILE FLOOR r TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNArE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING Town . of ` 6 Andover 0 :.. VV%No. 3.3 J/ .6� F e > .> r Mass BOARD OF HEALTH PERMIT T LD THIS CERTIFIES THAT.......... ........2.A(fWry.....• �� 1 ..................•••••• BUILDING INSPECTOR hasermission to erect ... .......... buildings on ......� . . ... �.�. L.'� y...••••••• • Rough P •• I Chimney Y e tobe occupied as........................ .........(0...—�. ................................. Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS CONSTRUCTION S A Service Final ................. . .... ... . BUILDING INSPECTOR GAS INSPECTOR Rough Occupancy Permit Required to Occupy Building Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector . COA sm� :Z-trq szos FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANTPhone LOCATION: Assessor's Map Number d Parcel Subdivision l Lot(s) , Street �2� �VL'✓l rc� (--h St. Number ************************Official Use Only************************ RECO DATIONS OF TOWN AGENTS: Date Approved Co ervat' n Administrator Date Rejected Comments Date Approved Town Planner . Date Rejected Comments Date Approved Food Inspector-Health\ Date Rejected e a_z ACV w�,l,n� Date Approved (o Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 5 CONS RaRTH AND, ATiO ER N COMMISSION MORTGAGE I145PEGTION SAY STATE SURVEYING SERVICE INC. 234 CABOT ST., BEVERLY, MA. LOCATION NORTH ANDOVER . MASS, NOTES SCALE = 1 = 40 FT. DATE MAY. 9. 1988 _. .., w This is a Mortgage inspection survey and not REFERENCE _ DEED 8 ....... PG . 139 an instrument survey,therefore this plot plan is for .. _ .. _. �K. 2418 + - - _--._. ...._..................•• mortgage inspection purposes only. RECORDED IN THE ESSEX NORTH _ P.141..-Q>;G�STRY _QF.DEEDS..... ........ • This survey is based ort survey marks of others. To CARLSON_ MORTGAGE. SERVICES. INC.____.__ -__,_ a Bushes,shrubs, fences and tree lines do I hereby certify that I have examined the premises and that the not necessarily indicate property lines. building(s) shown on this plan are located on the ground as 0 The building(s) are not located in the special shown and that the conformed to the ronin setbacks of the Y Q TOWN OF _NORTH ANDOVER. .MASS: when constructed, flood hazard zone,as defined by H.U.D. N/F TOWN OF NORTH �1aoVE'R vx " 234.50 — f q0 PRo^P�osAzD '_0Xtj0, 4 3 G76.5 St` 10+ Lrrr I I ___ LOT 9 ^� l._ar l o E t ti . C O `/ I✓t�iT RSC L_�E. . . ' .. - � .�' D •w- - :ar:' 'fi ♦ C T. •r.� •.. aSS' •�'w �w••xl. a. •z tet.„;• a. :1. .�-:r•. ...: ,.„<,_ - ..�#- A ..a,::•.:.� ... 1. �: �, x r' ,. �. 4.0- F •r, 1 (a4«" ,• '.y„ c �'�'•'+ -' �•.. �. �L-k"„•e`t -wP"�"' t' yfca•`f•nS- 7C��.jt .� A'I^ r'... .sh.,. .�'�.- R .r` '�'! ,w4 S •+C y�,,''a,, r:; ..,tT71..zy,+�., .;4. sX.Ley►. ,;•., �. _�� .. �_. .•- .•� 2 GA. Y, a �.;�� sk ws,r w ;,.xx« a'`a.- vcy .3 fix. .' rt *.. a iy+.S 't. '1 .t =r g SES .. � `+r �L l� � .i-. rY f 1 �n r. w _i..i. u`;�:;�' .a< ",..-mac'. �`•''^ ••.. � . . . r..., 1 - -, - �7`•.T ly,. ill-.Yzy 11U LL -� i-O• ! LAP_ 1{ . P.-9. I V EAC- w aV 7N _ - �, coNnxluous o'xna%.r_PrH '1 CEPAMIC TILE vEFr I ,r YI 1 vE¢T. I _ 1¢• - II-{� _ \ QFC;97 PFC�t- TtLP- TILL T I IN FEELING CLIMATE) _ �. •+c�TIC�L � ..I ,"(Ir n_CEA•�E TO Co•IN dy r2 cZltv:�G2 Ex9A.\S.ve _ ,. n.,<.)' , _ ,' - II_c al.`��I • - El cl 97 i 'THVCOL--%Z SC L (:mTEI C•aOv, 1 ,'C,j .-:+•TIC 11::•�UED 7�_ I_DL-2 _ •,_FaI�:+C. i._-5-n.•c NT Cr r • CECK L`CX _ COh2 G2Aw•e TO ACCOMODATE �• j. _ 1 � - � ..- C' ' '—� `\ ____---- -' I -• -�LIV.-ill \ •� hn .•.-.-r•^i�_ _ A�1+7�.0 I-�R+AI'NT IIS--'�' 7s _ TO `j'-- �`_ _ l'_o y}T'i rt �j ��yY ( �' I •'(' �, i _ - (Intir;xa-c• To 7• :N I I �...� III 1 'I 1 -;EEZ:N:CZ Gx':.7+5%e I -. �• 1' 2•CONOUIT- -itl�'\ V,I CGlO �_ IIw i i•. • . 1 d t `., 1� t _1) •.a. JCtNT �.!`•. =t el 1 �-ng 4• STEE_ EDA: ` -"1. IiI �� Fli.:L. ,• ;'-�xrT It)I'Iro 't'} (I1�� y /t' l! f'i�. ' !. '- CCI 11pL w.ILuE 1 r a i. r,T=- 1 1 ..•'.S.CGNN;CTI0NS S. 1', tatitulNh4 �. _ t: ACCUND A::: ��.j'�� 'ft•.�Y.p 5ump Enc.. WAY. . •( q T t3 LJWD[—QV\IAT1=E LIGHT r�TAIL c, E _ °. ✓ t ..-• �.,..o — - i EQUIPMENT L1ST _ :-• 18�a 19 x 2J• G:.A GU a .... - �. J Rum, a-xe-OCnIuS TO A41. •- I cNucK tl.e 7 O. sJS t' �"�?= WGT SQOTS-Flt;. will- ' >a--1 tmt: o.www n. IL 2 \ Il; iTiany')ARD CC)JST¢LJCTION ` 1 2`�.r'•c%rr toti'} ,• S�IITZMQVZP.�. POOL Cr tTl+lt J n n C D!•nRl'.-+G .qtr �•" nra.ni.•r.•.„•.x�wwm••wut .uw.u. k E SOit s a^ s r' ;� 1 • .. •• MAINDQAIN SUMP AIL gp1Y t.w..• N„oe„occ.laur+ >,IG?Ch1A� T AD tHQ M0 1s2o^�_� - c - a:.. •^:.fif#. ,.. .. � '..::nd.. ::�. -_: • ��+...,-- -,. -:.'ran. 9',^.'_ 3•.5.. ,.: � 1`"Y:9?'*- .. .. •.,yY'£= e -'�.'± '44-+�� - .-. �. ._...._?tT.v,._._.k`'c.....r ....:... -:...:.r ..., z,... ;f ..... .._.-5.,r .. - .. _.. _.. . _,... vs .... .. ,.-s'x.''._3",+• .Y�'#`�t _ - .--_- ...... �'':�_..._._ ��.n•x1,..,se.•�..._- rs.'war=.',,-:,.."ia,�,.:...:f.�.' .¢..r$-e;+r-..-.....:, ... _�c...-�.«.-.._-.__.. ., BUILDING PERMIToNORTH q btt,lC 6♦ tiO TOWN OF NORTH ANDOVER ?4': '`- ``•^' o� APPLICATION FOR-PLAN EXAMINATION Permit NO- Date Received �gSSACHUs�� Date Issued: IMPO TANT: Applicant must complete all items on this page LOCATION r f L- hre . • 74AJ Clec t164 A41 Print PROPERTY OWNER e-,Vg J 6tlaeAj z— Print MAP NO: � � PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Re air, replacemen Assessory Bldg Others: Demolition_ Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTIO OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: i CONTRACTOR Name:�Ca � Pr �s -{�c3 Phone: 1 1, /j - Address: � firs'e `� � Lj�� /U4� 6 &e3 Supervisor's Construction License: �l Exp. Date: Home Improvement License: / ro Exp. Date: / 1d -/0 ARCHITECT/ENGINEER Phone: t Address: Reg. No. i FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. O U �- Total Project Cost: $ � �S gDC9 FEE: $ ��tp Check No.: /#p Receipt No.: a O NOTE: Persons contracting with unr istere ontractors do not have access to the guaranty fund o-1 _ _, ignature of Agent/Owner Signature f contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I i i i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ • Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy � N Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location /d S rove., No. Date MORTq TOWN OF NORTH ANDOVER O A • , Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # i Building Inspector NORTII 0 0 4Andover 0 No. ? _ �`y z - dover, Mass.," T O - LAKE 1. I� COC MIC ME' `V 7�S RATED P\P� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT......... .�RN�+� .. ..�'�� ::....:......... .............. ....�...................... Foundation /1 has permission to erect........................................ buildings on .-1dr. ..C.iOI/'.!A........ ...... A.......................... Rough to be occupied as...... ...ri .... '� AtA�� Chimney ................ .... .............................................................................................. provided that the personcc ting this permit shall in ery respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 36_ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TR S ARTS Rough .... ..................................................................... .......... Service BUILDING INSP ' Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:; 161618 Exprratton 11/,12/2010 Tr# 277417 �I} �TYpe DB SCOTT SHEPHERD CONT RUO ION CO SCOTT SHEPHERD�-y'` 453 TINGREENHILL RDS AUBURN, NH 03032 Administrator Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supe - License: CS 71138 rvisor License Restricted to: 00 SCOTT R SHEPHERD 453 TINGREEN HILLND hi,[ AUBURN, NH 03032 ' Expiration: 11/4/2009 F ! ('ummissi,rner. . Tr#: 5114 '7�"i The Common wealth of Massachusetts 4, ! Department of Industrial Accidents Office of Investigations ttlt� 600 ff,"ashington Street ; a f Boston, MA 02111 www:mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/0tpniza6on/Individual)' Address: Ll 1'e City/State/Zip:--LJ,/ '? l/ 7_-� hone#:_. Are you an employer?Check the appropriate oz: I.❑ I am a employer with 4. 1 am a general contractor and I Type of prep(requires: employees(full and/or pam-time).* have hired the sub-crontractors 7.6. ❑Naw construction . 2.❑ I am.a:sole proprietor or partner- listed on the attached sheet i 7. ❑Remodeling Ship and have no employees These sari-contractors have 8. ❑Demoiition working forme.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 exemption per MGL 11.❑ P robing repairs or additions myself[No-workers'comp. c. 152, §I(4),and we have no insurance fit 12. Roof repairs -required.) .employees. [No workers' 13.❑.Other comp. insurance required_] 'Any applicant that checks bozow l must also fill out the section below shovAng their workers'co t Homeowners who submit this affidavit indicating they are doing all work and then hrte outside con�ttactors magationl icysubmott a new adavit indicating such 'Contractors that check this box must attached an additions:shad showr�g•the creme Of the sub-contractors and their workers,m—p.pc'i�•:, hon. I ant an employer that is pramding:workerscompensation insurance for my..enrployeex Below is the policy mid job site information. Insurance Company Name: 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 dttte� . Failure to secure coverage as required under Section 25A of MGI:e. 152 can lead to the irnposition 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 DlA for insurance coverage verification. I do hereby cern un fie pal pen of perjury that the inforn"on provided ab is and correct Si tum. Phone#: 117 ;01 011/ OP621 use only. Do not write in this area,to be completed by eily or town of ciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health Z Building Department 3.City/Town Cierk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: .sully Licensed and Insured Memberof M Better Business Bureau Member of NH Better Business Bureau �ir 0V0 411 ° 53 S. Broadway#2214 10 Stevens Street#141 �•; Salem, NH 03079 ' ' Andover,s�as� MA 01810 (603)890.0084General Contracting (978)475-0095 _ HIC Reg#159028 Newton, MA a(617)527-ROOF GAF-ELK Cert.ME16226 PROPOSAL SUBMITTED TO PHONE DATE STREET E-MAIL CITY,STATE,AND ZIP CODE JOB LOCATION L' Completely protect home with tarps to catch falling debris.Respect and Protect shrubbery and flower beds. Strip off existing roofing material down to the bare roof deck. Thorough clean up and disposal of all roofing debris on property Magnetically sweep property for nails. Inspect roof deck for structural defects and condition of plywood or boards.Repair and replace as necessary". Install 6'of GAF-ELK Weather Watch Granulated Ice and Water Shield at roof's eaves. t Install 3'of GAF-ELK Weather Watch Granulated Ice and Water Shield centered in all valleys. Install a 2'x2'collar of GAF-ELK Weather Watch Granulated Ice and Water Shield around all existing vent pipe penetrations. Install GAF-ELK Weather Watch Granulated Ice and Water Shield at chimney base. Install GAF-ELK Deck Armor breathable roof deck protection to remainder of the roof deck. Install new 8" L and R .24mm heavy gauge,, • -'(color)galva4zed drip edge at roof's eaves and gable rakes. Install GAF-ELK Pro Start pre-cut starter strip at roof's eaves and gable rakes. ' Install new Never Leak vent pipe penetration boots to all existing vent pipe penetration. Carefully strip off existing siding from cheek walls. ` Inspect sidewall deck for structural defects and condition of plywood.Repair and replace as necessary'. Install GAF-ELK Weather Watch Granulated Ice and Water Shield 1 1/2'on the roof deck and 1 1/2'up the cheek wall eaves for superior protection against Ice damning and wind driven rains. c G . Install _ 4 C - t- C r L desired color. �r -•" (color) Install new aluminum 8"x8"step flashing against cheek walls. Inspect ridge for proper 1 1/2"spacing on either side of existing ridge beam to allow for maximum exhaust ventilation.Cut in if necessary. Install {- (feet)of GAF-ELK Cobra ridge vent at roof's ridge for maximum exhaust ventilation.Hand nail to ensure �,f proper fastening. `7 Install Timbertex distinctive Hip and ridge cap.Hand nail to ensure proper fastening. ` Thorough clean up and disposal of all roofing debris on property.Magnetically sweep property for nails. Edmunds General Contracting prohibits smoking on customer's property. Edmunds General Contracting will Furnish and install all necessary materials to complete roof replacement. I .5 Edmunds General Contracting will provide a Thorough clean up and disposal of all debris generated during roof replacement. Edmunds General Contracting will recycle all asphalt roofing debris generated during roof replacement. Edmunds General Contracting will obtain all necessary permits to complete roof replacement work. ` +� Edmunds General Contracting guarantees all workmanship for the life of the roof system. Edmunds General Contracting will include exclusive GAF-ELK year Weather Stopper System Plus warranty. Edmunds General Contracting offers hand nail roof services at no additional charge.(yes/nojl Edmunds General Contracting will replace up to 2 sheets of Cox roof decking and 20'of fascia at no additional cost to the customer.Any additional replacement or repairs will be brought to the attention of the customer and additional arrangements will be made to address repairs. Ste• A�mee �Smartoney financing. "RoofNow,Pay Later." Thank you for the opportunity to bid on your roof replacement work. vii V,rupp!Whereby to furnish material and labor- complete, in accordance with above specifications, for the sum of: dollars ($ ). Payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized Signature: ` according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes, accidents or delays beyond our Note:This proposal may be withdrawn control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by us if not accepted within days. by Workmen's Compensation Insurance. + 0(000ptance of i3lopont -The above prices,specifications and conditions are satisfactory and are herebyr� de a outlined above.accepted. You are authorized to do the work as specified.Payme�rt w.ill.be aAuthorized Signature: �- ' /4,� O/!/U •. Date of acceptance: Authorized Signature: