HomeMy WebLinkAboutMiscellaneous - 127 GLENNCREST DRIVE 4/30/2018 (2) 127 GLENNCREST DRIVE
210/104.C-0058-0000.0
Date IJ:7...j7.Z/......
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TOWN OF NORTH ANDOVER
lop
PERMIT FOR WIRING
SSACHU
This certifies that .............................. .. .............................
has permission to perform ....
.............�G ,.,( t .. 5i� y
......
wiring in the building of..............1.-
.....................................
at.-14:7.... .............. .. .. orth An
dover Mass.
f Fee .... Lic.No. ............. ........
ELECTRICAL INS�810R
Check 4
10431
Commonwealth of Massachusetts Officio Use Only
ARRR;�
M Permit No
� �
Department of Fire Services
kY, Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 6,avebl'ank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASEPRINTEVINK OR YYPEALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perfofm the electrical work described below.
Location(Street&Number) /,?- 7 63-le- *I c-or es;7"r- 494C'
Owner or Tenant Z214 w Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No Check Appropriate Box)
Purpose of Building r i Utility Authorization No.
Existing Service ZA,61 Amps /*zvo volts dverhead � UndgrdFj No.of Meters
New Service Amps Volts OverheadEl UndgrdE:1 No.of Meters
Nwnber of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
/z/,ze
Completion of the following table may he waived by the lnspector of Wires.
No.of Recessed Luminna-117es No.of Cefl.-Susp.(Pauddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above In- -No.of Emergency mg ng
grnd. EJ grnd. 'El Battery Units
No.of Receptacle Outlets No.of OR BUIMIeTS F—MYEALARMS INo.of Zones
No.of Switches No.of Gas Burners No..of Detection and
Total Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
• Heat Pump I Number I Tons KW.......... No.of Self-Contained
No.of Waste Disposers Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW LocalEl Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
. Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs 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: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation!'coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE n BOND 0 OTHER ❑ (Specify:)
Icerti e 7uryy
certify, under the and tf r' that the information on this application is true and complete.
0
FIRM NAM: ,LIC.NO.:
Licensee: g,,,_ 4
_5;-* -f /-/ Signature LIC.NO.:/L9"
(7f applicable,epter"exemptBus.Tel.No.:
"in the license number line)
Address: Alt.Tel.No.:
*Per M.G.L c.147,s.57-61,security work requires Departmertf 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)n owner E]owner's agent.
__1 A___4- r- I
------ ------- ---- ----------- -
rice
The Commonwealth of Massachusetts
T ! Department of Industrial Accidents
Offace of Investigations.
600 Wasdaington Street
mit,kl Boston, MA 02111
www.tiurssgov/din .
Workers' Compensation Insurance Affidavit: Builders/ContracforsXleetricians/Plu mbers
A licant Information
Please Print Leeibl
Nalrle (Business/organization/individual):
Address:
Citystate/Zig: Phone#:.
Are you an etnp{oyer?Check.the appropriate box: ' -
I.❑ I�am'a em to er with 4, Type of project(required):
P Y ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors b ❑New oorisfruction
2•❑ I am.a-sole proprietor.or partner- listed on the attached sheet 7. ❑Remodeling
ship and.have no employees These su&contractors have 8. 0 Demolition J
working for
.in any capacity, workers' comp.insurance.
[No workers con .insurance 5. 9• ❑13uilding addition
P ❑ We are a corporation and its
required] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am s homeowner doing ali work right of exemption per MGL 11.[]Plumbing repairs or additions
myself,[No•worke'rs'comp. c. 1.52, §1(4),and we have no
insurance-required.]t em to-employees, 12•❑Roof repairs
p Y [No workers'
COMP. insurance required_] 13•❑.Other
*Any applicant that checks bo)t#l must also fi[lout the section below showing their workers'compensation policy information,
t Homeovmers who submit this of &vit indicating they am daing all work and then hire oulside contractors must submit a new affidavit indicating such.
$Conhactors that check this lox muststraehed an edditicnal shset shotvin.L Mm
r e of the sero conhactor an
their z'
mr..a camp.poli in:a,;,at vn.
!aar emptnyvr tizat is, roviding:wo„+seP,,' nr npoy col�ri
informa don. perasatiosa arasaararace f o>° a dees: Below!s flee polecy end job si¢e a
Insurance Company Name: '
Policy#or Self-ins.Lie.,#: r
• Expiration Date: •
Job Site Address:
• City/State/Zip:
Attach a copy of the workers',compefasatiota 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenalties ofperjury that the Mformationprovided above is$rue and correct.
Signature-•
Date:
Phoonne�;#:
of�cialr Luse only. Do not w.r&e,q taxis a:ea,to he cc^i�ii lgted b Cu Or ill
• p, .Y ,V t+3 •�officeat.
City or Town; Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town-Clerk 4.Electrical Inspector 5.PEinspedor
6.Other
Contact Person• Phone#:
PERMIT NO. 04043 f-1 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
I MAP NO. LOT NO. 12 RECORD OF OWNERSHIP iDATE BOOK PAGE
ZONE I SUB DIV. LOT NO.
�• .LOCATION i�"7 PURPOSE OF BUILDING
OWNER'S NAME` `l _j i���I�p _ NO. OF STORIES `L , SIZE
OWNER'S ADDRESS p �q/�t�L V-�. BASEMENT OR SLAB
ARCHITECT'S NAME ll SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME Q/ SPAN -
DISTANCE TO NEAREST BUILDINr DIMENSIONS OF SILLS
DISTANCE FROM STREET " POSTS
DISTANCE FROM LOT LINES-SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND IV
WILL 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 EST. BLDG. COST goo
_ 7 ams`r�� e
PAGE 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER SQ�FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED, BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED7D APPROVED BY BUILDING INSPECTOR
DATE
/F 1�L D
BOARD OF HEALTH
SIGNAT E OF OWNER CA AJTHORIZED AGENT
FEE
PLANNING BOARD
PERMIT GRANTED
YI ,
3 1s
BOARD OF SELECTMEN
BUILDING INSPECTOR
�J
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY QFFICES 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 _ _ B 1 2 13
CONCRETE BL'K. - PINE
BRICK OR STONE HARDW'D
PIERS- PLASTER
DRY WALL ,
UNFIN.
3 BASEMENT
AREA FULL FIN. B'M'T' AREA _ -
7, y, 1/4 FIN. ATTIC AREA
NO BMT FIRE PLACES—,'
HEAD ROOM MODERN KITCHEN ' r
4 WALLS I 9 FLOORS I
i
CLAPBOARDS B 1 2 3 GX-"
DROP SIDING CONCRETE --�—
WOOD SHINGLES EARTH
ASPHALT SIDING HARDW'D _
ASBESTOS SIDING COMMON ,
VERT. SIDING ASPH.TILE j
STUCCO ON MASONRY t
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STIRS. & FLOOR _
BRICK ON FRAME I :� :.- •— ..--,.'-_-' '.."'..'_
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR 1-1 POOR
11 ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE I HIP BATH (3 FIX.)
GAMBRELMANSARD TOILET RM. (2 FIX.) _
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY _
WOOD SHINGES KITCHEN SINK _
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER
ROLL ROOFING MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING 11 HEATING
WOOD JOIST PIPELESS FURNACE
_ FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & 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 I NO HEATING -
r
Location/� �_� r ���' �`
No. ' � Date
HpRTIy TOWN OF NORTH ANDOVER
10?.• , OR
}�o Certificate of Occupancy $
sACNUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ F
Check # t '
Building Inspecto(/
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1 SecRoi> far Cidd Use'�ni .771 7
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building 4--
ssioner/I ctor of BuildingsDate
SECTION 1-SITE INFORMATION Z
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Ma6 Number Parcel Number
1.3 Zoninlgl formal tion: 1.4 Property Dimensions:
Zoning District Proposed Use F-Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided R aired Provided
1.7 Water Supply M.G.L.C.40. 54) 1•S• Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) Address for Service
9 g-22,S— ,s' 1��� , � �o SFA
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service: O
Z
Signature Tel hone M
SrECTION 3-CONSTRUCTION SERVICES QO
3.1 Licensed Construction Supervisor: Not Applicable ❑
e
Licensed Construction Supervisor: o
License Number
Address
Si nature Expiration Date ic
g Telephone r
3.2 Registered Home Improvement Contractor Not Applicable ❑ Pte!
Company Name
P Y
�S u" ,C>/, I E)7 SUI 7F _Z�Z
Registration Number �...
Y ! V p r
Ex
puation Date �
Signature Telephone
NORTH
own of � _ Andover
0
No.
dover, Mass.,
LA �.
COCMICMEWICK V
ORATED PPS` -`C2
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
...................................................................... BUILDING INSPECTOR
THIS CERTIFIES THAT...... �....:...... ........ 5.
Foundation
has permission to erect........................................ buildings on . ................ 7.....`6../ ugh
to be occupied as I0 � Chimney
provided that the person accepting thiAW
s mit shall in every respe onform to the terms of the application on file in Final
this office, and to the provisions of th Codes and By-Laws relati 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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU STAR Rough
................. Service
B LDING INSPECTOR
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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
T Office of Investigations
600 Washington Street
Boston,MA 02111
°�M ,•�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ��(, _/ Please Print Legibly
Name (Business/Organization/Individual): Fred (p0,je/1,C/
Address: 102 6-1eAUn I- 3tf(le-
a i
leati r
City/State/Zip: AA Phone #: ?,T O.f
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employee's (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
5. We are a corporation and its
in ❑
o workers co insurance rP
[N comp.
required.]
officers have exercised their 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ 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:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inforrnation.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: V C 6OO 9T FOO / �
VY Expiration Date:
Job Site Address: /OZ7 C lenc&j City/State/Zip: u0
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
iN
fine up to$1,500.00 and/or one-yearmprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce under I#f pains and penalties of perjury that the information provided above is true and correct
Y 0,"A—,-
r J_
Signature: p [ Date: 1�
c
/ ,�—
Phone#: 1 7 0 4 f 5 c3 T h o
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person'in the service of another under any contract 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 all individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number-listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
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 permittlicense 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
provided to
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be 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
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
i
Y
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
Also,.note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
Z,Z- 4 5 -T�v c-, S IV C'/
(Location of Facility)
Signature of Permit Applicant
Fire Department Sign off:
Dumpster Permit
zos'
Date