HomeMy WebLinkAboutMiscellaneous - 135 JOHNNY CAKE STREET 4/30/2018 (2) 135 JOHNNY CAKE STREET
210/107.A 087-0000-0 }
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Date.. .-.t... .��..................
NORT/y, - 1
�a;` .;':�•��oL TOWN OF NORTH ANDOVER
_ 9 PERMIT FOR WIRING
Ss�CHUs�
This certifies that ...........°� 2. � ......... :........
p p .t�...,rJ..,.,�.................:... ..i..'...............�.1.
has permission to perform ...., . f-e vr. C -e. Y,0-4 i
wiring in the building of......4,,.;(/Y"lt-; .............5.
ti ...........................................
fat .":.....,... ..��......�, t V .t...................... ..:..,North Andover,Mass.
Fee.. .......Lic.No.�.-�......K.... .. ............... .. . .. . �� 1 %.
yj ELEC L INSPE OR
Check#
1003
N i
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Commonwealth ®f/Massachusetts Official Use 0111
o Department of Fire Services Permit No.
Occupancy and Fee Checked
,M BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL 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 perform the electrical work described below.
Location(Street&Number)
Owner or Tenant '� /')') Telephone No. 1 -�G�!'
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Buildingtility 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:
_
Completion ofthefollowin table may be waived by the Insector of Wires.
i
No. of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total
Transformers KVA
i No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- 1:1 o.o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlet o.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No. of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained
.. ........................................................
Totals: 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 No.of No.of Data Wiring:
Heaters Signs Ballasts
No.of Devices or Equivalent
n No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
�O_
THER:
tlttach additional detail if desired,or as required by the Inspector of Wtres.
Estimated Value of E ctrical Work _ (When required by municipal policy.)
Work to Start: C Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C VE : 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 cover is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCEBOND ❑ OTHER ❑ (Specify:)
X certify,under thepains and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: . LIC.NO.:
Licensee: t241,,,,_ 46-ez!�b Signature LIC.NO.: g �'
(If applicable,a er "e pt"in the license nztmb�) Bus.Tel.No.• %���
Address: ( Alt.Tel.No.. ,32.
*Per M.G.L c. 147,s.57-61,security work requires Department of Public afety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
❑ 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 the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑ Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments: i
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass IN Failed Re-Inspection Required($.)❑
Inspectors Comments:
i
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass Failed Re-Inspection Required($.) ❑ s
Inspectors Co ments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
oe
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhoid@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston,MA 02111
www.massgov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information PIease Print Letzibly
Name (Business/Organization/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. F1 New construction
eI
ployees(full and/or part-time).* have liired the sub-contractors2. m 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. E]Building addition
[No workers' comp,insurance 5. El We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]i employees.[No workers' 13.[i Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T-Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine u to$1 500.00 and/or one= ear imprisonment,as a as c'
p � y p well civil penalties in the form of a STOP WORK ORDER and a fine
ofup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby rider the pains nd pena ie ofperjury that the information provided abov is rue and correct.
Si afore: !�5Date: / 1.1
Phone#:
Official use only. Do not write in this area,to be completed by citor 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 � �
r
Informati®n 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 producedacceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance 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 y
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 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 Commonwealtl of Massachusetts
Department ofladustrial Accidents
Office of Investigations
600 Washington Street
Boston.,MA 02111
TO,#617-727-4900 ext 406 or 1-877:MASSAFE
Revised 5-26-05 Fax#617-727.7749
wwwmass,govfdia
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iaORTli
"° TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�O+arm rte"'(9 SSACMUS�
tqF
This certifies that .......... �.............................e�........................................
has permission to perform .....Afuelw: ...... . ....................
wiring in the building of.....jw-�.E5....... mz.. ........................
at....... �+........ .. ......s� ,North Andover,Mass.
� �Fee..................... Lic.Nd�........�. ...�.................. �-.,...
ELECTRICAL INSPECTOR fJ
Check #
5669
Tlc Cornmunwcalth of Aja!;sachusetts V _ `'''
Dfrportmftnt of Public Sgfcty
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Oarl..c1 /«060W
d0AR0 OF FIRE PREMMON REGULATIONS iV CMR 1200
3/90 fern%1v"k)
APPLICATI N FOR PERMIT TO PERFORM ELECTRICAL WORK
%wk la w Nbr*1ed M soardaeaa v tM Maiaathwetr uka1 Code.$17 CMR 12.110
(PLEASE P IN nM OR ME ALT. XWOMUnON) Date_ . ml�z/
City r Tovn of �jDyF =o ft Impactor of Yirest
rs d applies for a psnit to perfors the eleetileai %W* described below.
LocatioaM S at A Naber) . l3 5 —
Oma or t
Owiterts Address
U this reit is
De Monivactio4 with a buildittt perttitt Yes L110 ❑ (Check Appropriate Dox)
( purpose of lkiildiiAti- dE�ll�6f �vriiity AuthorLutioa vo.
uUtinp Service .d ds
Awpb Volts Owrt�ead
----�` ❑ Undird No. of haters
lieu Se�rvioe _r,_Aaps ---...- Volts
�----- C+►ernead ❑ Undsrd❑-_..No: of hetero . . .
Hmber of Feeders ad Aapatv.7.
Location add Nature of proposed $lettrical Work
y.
No. oftiin='dutlslr'a lie. of lot tiros - to
Nei of ii>i Bkpt ss writiiit t pool Above
. of t5raas
forsers IVA
No. otafe�e puttl�tti ' Not ' y
t Oil >lttrnertit of lfaits
Noz of. Srfteh Outlets Ga No. of CAB &wmrs
.�
nU ALUM No. of Zones
Nb,,of.lips r is
No.__e! Air Coad. 11e. of �eei
Yotal 1b. of
N0 bf ploi'of to
r 281tia
Devices
No of dish ori 81011 hrsa llestittp No. of Sag taieed
:- veteetioa varices
Not of g r_
'—
3FBl1p.a'ti Detiiess mal❑ apal
Othsr_etion
o Nei olaLev Voltage
Dallsats.
ho , t yd, � NaltiaSe Tubs� No. of
Motors Total iD
htirtluaat to the requirments'of !lassadmootts Csneral Laws
I have a e tftht Liability huurinee poli including ity Capieted operations Coverap or. its substantial
i
NO I hive atdbi♦titted valid proof of aatae to this office. YESYES[] 110 LTJ
f you puce elifscked It$, pieai6 indieati the type of emrap by Chet
kitts the appropriate box.
SNSU1tAfiCL ] p►m ❑ 0I'1tER❑ (Please Specify)
r
Eat iiaee Yalui of Electrical Mork S `(Upiration ate
Work to StarcA,5-Ig, f:. Ihapeetion Date Requested:
RouO -J&/� C*A Final
Signed under the penalties of perjuryt
rum NAMEG
_ LIC. NO..
t! Licetruee .. '�2 rii �� zy Sitneture
LSC. No.
Addtriss_ Due. Tel. No. -c�Sa
OINQR'S INSU1wICIi 1UIVDt= 2 err a241 i ft.
+wfrs that the Lies"" �jL-M w the�lnauraaes cewrasa or to au -
atantiap equivalent as required yy Messaeosatta Ceearal, ; t tyr s�p�e at this psr�it
appliestion waives this reNirs�ent. owner Apnt (please Mock ons)
Signature o Amer or Anent Telephone No. 1vxn m 8
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ail ,. *.. ! t�.. H: • � '
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The Coin inunwcaltli of jqu;;saciiusetcs Us, VOY
DcDarimtnt of Public SgfeYy
BOAR OF FIRE FREMMON REGULATIONS LV CMR 1200
3/f0 hun•i.�r t
APPLICATI N -FOR PERMIT TO PERFORM ELECTRIC
.perk M►. w, ,ed M. e..Ml, b,arre.,Cok t!!CMR IL-N L WO R K
(PLEASE P IH nM OR T pE ILL INFOR2ia,TIO
Date _
� City r Toon of
l�A2T1. 6�r�jp � To the Impactor� iy gpllu ter a pewit to st Oeecor of yiross
pe em thO elec
tsiRal cask saesibed below.
Loeatioa a at A Nusi»r)_ 136 —
't
040408
2s this persit is eeajtmctioo vith
>tirpe.. of fuildiAa build
int peraitt 7e! LvJ I{o (Cheek Appwpsfata. foot)
= _ � �5"�h�llL6l�
,rlit�tr Autbal"tift po•
Fxisting Service dvoiu 0wshead
® Urfdird
lk+► No. of !!eter2-2 'e1t
-- •••:.., / _Volts 0»esfread ❑ ilodSrd❑__..Ate: of I%tess�_ '
*A*w of Peedert said Aapadtr
Loeatibn cad Natuna of,proposad Plettrical WolkAw
f-
No. it Lisliiag 66tiela
Ito. of Not dabs
ft*>r
. of Transforms
Mei of
1NA
ftrirarL� Tai Abm�❑ . ❑ tZetnarat.ess
No, et.� ii`d+aitt� r Ne. of Oil furnars VA. of
lbs' of B+►iteb Outitti � -I–
E. . ib. of Gas fusnert
nu MAW No. of teas
lioc of _ .
i tai•. lie. Of AirtCoM. t; ttutisg D Bateetift i i
INN
No , of 11lsbnlll»rri apiq/�soa vesting D. o ae1 Ceataieed
Not o 1!t)ier `'
(sating Ds�ieea a mmici aarite!
xw
Local❑0 OXCoru�ectiae❑�r
Ib of Mater;llsat ri >0t i ltailales
LOW Voltap
No 1id�Eb Matiait'ltib!$ No. of !beers !oral NT
OTMI .
INSO>t 7VI`yiAGE! hr"ant to the sequiresents et Maasacbwette General Laws
I bavi a t:attedt Wbili Liturance Tolley including
2 ha�ie lttbnitted valid Cospleted
equivaitnt: YBS !1pOto this
Coverage NO D_=tantiai
If you baize chocked YESr pita!o ittaiEeti the proof of rasa to this office. [�
type of CO""Is by checking the appropriate hoz.
INSC1ItIWClf — fbND �" OZ'ltflt (Heise Specify)
Istibated ValUe of r .. . I
leetrieal ebrk $_ iration ace
Work to Start r
.._, 2d2peetion Date Requested:
Signed udder the penalties of ptriuryt
FIRM NAGE
Lieenaeev2 rim y6zi�.cr LIC. NO.
aignaturt
Address •ua. UL No. L1C. M0. r
psi
LZd
:0841ta til ltitUR a WVZR' l a :+rare that the Lieessee es t Alt. ?al. No.
acantlal equivaledt as wNired by Musat usetts General w "ra cererate or is sub-
Application valves this r�equirestnt. Dir • t s0►,signetura on this peisit
t (tleaN eMek tae)
Telephone No
SiRnatu-e o .
Ounrt or Aeent too m I
4
�o bsy L9
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Date.................... ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SA HUS
This,certifies that ... ...... .................
has permission to perform ......J�.-/(........ ............
. ..... ....... .... .....
wiring in the building of.....
. ................................................ ............
at. 2....7........ .. 7c!.. .v f .. ...... .. .... ... ,Norh Andover/I
Mass
Fee.. 5 ...... LAC
No
ECTRICAL INSPECTOR
Check #
-� lU�!!1!l9VODFMcfaffUff Uff Qy�69g�6gl4,BBddSi¢;L6� �/ a..
Permit No. -�
Department of Fire Sere 08s 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 Cbol.527 CMR 12.00
<p LEASE PRINT 1NINK OR TYPE ALL INFORMATION) Date: J 9
City or Town of: N®R7['16[ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant Q Telephone No.
Owner's Address 1 L it- '
Is this permit in conjunction with a uilding permit? yes � No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
A Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:' ' 'r-si szrj
Completion of the following table may be waived by the Inspector of Wires.
No.of Total
No. of Recessed Luminaires No.of Ceil.Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets
No.,of Hot Tubs Generators KVO`
ove In- o.o mergency ig mg
Ab ❑
Swimming Pool ❑ Batter Units
g rnd.
No. of Luminaires rnd.
a
No.of Receptacle Outlets 8 No.of Oil Burners FIRE ALARMS No.of Zones
3 No.of Detection and
No.of Gas Burners
No.of Switches Initiatin Devices
Total No.of AlertingDevices
No.of Ranges No.of Air Cond. Tons
Heat Pump Number Tons KW No.of Self-Contained
No. of Waste Disposers Totals: . ••••• ••• •• Detection/Alertin Devices
Municipal Other
No. of Dishwashers Space/Area Heating KW Local❑ Connection
Heatin Appliances KWSecurity Systems:
No.of Dryers g pp No.of Devices or Equivalent
No. of Water .•No.of No.of Data Wiring:
KW Ballasts No.
mof Devices or Equivalent
Heaters Si ns
Telecommunications Wiring:
No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent
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 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [-BOND ❑ OTHER ❑ (Specify:)
Icertify,under thepains andpenalties ofperjury,that the information on this application is true and conillete.
FIRM NAME: LIC.NO.:
Licensee: . Signature LIC.NO.: -
(If applicable enter "e nz t"in license nu er line.) Bus.Tel.No.:
Address: �.' c 2 Alt.Tel.No.:-CO- L =2 y
*Per M.G.L c. 147,s.57-61 ecurity work requires Department of Public Safety"S"License: Lic.No. 5
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
Owner/Agent PERMIT FEE: $ �
Signature Telephone No.
a-s
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41
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
ki www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractorsf lectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): JA '>��al � ��cCC �fI Ct
Address: 3 k1�Is�•�. S
City/State/Zip: ��`�l� V1�'� GIT3 �L 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
to ees full and/or part-time).* have hired the sub-contractors
p y ( p ) � 7. E]Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. �uilding addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
of per MGL 11.❑Plumbing repairs or additions
3.F1riht exemption I am a homeowner doing all work g pon p
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.] employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box 41 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.
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 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.
I do hereby cep ify under the pains andpenalties ofperjury that the information provided bov is true and correct.
Signature:
!n/
210
/ �� •�/
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
BERNADETTE GIBSON,GRI
REALTOR®
rti
(978)475-2201 OFFICE,(978)984-3112 FAX
I, (978)984-3112 DIRECT LINE
Mb (800)458-4004 TOLL FREE
Bernadette.Gibson@NEMoves.com
• • I 18 F ® ,
_ 0
RESIDENTIAL BROKERAGE Q
305 North Main Street,Suite 102
Andover,MA 01810
Owned And Operated w .NewEnglandMoves.com
By NRT Incorporated.
135 JOHNNY CAKE STREET JS-2005-000722
Proiect Detail Report
Printed On:Mon Apr 09,2007
Project Name:
GIS-#: 7495- Project No: JS-2005-000722 Owner of Record LAMPASSI,JAMES J&LUCY A
'LORT4 t Map: 107.A Date Submitted: Mar-07-2005 135 JOHNNY CAKE STREET
Block: 0187 Status: Open NORTH ANDOVER,MA 01845
Lot: Work Category: _ Work Location: 135 JOHNNY CAKE STREET
Zoning: Proposed Use: District:
c �rgtsc°� land Use: 101 Proposed Use Detail Subdivision
sK
Description BASEMENT FAMILY ROOM Comments:
of Work:
Department Status
GeoTMS Module: Status File No. Comments: LCDate:
Board of Health GREEN FLAG BHJ-2007-000012
Building,Electrical&Mechanical Permits GREEN FLAG BEM-2005-000560
Permit History
Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work:
Building BP-2005-0542 Mar-04-2005 Expired Residential Alteration&Repairs JS-2005-000722 BASEMENT FAMILY ROOM
r
GeoTMS@ 2007 Des Lauriers Municipal Solutions,Inc. Page 1 of 1
`.� Locations
No. Date
NORTH TOWN OF NORTH ANDOVER
0
� w
9
i Certificate of Occupancy $
MUS E��' Building/Frame Permit Fee $
AC
Foundation Permit Fee $
Other Permit Fee $
f TOTAL $ �
i
Check #
18(.145 / Building Inspector
f.
�c
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT RVAI&RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Air ,
BUILDING PERMIT NUMBER: DATE ISSUED.
/ Com _
SIGNATURE: 2LL
Building Commissioner/I for of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number: O
36 00 *� n� �U,�
Map Number Parcel Nudiber [�
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Ld Area Fronto ft
1.6 BUILDING SETBACKS it
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
I.S. Flood Zone Information: 1.8 Saw
1.7 Water Supply M.G.L.C.40. 34) ansa Disposal System:
pubes ❑ ppm ❑ Zone Outside Flood Zone ❑ Municipal ❑ on Site Disposal System ❑ >t
SECTION 2-PROPERTY OWNERSIrIIP/AUTHORIZED AGENT ���+o t I C �i stri Ct: Yes �,i 7 a
2.1 Owner of Record
Name(Print) Address for Service:
t
I a Fe Telephone
c
.2 Owner of Record:
bla�.,��tr e P �
mrint Address for Service: 0
zI
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1.Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor:
License Number p
Address l�
Expiration Date
Signature Telephone r
I
.2 Registered Home ZIMPement Contractor
Not Applicable ❑
Company Name
3-0 Registration Number
Address r'
3 S d(/,C,� liyr9!ic" �� i' ��/lC� jIG /t/ Expiration Date z
Signature _ Telephone G)
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check a0 applicable)
New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) 0 Addition ❑
Accessory Bldg. 0 Demolition ❑ Other &,"Specify 't e-4 &Zk
Brief Description of Proposed Work: '
I /
I
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Completed b 't applicant .;,:: .
1. Building Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee tat x(b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 a Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/-g 441'og e� as Owner/Authorized Agent of subject property
Hereby authorize_ to act on
y behalf..' al a s elati to work authorized by this building permit application. _
iature of Owner Date
SECTION 7b OW R/AUTHORIZED AGENT DECLARATION
I,//d7/C'/��/-C !i ✓L c S�-�. ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are Lrue and accurate,to the best of my knowledge
and belief
P in
"eiat�'t�lre wner/A en Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRVlBERS I 2'qD 3
SPAN
DM ENSIONS OF SILLS
DIMENSIONS OF POSTS
DIlb1ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
II
t
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION
PHOWE 3
LOCATION: Assessor's Map Number jo 71 _ PARCEL
SUBDIVISION LOT (S)
1
```STREET ST. NUMBER
OFFICIAL USE ONL
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
---------------
�SEPTICINSPECIT&- EALTH DATE APPROVED _1? • ��� 4—
DATE REJECTED
COMMENTS 6�_
' d 5
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
DATE_
Revised 9197 Jm
Board of Building Regulations and Standards
- _ HOME IMPROVEMENT CONTRACTOR
Registration:. 123296
Expiration:. 1/22/2007
Type:-DBA
3-D BUILDING&REMODELING,
MICHAEL DUFRESNE
35 OVERLOOK DR:
ATKINSON,NH 03811 Administrator
The Commonwealth of Massachusetts
> Department of Industrial Accidents
Offke of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
Name:In c G94dF-,,r e_ Vs r1wi-v_5'
Location: 4. rl w-,c ole-'
Cityf4;1-4/Av so-c- Phone # d 0-3 F
I am a homeowner performing all work myself.
am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers'compensation for my employees working on this job.
ComDanv name:
Address
City: Phone t '
Irwranoe.Co. Policv#
QompaMf name:
Address
City: Phone#
Ins�itartoe Co. P0UCv!t
Failure to secure coverage as required under section 25A or MGL 152 can lead to the imposition of aWnN penalties d,a fins up to 11,500.00
and/or one yews'imprisorrnent.W maU_as.c hd Amalties-in th8h=dA STOP WOM ORQERsnd,a.tias dpenafts of,aan upnd.me. I
understand that a copy d this statement may be forwarded to the Office of Investigations of the DIA for coverege verification.
I do hereby certa'ly under the pains and naltles ofpenury that the imbrmeNqu provided above is true and correct.
Signatu Date - 0 s
Print name i e - / Phoney>s _
Official use only do not write in this area to be completed by city or town offider
City or Town P ensi
ng
[]Check N immediate response is required ❑ Builthng Dept
[I Licensing Board
Contact person: C] Selectman's Olfke
Phone ❑ Health Department
❑ Other
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
The debris will be disposed of in:
(Location of Facility) '
Sign re of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
T4ORTH �
ovm Of _: 7Andover
0 = = 3 _ y_�noS—
)L LA o dover, Mass.,
COCMICKEWICK ��
ADRATED PPp,`�5
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT........all........... ...... / ......................................:.... Foundation
has permission to erect... !w�. ..'1............ buildings on .... ......... o.�+. '�.1t .,,.,. Rough
t0 be OCCUpled as r .".dx ....� ..N AS �• lo Chimney
provided that the person acceptingi1�s permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relatinglo the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. 1407A I PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
.
UNLESS CONSTRUCTIONS TS ELECTRICAL INSPECTOR
` Rough
...... .. ...................................... Service
.... . .. . . .. .. .....
B LDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.. Burner.
Street No.
SEE REVERSE SIDE Smoke Det.
f
Lo(tation
No. Date
6
NaRTN TOWN OF NORTH ANDOVER
n Certificate of Occupancy $
} °
Building/Frame Permit Fee $
cMuFoundation Permit Fee $
s� sE
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Wilding Inspector
1 2 6499D (19;51, 59.00 PAID Div. Public Works
Location-/
No. -�' ✓ Date
40RTN TOWN OF NORTH ANDOVER
9 Certificate of Occupancy $
* ; ; Building/Frame Permit Fee $
Foundation Permit Fee $
ss�cHust
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
` Building Inspector
r 06/19/9B 09:57 59.00 MIND Div. Public Works
1)E'IZM, IT NO. APPLICATION FOR PEA MIT TO BULLI)******** O11111 ANDOVE'R, 'MA
nl%P N(1. C� LIIF.NU. Z. HI(OHII l)F O\1'NI RS111P DATE BOOK PACE
7111,t. SUB IIIY. I0 I NO. AP— v
11)1 ,(ZION PI)HP(CiE 01 BIIII I)INI;
fMoNEWS14At,1LNn. (Y SIOR11:S
u e-4-V 4 19 SS
I)WNI WS ADDIIF.SS �� -3—
f� BASEAIENf(N2 SI All
J t
ND RI)
AH(1111 E(-I'S NAME 5171(7F II CxXi l In1BLRS 1 '(/Q . ;1 2 3
BIIIIDER'SNANIE ��//� ��,-��®R,� SPAN /
DIS'IANCETONEARESI BUILDING 0 ko"t DInIF.NSI(NJS(IF SILLS
DIS I ANC'E I ROM SFREET (O of DII.ILNSIONS Ol:POS I S
DIS I ANCE FROM LOT LINES-SIDES �RE/(R 1 'T DIMENSIONS OF GIRDERS
AREA OF LOf FR(NJIAGE II1,16Iff OF F(AINDAIION TI IICKNESS
IS BIIII.DINO NEW SIZE OF F(XYI INC !� X"Q
IS 111)11"DIN(;ADDITION �� MATERIAI.OF CHIMNEY
IS BI111_DIN(;ALTERATION �/ IS BUILDING ON SOLID OR FII LED LAND
N'ltLBUILDING CONFORM TOREQ IIREMENISOFCODE �� ISBI111DING C(NJNECIEDIOTOWNWAIER
BOARD OF APPEALS ACTION, IF ANY IS BI111.DING CONNECTED TO TOWN SFWLR
IS BUII.DING CONNEC-I LD TO NAIIIRAI.GAS LINE
INS I'll(A IONS 3. PROPE1211- INFORAIA7I0N LANDCOST
ESI.BI I)G.COST
P4GLA1 Fill.01 If SECTIONS 1-3 EST. BI,DG.COST PLR S12. FT.
ES F. BI[Xi. COSI PER ROOM
EI.ECFRIC METERS MUST BE ON OtJTSIDE OF BUIL DIM; SE19IC PERI II F NO.
A"ACI IED GARAGES MUST CONFORM"fOSFATE FIRE REGUI.AfI(NJS a. "1PPIto%,LD Ill':
PI.ANS MUST BE FII.ED AND APPROVED BY BI IILDiNG INSPECTOR Bl ILDINC INSPF.(`f(IR
DAIE Fl FI) � OWNERS 11:1.M �
C()NIR.11E1.11
!Y72
Z G
C(>rF1 R.1.1C M D ZIA
SIGNAL'ORF OFOWNER I)I2Atli IHN2IZF AGLNT ����ail�,
PI_RA111(AZANfE1) 19
FORM U - LOT RELEASE FORM # V71- 7 g
Ze
INSTRUCTIONS: This form is used to verify that all necessary provals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION*
APPLICANT— ' PHONE_1213 Z/ !�-
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET ke 4 ST. NUMBER
******OFFICIAL USE ONLY*********
�A
RECO NDATIONS OF TOWN AGENTS:
AZXI.0�6 OTIC
72v OF CK
CONSERVATION ADMINI TRATOR DATE APPROVED
DATE REJECTED
COMMENTS
s bis i n_ eC L41f-0- -6 LL - ` � d MA,
- cy K a c— P&CX
TOWN PLANNER DATE /APPROVED
DATE REJECTED
Q. 0-4-4.u
COMMENTS
FOOD INSP CTOR-HEALTH DATE APPROVED
DATE REJECTED
TIC PECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS �.
>2.
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
� NoRry
Town of Andover
O - G
No.
* :7_ -
co
/ c? 19c �
0 - s LANE A dover, Mass.,
000NICHEWICN i�'�`
.9s �Aq E D A'
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
�-�- / BUILDING INSPECTOR
THIS CERTIFIES THAT................................... -............. ... .P .S..S........
Foundation
has permission to erect.........44.A.(.76l 00 4 buildings on ...../.. ...........J.Q.N.1 .Y.C. k ........... Rough
to be occupied as........................................,,........./..5'`...X 3 t�c
p ...................................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION ST S;�
ELECTRICAL INSPECTOR
Rough
................................ ..... .... .... . .. ... . .......................................... Service
B DING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
Smoke Det.
MORTGAGE PLOT PLAN
EK SURVEY
17 ROYAL STREET, LAWRENCE, MA. 01841 Tel. 505-975-1413
MORTGAGOR 4AM y03/ DEED REF. PG. 77
ADDRESS OF PRINCIPLE BUILDING PLAN REF. 8083
DATE OF INSPEC7tON
z
5 OO oo
13
o�
I-Of /(
�y.7o
�1
�d
NOTE This mortgage Inspectlon was prepared ����N ! `%. ` I FURTHER SATE THAT IN MY PROFESSIONAL
sPecMcdly for mortgage purposes and Is not to c� a OPINION the I struature/s and ecce»wry
be refiled u n as a survsy�. E3C lie1/lrY accept* T' ^' outbuetdinss,
AU EL
no rspa 1lty for damages tyo.86e69 with the setback requirements of the lord
rellanoe by anyone otter than the sold mtrtaage6 �o� zoning ordinances, and that no enchroachmen&e
and lie awggna In connectlon kith iia �omqjor
mort ® e fbiancin to sold rnort a or. s fCIStER J�, of putt nes wxept c either way ocross
g 9 9 9 4 io 5 propert lines t as sisawtt.
N �o Y e�P
A( LP
CER nF1CATION TM
101. Property I• hot In a Flood Hazard Area.
Thisp Z Property Is In a Flood Nuard Area.
c�ettltfca4latt V bgsed on the l on c
ocafi t swvay markers E3& IAfdtnatlon Is buuflldiAt U ifetmetntne Flood hazard.
of othwa, Ind does not represent a propefty xUrvey, therefore Mood haxaN datOmIned *m dIvrlaist Federal Flood
.'Ptaeta shown aro not to be oved for the saicbllsfiment o1 Insurance Elate Map Panalf
Property lines.
I
✓1iv. ��xnnaru��ea�l�- a��•llc�.laac�u�efC.t
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Number: Expires: Birthdate:
CS 648898 81/84/1999 07/041954
Restricted To: 86
sOAVID M MORIN
41 BALMORAL ST
ANDOVER, NA 81818
r'�(�oowcmoauuea/�6 o�✓�aaoaa4«aella
HOME IMPROVEMENT CONTRACTOR
Registration 110320
Type - INDIVIDUAL -
Ezpiration. 10/20/98 4
DAVID M. MORIN'
41 BALMORAL ST .
&-r'W0VER MA 01810. . i
ADMINISTRATOR.
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