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HomeMy WebLinkAboutMiscellaneous - 13 UNION STREET 4/30/20184 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .(.�S1D�....l� ............................... has permission to perform.,+. ......1r,,;Q..V%A ,.rl!, Q : ................ wiring in the building of. .... ...ii,.a.,`,',, .. Fee ........................... Lic. No-(../��.......}�yp�xji ........... Y �.I 1,�� W Check e F• �� L Nrflal �N�. � �� ���� N (h <C\ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS `O'ffiycial Use Only Permit No. Occupancy and Fee Checked [Rev- 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: -- o;2 / 15 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) 1-3 Uri �%I _Sr Owner or Tenant Telephone No. Owner's Address t[ a Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (::7 toV No. of Meters No. of Meters Completion of thefollowing 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- ❑ rnd. rnd. o. o mergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. 2 of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number - Tons KW ....."""........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of fires. Estimated Value oflectLk 'Work: 7D© (When required by municipal policy.) Work to Start: Zj 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: INSUIRANCE�R BOND ❑ OTHER ❑ (Specify:) I'certify, under theT s andp/enalties ofperjury, that the information on this ap lication is true and complete. FIRM NAME:. f �1 �'� c��� 'l� � Gf%// m � LTC. NO.: if --se? Licensee: Q ! Signature LTC. NO.: (If applicabl n ! "y empt" 'n the license number line.) . ` Bus. Tel. No. Address: C l oii461(7/) het^ Nt-F alt. Tel. No.: -''2'2'2'2 *Per M.G.L c. 147, s. 57-61, security work requires Department of Publi 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 $ y� Signature Telephone No. PERMIT FEE: �j ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the,provisions of M.G.L. c. 143, § 3L, the 4 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 v electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed:** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Co nts: Inspectors Signature: Date: FINAL INSPEC �N: Pass EN 1ZFailed Re- Inspection Required ($.) ❑ Inspectors Comments: f Inspectors Signature: %,L Date: % M DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com A The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: P B ©;aC City/State/Zip: G?CI,O"gipay tv f Phone #: 60-3 _ ?6 5 Are you an employer? Check the appropriate box: 1. ® I am a employer with _employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. remodeling 9. ❑ Demolition 10 ❑ Building addition I L ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ 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. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. �yc Insurance Company Name:Gp Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: /3 V f? (0 /1 ST City/State/Zip: N, '4nCtin/eI 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. o-,, - ?'65- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # ,;R1 )5 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: N Information and Instructions e 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 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia M I I L " I: Date.. -/,/I %- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... f'..`"' ....... (....'? /�,. Q .............. has permission to perform...6 .................................................:... plumbing in the buildings of...........Al/..Vin............................. at .............................. .............................................. North Andover, Mass. Fee.`�. ..... Lic. No.�Gb�.............................................................................. Check # O / 413 PLUMBING INSPECTOR 70 2 f P TYPE OR PRINT CLEARLY 5 ,/ MASSACHUSETTS APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY „A/; �DU c/-_ MA. DATE PERMIT # _ JOBSITE ADDRESS -10 Y -V j' t OWNER'S NAME _JV OWNERADDRESSt>'✓1 1 -N%/\S f TEL EL _ OCCUPANCY. TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ NEW: ❑ RENOVATION: ❑ FIXTURES 7 FLOOR BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER REPLACEMENT: [� FAX RESIDENTIAL [5—' PLANS SUBMITTED: YES ❑ NO ❑ I have a current -liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142.. Yes E] No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, -and that my signature on this permit application waives this requirement. of Owner or Owner's CHECK ONE BOX ONLY: OWNER ❑ 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 NAME Peter J. Crane SIGNATURE LIC # 21805 MP ❑ JP] CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street CITY Haverhill STATE 11k ZIP 01830 EMAIL annacrane.ac@verizon.net' TEL 978.771.1155 CELL 978.771.1155 FAX i a =4Ed61= The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): P; � /7 Address: City/State/Zip://- � . � /,, �.1/ Phone #: Are you an employer? Check the appropriate box: 1. ❑ am a employer with employees (full and/or part-time).* 2. ' I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance., 6. ❑ we are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.0 Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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. 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). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and corrept. 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 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' compensatioii'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia . Location G'%2 ' ' "�--�' ' --IZ70 � No. ` G / Date TOWN OF NORTH ANDOVER O w F ; p Certificate of Occupancy $ CH Building/Frame Permit Fee $ ���• Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1535 5 Building Inspector/ ai 11V1� ULA% V Al ML 7 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: Address Signature I ITelephone 3.2 Registered Home Improvement Company Name Address License Number Expiration Date Not Applicable ❑ Registration Number Expiration Date TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING a` BUILDING PERMIT NUMBER: / DATE ISSUED: �`- 02 (4 SIGNATURE: 141411 Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1Property Address: 1.2 Assessors Map and Parcel Number: .. j10, Ono-)5;l /V tw,pr 0 Map NumbAr Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 11 Front Yard Side Yard Rear Yard Required Provide red Provided Regifired. Provided 1.7 water supply MGLC.40.tM).1.5.�Flood Zone Information: 1.9 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record si- ame (Print) Address for Service : Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone ai 11V1� ULA% V Al ML 7 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: Address Signature I ITelephone 3.2 Registered Home Improvement Company Name Address License Number Expiration Date Not Applicable ❑ Registration Number Expiration Date SECTION 4 - WORKERS COMPENSATION (NLG.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 .......0 No ........ 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Q Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition ❑ Other 0 Specify Brief Description of Proposed Work: temcdeled 4K,=:.hen + 6a+L4 1'� klcerylen'�— wl()&f'oS hea4e-r-g clddi&o o ( r,>Aa SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item 1, Building Estimated Cost (Dollar) to be Completed by permit applicant X23 5 vQoc) (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plidmbing Building Permit fee (a) x (b) ` r 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 7 as Owner/A orized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Print Name SiOnAturt. of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2 ND 3kw SPAN DIlvIENSIONS OF SILLS DMNSIONS OF POSTS DIlvIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1 D. Robert Nieeita, Building Commissioner TOWN OF NORTH ANDOVER Dire of the :3aailding Department Community Development :and Services 27 Charles Street. (North Andover, Massachusetts 01845 DEBRIS DISPOSAL FORM Telephone (978) 688-9545 FAX (978) 68'8-9542 In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, s 150a. The debris will be disposed of at / in: (Site location) Signature of permit applicant Date Michael McGuire, Local Building Inspector James Deeola, Electrical Inspector James Diozzi, Gas/Plumbing Inspector - []. Robert yJ/CettaBuilding Commissioner (978) 688-9545 -,1978) 688-9542 Fax ' Town of North Andover Building Department 27 Charles . North Andover, MA. 01845 � ' ` � HOMEOWNER UCENSE EXEMPTION Please print ` DATE � I Number Street Address map lot f Name Home Phone Wo Phone PRESENT MAILING ADDRESS Onam SZ City Town State Zip Code � The current exemption for ^hommezwmers~was extendedboinclude ^ wner-occupied dwellings cf�mun�scr�soand toaUovv �-- nctpossessaUoens�pnzv�edthstthemxmerac�xas - - � - --------'~~~^~ . _ supervisor. (State Building Code Section 108.3iS.1) ^ DEFINITION OFHO Person(s) who owns a parcel of land on which he(she resides or ------~'^ there i�or�h�endedbpbe, aone ortwo fanUydvv�'~~^~^'~""" dwelling, attached orwhich�~^' detached ao- tosuohuaeandA�rf�mns�ncb�n�' �4pensonvmwacz��n�c� ------ -_`, n���anmnehmmehme two-year period shall not betmnsideredahomeo^mar ' The undersigned ^homeovwner"ass.aaresponsibilityfor with the State Building ngCodeandomar Applicable codes, by4ow�. ro/as and regulations,no. ' , The undecs�ned^honeomn�"oed�imsthat hebheunden�andsthe Town o[No-And~arBui/dingDepartment m/nimumninspection procedures and requirementsand that 'ab'~will comply with said procedures and requirements. ^ ` HOMEOWNER'sS/GNATJR .� APPROVAL OFBUILDING OFFICIAL J O `6 i rd A xx E� w° ch O v w° Cob U w CQ C2 io w O W wo' w OF � C2 Fo w w cn cn 9 uj 0 am z 0 U6 O O 4.j O O CD Z O D H y .E L CL co C O co w m a. CO) 0 cv CO)zs C O V O L O V co d CO2 C CO GM C 0.— M C m m • 0�:co o ` V C-) fl:�c ev c 1.0n �J i o R 3 N� o o m�(.� J +►:E_�^ v o` 4=3 _l /`fie m c E \: N N ' o . y C-0� O N . HE ® O aC � Os m cm \ o cm o = — v:�: acr m J; or, O Y VmN � Z l_ Acm O `y c n c c _ O.L.. p N 4:�� L ELI O C.L.. r - m y •E a=oc 0,0 C N Z o LLI m, 6- mn o� vCM A 0 N = t- L O 0 nim 0 U6 O O 4.j O O CD Z O D H y .E L CL co C O co w m a. CO) 0 cv CO)zs C O V O L O V co d CO2 C CO GM C 0.— M C m m