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HomeMy WebLinkAboutMiscellaneous - 135 SOUTH BRADFORD STREET 4/30/2018 (2) 135 SO BRADFORD STREET J 210/103.0-0031-0000.0 Date.... °FpTh�a TOWN OF NORTH ANDOVER to, ' PERMIT FOR WIRING • Thiscertifies that ............. •/••' ...................... `............................................. has permission to perform ..............`:-qzt%/.................................................................. wiring in the building of....................... +!..� 1t.A C ............. ................................................... at ..". ...�3.....��........J...... �r-�J�. ,North Andover, ass. ............ . v FeeS ........--^.....Lic.No.�... .. 5............ ..... . ..: .... ............ .+ (� s-L ELECTRICAL INS' CTOR Check# I v 116S' 3 y Commonwealth of Massachusetts Official se Only Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS 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(NEC),527 CMR 12.00 (PLEASE PRINT IAT INK OR TYPE ALL INFORMATION) Date: b b 11-6 13 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) 055? 3oj'tN IE� ,2y.2 e-,-T. Noe-rq A,1QD1JM7- wAh Dig43 Owner or Tenant �hAu---5 AW C wo 1"ynl �Z, I moi.wt@4-- Telephone No. Owner's Address t-35 -50L)114 'F3FA t7 -Lg '3T. X/DtSI" pc,,/= �V.IA- ar:4h5 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building (ZF s►t?�r�.P��' Utility Authorization No. - Existing Service I oa Amps 1 t o / 7,-Lo 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: RC,uo!}FLg-t 135 So Fia.-toy2.o S'l. 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 I No.of Hot Tubs Generators KVA r No.of Luminaires -1 Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones i No. of Switches 4 No.of Gas Bumers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons 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 El Other Spg Connection No.of Dryers Heating Appliances KW SecuriNoto Device s or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent ecommunications^ No.Hydromassage Bathtubs No.of Motors Total HP TelNo.of Devices or E u valent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: -1'�j5 o.oo (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 M BOND ❑ OTHER ❑ (Specify:) YN I certify,tinder the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . M k(LC -A L, N LIC.NO.: ?V1016-1 bh-► $d-f Licensee: CA(2-A51-EN T Signature LIC.NO.: I 6 t (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: Address: -1 AAj, p-Z-IY4 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work req ires 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. ❑ 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 r 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 conceming 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[N Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: U.— ��-S Date: =Com Failed 0 Re-Inspection Required($.) ❑ n Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com e4 The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations kvi 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le;?ibly 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. ❑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.# �• E]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. El 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.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees.[No workers' 13.[i Other f 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. Insurance Company Name:. P Y Policy#or Self-ins.Lic.#: 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 forth of a STOP WORK ORDER and a fine otup 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 cert under the pains and penalties of perjury that the information provided above is true and correct. - Signature: Date: 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 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 Fi 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 a (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�,MASSAFB Revised 5-26-05 Fax#617-727"7749 v vw.Mass.govfdia Date. �.. 7.Dlo........ NOR711 °`< ;•�"� TOWN OF NORTH ANDOVER ° A PERMIT FOR WIRING 1 cMusE�� K This certifies that - A _ has permission to perform ..:......................-... . ........... i1wiring in the building of....... �:�....��..9....................................................... f�.......................: ........ �� .......... ,North Andover,Mass. Fee c............ Lic.No A-�:�, : "-Z ,!,�..... .......... ELECTRICAL INSP E&OR Check # 6999 Pernzit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leaveblank) f ; f APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W'JRK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CIvIR 12.00 (PLEASE PRINT IN INK OR TYPVc--,) L INF RMA TION) Da t e: od- 1 � , (� City or Town of: a�>t� To the inspector of Wires: 1 By this application the undersigned gives notice gf.his or uiten/tio to perform the electrical work described below. Location (Street&Number) �.�d Owner or Tenant �j P Z1 kYiA,,.,je,4;j Telephone No. Owner's Address Is this permit in conjunction with a building p rmit? Yes ❑ No (Check Appropriate Bos) Purpose of Building 31 k7 5�� 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: 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 TotalTransformers KVA No. of Lunvnaire Outlets No.of Hct Tubs Generators KVA No. of Luminaires Swimming Pool Above E] In- ❑ o. o Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches25' No.of Gas Burners No.of DInietection ing Devin es � No. of Ranges No.of Air Cond. Total Tons No.of Alerting Devices 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 SecN of Systems:* s or Equivalent I 1 No. of Water KW No.of No. of Data Wiring: i >� Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: — �6) Sy ttach additional detail if desired, or as required by the Inspector of Wires. � Estimated Value of E ctrical Work: (When required by municipal policy.) Work to Start: GJ l Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provi es proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND E] OTHER ❑ (Specify:) (� /� I certify, under the pains acid penalties of per'ury, that the information on thisNppli r�tVotz is tt ue atzd complete. FIRM NAME: 1-1-J-0 kl 1 LTC.NO.: 3 f' 3j Licensee: r/ Signature LIC.NO. (If applicable, enter "exempt" ' the lice se number line.) Bus.Tel.Na Address: ` l Z. Alt.Tel.No.: *Security System Contractor License required or this work;if app icable, ter the license number here: 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: $ 1 j Signature Telephone No. I S3t.•wrN Vr AINDUVER �ommerciai: Viewer Ejection Pump: $2J.UU EL . /``ICAL PERMIT FEES a) including photovoltaic& Signs: $25.00 each ballast (Effe March 12, 2003) generating Equip Per KVA $1.00 Smoke &Heat Detectors& MT � PERM tx], 1;,5 b)un-interruptible power systems, Initiating Devices: RESL TIS $2S 00 per KVA$1.00 Residential: $1.00 each ColvZixcL�L $50 00 c)batteries over 100 amp.hours,per Commercial: $60.00 up to 10 `' �`' T cell $1.00 devices over 10-$1.00 each OLJ'I,SIDF OF BUI.LMNI G Heat Devices: $1.00 each Space Heaters: Air Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each Alarm Systems Security: (for fire Hydro-Massage Bathtubs/Hot Sub-Panel: $25.00 systems see smoke/heat detectors) Tubs: $20.00 each Swimming Pools: Residential: $40.00 Lighting Fixtures $I.00 each Residential: Commercial: up to 10 Devices Lighting Outlets: $1.00 each Above Ground: $25.00 $60.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 $1.00 each $20 each Commercial Pool: $100.00 Carnival Equipment: $50.00 each Motors: (per hp or fractional part Switches: $1.00 each Ceiling Fans: $1.00 each thereof) $2.00 Temporary Service: Commercial New Construction or Oil/Gas Burners: Must have Utility Authorization Number Alterations: Residential$20.00 each Residential$25.00 $100.00 per 1,000 Sq. Ft. of Commercial$20.00 each Commercial $100.00 Construction Space Office Furnishings: per circuit$10 Transformers: Commercial Service Change/ (Relocatable Partitions/Cubicles) a) capacitors,Per KVA $1.00 b)ducts,conduit&conductors Repair: Outlets&Fixture: $1.00 each Mc) each manhole have Utility Authorization Number Ovens Built in/Counter Top Units: (Associated nhle o $1nt Transformers)$25 $100 (fu $5. (first 100 amperes or fraction,one $10.00 each le 00 meter) Panel Change/Circuit Breaker: d)each handhold$5.00 a) each additional 100 amperes Residential: $20.00 e)per KVA$1.00 capacity or fraction. $30.00 Commercial: $25.00 fl primary feeders, $25.00 each(over b) each additional meter$25.00Phone Jacks: See 600 volts,non-utility owned)Commercial Temporary Service: data/telecommunications g)vaults and equip. $25.00 eachWashers: $15.00 each $100.00 Ranges $15.00 each it .ust have Utility Authorization Number- Receptacle Outlets: $1.00 each Waste Disposals: $5.00 each Commercial Repair and/or Water Heaters: $30.00 each Recessed Fixtures: $1.00 each Maintenance Permit: (Blanket Re-inspection Fee: $25.00 Permit)up to 2 Electricians$150.00 *For Multi_Pamil�T & per air of Electricians over 2 $50.00 Repair to Service Residential: t $20.00 Large Commercial Project Data/Telecommunication: Residential: $1.00 per port g Residential New Construction see If%irin Inspector for Commercial: $30.00 up to 10 (Dwelling): $220.00 pricing: devices over 10-$1.00 each (with service up to 200 amps) (Paul Kennedy 978) 623-8306 Must have Utility Authorization Number . Dishwashers&Disposals: for services over 200 amps see below (Office Flours 8 ani to 1.0 ani) �. $5.00 Each a) for each 100 amps capacity or Dryers: $15.00 Each fraction add$20.00 *Inspection Emergency Lighting(Battery Units) b)each additional meter$10.00 Schedule: $ 1.00 each unit c) each additional panel/sub panel 1 ROUGH Feeders or Sub-feeders: $25.00 1. FINAL each 100 amp capacity of fraction I TRENCH (i f applicable) thereof Residential Additions/Alterations: Residential: $5.00 each $220.00 maximum Commercial: $15.00 each Residential Service Change or ADDITIONAL ' Gas/Oil Burners: Underground Service: INSPECTI()l�iS •x,$25.00 (if � Residential: $20.00 each M applicable) Muustst ha�•eUtility:�rrthorization Number a pl? ) Commercial$20.00 each a) one meter,up to 100 amp capacity :ell $40.00 (revised 07/05) b) each additional 100 amp capacity or fraction$20.00 Iy®yrOFPUBWS4FS/Ypermit No MMOFFLREPREVFNI10N191UMM52i dniza �pwy At Fen Checked APPUCATIONFOR PERu.WMI'TTo PERFORM ELECTRICAL WORK a AORK TO 9E pEMRMED IN ACCORDANCE W�THE MASSACHUSSTS ELECTRICAL CODE,527 CMH 12.00 CtPLEASE PRIIVT IN BM OR TYPE ALL INFORMATION) To the Inspector of Wires: Town of North Andover to perform the electrical work described below. The undersigned applies for a permit Location Street 3 Number) l 3 Owner or Tenant OWN A Owner's Address S"e Is this permit in conjunction with a building pemtit» Yeses No M, (mak AppmpnaM Box) 4!( 3 5 7 Utility Authorization No. se of Building 1�/�5/c st' ' Purpose U C3 No.of Metes Am � �• ► VOiu Existing Service �/Gam'— �� Ovethed � U � No.of Metes �� Nrw Service -�L'`' Amps��c� 1�.. Volta t>.rerhead Am 'ty Number of Feeders and P� r •_ 77 Location and Nature of Proposed Electrical Work dTrarwterro.r. Tout No of uandmt No of Hot Tubi KVA Po Na d t,iahiin{� Swhpadna ol' Above Beiaw Ckrraatar KVA No.d Oil Hurlers Na of Emeraeaer LiaFrdna Battery Units No.of ReceptecM Oudetr No of switch Outlet. No.d Oae Homer No.of Air Cond. Tod FME ALARMS No.of Zonas No.of Rama* Tsar No.d Herz Tod Total No.d Detectloo end No.d Dbpouir Pu Toa. KW oa Space Ara Headpa KW Na&of d Soupft d4tp Devices No.of Diehwuhers No.of Self Captained Deviceso Heatirta KW Loer Connection. No.of DUM �y Na d Na d No.of Wata Herten s Bdluh No.Hydro Muee{e'IS�o Na of Motor Tod HP i OTHER.0 r L Lt 11 ,7 CMW Ynumr�OeC Pllnimtditete4itmreibdG°�I9iva orlss+>1>�rlitla}avaiest YES NO 1ha�eaaae�tl�bi,Yl�isee 'i �� gym ihavedrndm'YB%phand®lebetypedoovmgby lhnesutar+edveldpioddst;netfli90ft Y� �pddngtheqRFFA=ba QnIPRC�w�'ir�+ Esome�dvalleafDediiolWodt$ Find � WakIDSM ' 'r•�= g �� � — urldm pea�bdptf �r. Ii=wrb 4 l 0 1 3 RRMNANE •� ..,� l� ��raiz. � I�nmiseNo i iaer�E 7 r // �i �,1 7 Tia f NQ. 1 /I.TdNQ � IklH>�lx OT�aib�eQlV8bY8lRr}��►IV16�1�{�18V1{ OWMCSM WAMBtlotnaweelfirriheLi mee ' xddARprsPnondispm►ri thi,� D (Please check one) Owmx Telephone No. nowummopERM FEE e i 461 5 _ Date......1... �a :.d:.... NORTH °`t"`°:•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ��ss�cHusE� This certifies that e45g�. . 04! ' �....,,,,. has permission to perform .....SG'P—..Pi e,.F v���,t>J ' . .. wiring in the building of.................................................2,/rel /, ............................... j j SDri7y ! at................................................... .,��G?............ ,North Andover,Mass. vv rt Fee...�r ':'-. Lic.No!�137a'3 ,,�� .. .............. ... ............ .. .. ELECfR[cALINSPECTO P Check # DERUMW POFPVR[JC3W [Y Lft*WINd,BaM0FFD[EPFE'VF 7nV=UAT1gi 527adRas Fees Checked �.�-..— APPUCATTON FOR PER&ff TO PERFORM ELECWCA,L WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WRH THE MASSACHUSSTS MlcntICAL COD157527 CMA 12:00 PLEASE PRINT IN INK OR TYPE ALL OmRMATION) p `�I k o Town of North Andover To the inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 3� ✓��-> t/��y�iG �z? f Owner or Tenant rAnv- Owner's Address S� t Is this permit in conjunction with a building permit: Yes[n No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service /� 61 Amps olh Overhead �„ Underground 0 No.of Meters New Service RG�� Amps/-2 zVolts Overhead Undergrond C No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lumina on" Na of Hot Tubs No.of Tranaaxmers Totd No.of Lighting R=M 3wimmins PodKVA' Above Below Omreratats KVA aryorld 11 171 No.of Receptacle Outlet No.of Oil Bums No.ofEmeraeWy Downs Battery Ddu No.of Switeb Outlet No.of dee Homers No.of Rnraea No.of Air Cand. Total FIRE ALARMS No.of Zana Tan No.of Disposals Na of Heat Told Total No.of Detection end PoTon KW leittattea Devices No.of Dishwuhms Space Ara Heating KW No.of Sounding Devices Na of Self Contained DettiCtimu%oudlagDevlin No.of Dryee Heating Devices Kw Local Monidpel � Other No.of Wear Neaten KW Na d Na of Connection Siam Belbule No.Hydro Mauage Tabs No.of Motors TOW HP 4 OTHER, r� / / /J %n'�J !i✓/o✓{�� /G� �t l av/ �7. ��t'G✓ qv,G�!'j rh �.��..�2 f�l� _e LJ =Camp Plsalsutbmerac�aeilesl0efll�IasedalastiCiQr®1IeWa ]11�1CaQaQYLiE )IB ) ylli Cbl 'B�1� Or�Sli�li�lt} E YES lha�esdxnllsdvaidpoafdswablte�an Y$S a)uuhme �Pha 9z c( wmWby WakuSmR ��fit'/z g�� g�� Ro* EWMdValmedElmd®IW. $ J ,c ,�ledund��l?�letleatfptl<jisr � FEMNANIE /1��✓G IicmzeeNa 4- 0 7,Y-3 Lic� A7 gown i�omleNo LXI jiL I-- ,<<r���z� ` G�, ej Ehidn lsTdNn 7Kl (I35'-Ci?GI f � owtmt'sII�AJRAN�wA1VHt;ia�awaedlatlheL+o� �i� AtTdNo �� a�s�h�mooalegtiva�tasraquiiedbyMteamdR>�ctalaalLsec arddutrrw igaueonlftspeonntappic�ivowai�eshimaquemeat (Please check one) Owner AgentSignature or Owner or Pig= _ r Telephone No, pg� FEB Date. 1'1pC��. .?. . A HpRTM spy`, 3 OWN OF NORTH ANDOVER - PERMIT FOR GAS INSTALLATION • a . 9 SACHUSESA This certifies that . . . �"�` ! . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . �ff `�nn �. . . . . . . . . . . . . . . . . . . . . . .• at . . .� . OPS!! . S , North Andover,,/Mass. i Fee. : G�. . Lic. No.J j. tk.'! .dn _yC GAS INSPECTOR Check# 5 2- 8 6 MASSACHUSErrS UNIFORM APPLICATON FOR PERMrr TO DO GAS FTrrING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS i Building Locations Permit# Amount$ � ��e'r=�� Owner's Name ���,(,1."�Z New Renovation Replacement Plans Submitted El 0 El c� zi a c c t~ WW9 F d w O rU� O E~ 3 °G U0 • a A a c SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR - 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type) Ce one: Certificate Installing Company Name Corp. Address /1M( L- V---a 0 Partner. >-A, Business Teleptione LA-7i5 -`5L-kZ—4 Firm/Co. Name of Licensed Plumber or Gas Fitter 't- ✓1�= INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 No 13 If you have checked yes,please indicate the type coverage by checking the appropriate box. 13Liability insurance policy 13 Other type of indemnity 13 Bond i Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 1 i hereby certify that all of the details and information I have submitted or entered)in a ve application are true and accurate to the best of my knowledge and that all plumbing work and in ations erform n 'r P it Issued for this application will be in compliance with all pertinent provisions of the Massac use s Sta o e h ter 142 of the General Laws. gnalbre of Licensed Plumb Or Gas Fit Title yjumber i 1-1�� Tit City/Town © Gas Fitter License Number Nlaster ' PROVED(OFFICE USE ONLY) Journeyman I A-� Location ,/ 3 7 90 At A O I No. dZ- Date Cld r— �aRT� TOWN OF NORTH ANDOVER Certificate of Occupancy $ �'�s',•°•t1�' Building/Frame Permit Fee $ �cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 15529 " Building Inspector I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT i APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �q BUILDING PERMIT NUMBER. / DATE ISSUED: ic SIGNATURE: ...� Building Commissioner/Inspector of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: f 1.2 Assessors Map and Parcel Number: 0000 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R aired Provide R red Provided Re red Provided v 1.7 Water Supply M.GL.C.40:' 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record (�. t r 2+rnm 135 Name(Print) Address for Service -03- -3503 Signature Telephone 2.2 Owner of Record: �aYres P, Z��n X35d �fiweek p p Name Print S Address for Service: 0 Sin re Telephone 9 SEC ION 3-CONSTRUCVION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License NumberA-)/, "n Address Expiration Date i Signature Telephone r i 3.2 Registered Home Improvement Contractor Not Applicable ❑ ` v Duval Rg0&g Company Name P.O.Box 637 / / z7? North Readin&MA Registration Number r 01864 Address -- 2 r 7— Expiration ate ^^� Si ature Telephone Y/ SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin4eimit. Signed affidavit Attached Yes...... No.......❑ SECTION 5 Description of Proposed Work check all a h'cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0,,-gpecify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant . 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(8)X(b) 4 Mechanical HVAC (.J .---- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1y V1 Z as Owner/Authorized Agent of subject property Hereby authorize to act on !�t= s relative to work auth by this building permit application. $ [�mJ Signature of Own r Date SECTION 7b OWNER/AUTHOR ED AGENT DECLARATION I, LV� dorized Agent of subject property P.O.Box 637 Hereby declare that the statements and information on the foregoing application qqbWpjAdWW&ffAto the best of my knowledge and belief 01864 Pri me Si nature f Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB PD SIZE OF FLOOR T ABERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IIEIG[IT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r. 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 c11, S150A. The debris will be isposed of in: (Location of Facility) Sign ture of Flermit Applicant Date s NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations • Boston, Mass. 02111 . Workers'Compensation Insurance Affidavit Name Please Print Name: Duval Roofing .s. .ex Location: North Reading,MA 01864 City Phone # 0 I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. C_ omoany name: Duval Roofing Address P.O.Box 637 North Reading,MA City. 01864 Phone Company name: Address Cfir Phone# Insurance Co._ Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 andlor one years'imprisonment_as well_as_civii.penattles-inlho m da_STOP WORK ORDERand..a.fine of.($100-00)a`114 against-me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby car*under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone#Official use use only do not write in this area to be completed by city or town official' City or Town Permit/Licensi ❑ [_-]Check if immediate response is required Building Dept Licensing Board ❑ Selectman's Office Contact person: Phone#. ❑ Health Department Other F NORTH Town of _: Andover No. dower, Mass., _7/6 /goo COCMICME WICK y IdRATED Is 7 ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT N BUILDING INSPECTOR ......................00 ......Y.�.......�..�.i� %"­**** ............... Foundation has permission to erect...... .. .......... buildings on ....... ............. .... Rough WA to W 1/140 Chimney to be occupied as............................................................ ............... .. ................................................................ .. provided that the person accepting this permit shall in every respect coniS&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 Inspe 'on, Alteration and Construction of Buildings in the Town of North Andover. '0 a PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS 1 UNLESS CONSTRUCTION S �a S ELECTRICAL INSPECTOR C. Rough ............� ....... ....... ...BLJII.DING INSPECTOR Service 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. -71 ' Page No. of Pages Proposal Builders License # 58443 Home Construction Reg. # 109288 D(T uo 8Z D a o 00U'a'[0m0 o (789) 944-9994 (998) 666.2559 "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 PROP S LSUBMITTEDTO- _4-' U STREET JOB NAME r CITY,STATE AND ZIP CODE JOB LOCATION We hereby submit specifications and estimates for: Recommended Optional y r, — — — — —— (Included in price) (Not included in price) ✓ Rip& Remove all shingle debris from roof&job site: ❑ 1 layer U2 layers ❑3 layers or more ✓ Repair/or Replace any roof decking; not to exceed 50sq.ft. •r Install 8"aluminum drip-edge/and rake-edge along entire perimeter. Choice of mill,white or brown • Install ICE&WATER underlayment along horizontal eaves,valleys, sidewalls and sky-lights&chimneys Install premium base sheet underlayment between roof deck and roofing shingles Install 25yr CertainTeed/GAF/Tamko or Owens&Corning traditional 3-tab roof shingles ❑30 year Install 30yr CertainTeed/GAF/Tamko or Owens&Corning architectural roof shingles ❑40 year ❑50 year ❑Lifetime *See manufacturer warranty policy for more details V Install new aluminum vent-pipe flange(s) Chimney(s)counter-flash and re-step existing flashing ❑Cut& Install new lead flashing f/ Ridge-vent/exhaust vent with low profile design, hidden by shingle caps ❑Soffit-ventilation ❑ Roof louver-vents f • Seamless style aluminum gutters-custom fabricated at job site ❑downspouts r, / Other I *Please Note:All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear-off Price includes all items above that are checked only/others may be priced separately upon request. Pe Propase hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: — Total price not including options. dollars($ �� ✓ (-' J. Payment to be made as follows: — —� 30%deposit required before ordering materials.Balance due in full upon day of completion. Please make all payments out.tgKenneth Duval;mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of$50 per week for all outstanding bills due upon day of Authorized - completion. Signature -Accepting proposal means agreeing to the terms of the enclosed binder` Note:This proposal may be \contract.'Plcase sign contract&return top copy(white)with deposit. withdrawn by us if not accepted within J days/ 4 Location '� No. O Date - ' r NORTH TOWN OF NORTH ANDOVER 31 � .• OZ 0 A ` Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHus r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # _ 18393 Building Ins 1640 or t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER DATE ISSUED: X SIGNATURE: Building Commissionerfl for of Buildings Date B z SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �`o v a9031 Map umN ber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone "�i�e'FI ne 0 Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERS � /AUTIIORIZED AGENT Historic District: Yes No m 2.1 Owner of Record Name Print Address for Service Cb$—�11 ,-0312 ign ture Telephone 2.2 Owner of Record: ` O Name Print Address for Service: z M Signature Tele hone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0,5 f 0 License Number s 7iy1f�S �—'D /yliy I Address Expiration Date �� ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ �%Z/AlQ A M01-44-46Ce / Company Name ` ` O ( M n ���� �� ��/�v�� �� Registration Number r' Address 6 5-- rM Expiration Date Signature Telephone a�, l SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other Specify S N6 -I DDI✓ %o �FgW7 Brief Description of Proposed Work: 51nlN6 4 t,,_m_ u r?, IQC F�17 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be (I ,:��0 , Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee ta)X(b) 4 Mechanical HVAC 5 Fire Protection r- 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Bmbw Z>1 as Owrer uthorized Agent>ofbject property Hereby authorize to act on My behalf,in all mattes relative to work authorized by this building permit application. r Signature of Owrrer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,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 Signature of Owner/Agent Date r. NO. OF STORIES SIZE BASEMENT OR SLAB r SIZE OF FLOOR TIMBERS 1ST ND RD 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS 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 NORTH Town of over No. AI DIL is= LAo dover, Mass., COCHICMEWICK V ' AORATED `s BOARD OF HEALTH PER IT Food/Kitchen Septic System T • BUILDING INSPECTOR THIS CERTIFIES THAT ' .................................... ........ ................. . .............. Foundation has permission to ere ........... buildings on Rough to be occupied as Chimney . ......... .... ... ...... . .............. .............. ..... . . provided that the person acceptin s permit shall every respect conform to the terms of the application on file in Final this office, and to the provisions a Codes and -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 STARTS ELECTRICAL INSPECTOR rRough ..................................... Service UILDING 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. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Numbers.-CS, 060289 Birthdate 07!©3/1959 Exprres: 0�/03f2006 Tr.no: 1228.0 Restricted: 'JG jJ �. BRIAN D HOLLENBECK�:,= 9 THOMAS RD METHUEN, MA 01844�?��- Commissioner 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: S :5 �� s�'_ 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: ISD n7S j2p_CYCG ANG (Location of Facility) Signature of Permit Applicant Fire Department Sign off Dumpster Permit Date i ..c of/Y/assactiuselts 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/Organization/Individual): yyD -/l`1j9E Cl--' Address: Q T46"'IP-,P.> City/State/Zip: �2rr. ��/ /�!'. Phone#: 12- 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 mployees(full and/or part-time).' have hired the sub-contractors 6. El New construction 2. I am a sole proprietor or partner- listed on the attached sheet. t ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. o workers' co 9• El Building addition [N comp. insurance 5• ❑ We are a corporation and its . 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' co c. 152 1 4 comp. ,§ ( ,and we have no 12Q Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.0 Other 0114COw-1 Any applicant that checks box#1 must also fill out the section below showing their workers'compensation infomtation t Homeowners who submit this affidavit indicating they are doing all work and then hire outsidepolicy contractors must submit a new affidavit indicating such Homeown tContractoTs 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 thepo/icy and job site Information. Insurance Company Name: Policy#or Self-ins.Lic. #: 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 ' fine up to$1,500.00 and/or one -year'tmprisonment,as well as civil penalties in the form of a STOP WORK OaRDER and a penalties of 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 certify under the pains and pena o perjury that the information provided above is a and correct Signature: Date: - f Phone#: 03/7 FOther e only. Do not write in this area,to be completed by city or town gfjklat Town: Permlt/License# thority(circle one): f Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector rson• Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employersservice of another under any cone workers' comPensafion for tracet of hire ' Pursuant to this statute, an employee is defined as ...every person in the 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 m 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 sons three ���enconstructionresides ortherein repair or on such ant of the dwelling house dwelling house of another who employs persons 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 41 . Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if s)name(s),address(es)'and.phone number(s)along with their certificate(s)of necessary,supply sub-contractor anies(LLC)or LimitedUability Partnerships(LLP)with no employees other than the insurance. Limited Liability Comp 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 affidaoverage. Also 4t may be submitted to the Department of Industrial Accidents for confirmation of insurance p ication for the permit or liicense isbeing requested,not the Depdate the afridavit. The artment of shouldavit town that the app be returned to the city or questions regarding the law or if you are required to obtain workers' Industrial Accidents. Should you have any 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 bo tm of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the app , Please be sure to fill in the pernut/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 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 Revised 5-26-05 www.mass.gov/dia d/�P d Location /-3 S S No. Date �ORTM TOWN OF NORTH ANDOVER Of*"•O ,",1.0 3? ' aL Certificate of Occupancy $ Building/Frame Permit Fee $ R swcNus Foundation Permit Fee $ Wtoo D Other Permit Fee $ QD TOTAL $ y2 Check # 15345 / Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 1PPLICATION TO CONSTRUCT REPAIR,RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING „Y> 3UILDING PERMIT NUMBER: DATE ISSUED. G! O >IGNATURE: J/1 P Lg—,A-� � Building Commissioner/1for of Buildings Date iECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 135 SoA\ % 1 3% �/' IV G V -�A 't-j/�NUv2v Map Number Parcel Number Y-1 �_ 1.3 Zoning Information: 1.4 Property Dimensions: roning District Proposed Use Lot Areas Frontage ft ..6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required Provided red Provided .7 Water Supply M.G.L.C.40.ti 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: ublic ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System D >ECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M !.1 Owner of Record 11 .� .�G�.w�c-� ��Wt Wl�✓ �/ I� � �b u� �jl2>����? �7 dame(Print) Address for Service: QQA.,-, X78- W- 3U(P signature Telephone !.2 Owner of Record: Name Print Address for Service: O Z M ;i nature Telephone iECTION 3-CONSTRUCTION SERVICES 90 A Licensed Construction Supervisor: Not Applicable ❑ .icensed Construction Supervisor: License Number Wn Wdregs 4 Expiration Date ic signature,( Telephone r -.2 Registered Home Improvement Contractor Not Applicable ❑ 0 ;ornpany Name l �4 Z 1 r ,W O V�� / eog e,4y�a n �d A ,n O(a, Registration Number IV�rI 7 address i z Expiration Date G .i nature Telephone SECTION 4-WORKERS COMPENSATION(AML.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 unit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Desch tion of Proposed Work check all applicable) New Construction ❑ Existing Building 0^ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify ' Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be +IOP . Completed by penrut applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical(HVAC) `d 5 Fire Protection 2S to ' .. 6 Total 1+2+3+4+5 p0 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETEb WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property I Hereby authorize to act on I 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 Signature of Owner/Agent Date i NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND 3 RD SPAN DF\4 ENSIONS OF SILLS DIIV ENSIONS OF POSTS DIMENSIONS 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 - MOD STOVE INSTALLA HON CHECKLIST Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stave installation and not to the stove construction. Stove `.� A. New il�•EyJ Used S. Type/radiant I'otn6r,tklu lit- Circulating C. Manufacturer_�o L2 I ' Lab.No. r'V L 1482, X73 Name/Model No. 1%3 CIg Collar size Dimensions/Height r, Length lei VL Width Chimney A. New Existing X,S I V v 50'YV B. Size(flue area) C. Other appliances attached to flue(Number and flue size) N D. Prefab(Manufacturer—name and type) E. Masonry/lined VAA DAxV (C0K tC Pue liner 1' ►2E dLi✓ Unlined -type 6 manufacturer) F. Height(refer to diagrams) cap N 0 IZ'' hull. ouE� Icr i �— MIK \.' '.11'�• 3 MIK .ot .\.11; ;•illi. 1 IS:r ttlN. n HEARTH CHIMNEY HEIGHT Hearth(non-combustible) A. Materials (et^y/ le B. Sub-floor construction N A C. Minimum dimensions(refer to diacram) Clearances and Wail Protection(see s:cve ins;atlat:cn c!e_rances chart) A. Type of wall protection provided �r�( � VI/tDutSOIQ�V B. Clearances(refer to diagrams) 1 --------------- Iu 14ti- I FIREPLACE �"` "' ORNER WALUCENTER. Y Town of Andover 0 .1 No. Ll A, LA o �` dover, Mass., 3m %i ' a COC MICKEWICK 7�S RATEO H BOARD OF HEALTH PEIRMIT T DFood/Kitchen Septic System A. S � 1A�► 1�`� r BUILDING INSPECTOR THISCERTIFIES THAT.................... ! ......................... .................................................................................................... Foundation has permission to erect... . .......... buildings on... ...3.. 50 V�.... .�A r Rough .......... ........... .............. .... .. V �.p .... . l.. . ..I CA AM Cs 0 Chimney Aato be occupied as............. ................1111 ........... ....... . . . ...............................................................******.... 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. 103131 03131 i PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR C Rough Service BUILDING 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. r SEE REVERSE SIDE Smoke net. f .f Date. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUSE� This certifies that has permission to perform'-Y. . . .. . . . . . . . . .. . .?. . . plumbing in the buildings of . ;,�x -.�.: R-t!. . . . . . . . . . . . . . . . . North Andover, Mass. Fee . .Lic. No..' ;/ �. . . ��7GNZ .. . . . . . . . PLUMBIECTW Check # 5071 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS �J Date �� 7` O� Building Location S y��`7 ��' wners Name j� /�-�1 r7C Permit# Amount '47— �� Type of Occupancy /I New Renovation ReplacementEI' Plans Submitted Yes No ❑ FIXTURES z d w a o z a w Zz O z a U zP: fx >194 H ri Z A a a O x F W > F p" Z v� Z. W O U W RASE" yr Lst:Hj0CR Z�DHAOCR M>A >I sMHAOOR sM1110CIR 7M11DM sMHjOCR (Print or type) Check one: Certificate Installing Company Name—Ad IY--C ❑ Corp. , Address -15-7 'A�«- M-Pirtner. �= / �L'L.�i�� � U Business�ione ''7�= �T- - 2 Firm/Co. Name of Licensed Plumber: jl-Gcr— Insurance Coverage: Indicate the e typ of insurance coverage by checking the appropriate box: Liability insurance policy LTJ/ Other type of indemnity ❑ Bond ❑ ' Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above thrence i Signature Owner F1 Agent El I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this pp I' don will be in compliance with all pertinent provisions of the Massachus umbi de �Ine Ge ral Laws. By Signature o icense um er ' Typeco`f plumbing License Title G� -T �— -:>( ,.,�/ City/Town License um er Master �Ce� Journeyman ❑ APPROVED(OFFICE USE ONLY LLL......111 i Date... ... /....... . AORTI, Of ..io ,°'1.y0 o? �` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �"ty ,SSA NUSEt This certifies that . :`° .. .. . .. . . . .�I�. . 1. . . . . . :`. . . . . . . . Ls permission for gas installation ::.' :. . . . . . . . . . . . . . . . . in the buildings of . . . .`. . . . . . . . . . . . . . . . . . . . . . at .. . . . . . . ./� --'.!6 , North Andover, Mass. Fee:S.`.�. . . Lic. No%�.`�. . f� r�: .. A . . . . . . . . . . . GAS INSPECTOR v Check# ' a 3E5 `' �7 MASSACHUSUTiS UNIFORM APPUCATON FOR PERMITS DO GAS FITTING (Type or print) Date 1,,2117,- 510 NORTH ANDOVER,MASSACHUSETTS . Building Locations 131- 57' 1,?~�w^ ?7/) 5 Permit# Amount$ Owner's Name ��.� New❑ Renovation Replacement U Plans Submitted � � U v� a x n F O O O O w F C4 w H o a z w W W F i z a a o o z z o w o z 3 A a U x A a F o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4 T H . F L O O R 5TH . FLOOR 6TH . FLOOR 7TH . F L O O R 8TH . FLOOR Nameor type) ��_7 {� -C,C-� Check Cnoe: Certificate Installing Company Address 0artner. Business Te ep one <77RYCr7 ?C_yl 2 E] Firm/Co. yName of Licensed Plumber or Gas Fitter 213526ry*Al_o INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0,_ No If you have checked}_es,please indicate the type coverage by checking the appropriate box. Liability insurance policy ®� Other type of indemnity El Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the T ass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent t hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this appli tion will be in compliance with all pertinent provisions of the Massachusetts St and C fro r 1 �th�ea By: Signature of Licensed Plumber O Gas Fitter Title Plumber yo2 City/Town Gas Fitter License Nurnoer Master APPROVED(OFFICE USE ONLY) Journeyman