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Home My WebLink AboutMiscellaneous - 137 BARKER STREET 4/30/2018 137 BARKER STREET j �� J 210/035.0-0099-0000.0 / �- �i If �h f G I Date....G".. .f. ...... ... PORT/j 03?°; "';;';��ao� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,�BACMUS�� This certifies that ....................�,fq--(/ ...... has permission to perform ..........&.��T` ............... ............................................................ wiring in the building of.................14 e.-KS 0P.. at .......I... J..-7 �i /Z Sl........................ North Andover,Mass. ............... .................................. . Fee.0.T-',0 — Lic.No. 3 S OS ......... ............... ...6...'..... ...::r .. ECTRICAL INSPECTOR Check# 2 1 �: 1� Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ( Zl � 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(NEC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL)NFORMATIOA9 Date: a- 1 I— R Q (q 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) j rr Owner or Tenant 2,0 91 Q 4---' Telephone No. Owner's Address t� Is this permit in conjunction with a buil in permit? es No Check Appropriate Box P J �� P ❑ ( ) Purpose of Building Q 6 Utility Authorization No. - Existing Service Amps t'ZO /ZtGVolts Overhead❑ Undgrd❑ No.of Meters I New Service Amps / Volts Overhead❑ Undgrd [j 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. f Cell: us .Saddle Fans r s Total No.of Recessed Luminaires No.o I�— P (Paddle) TransKVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] No.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and () Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number To.ns._..... 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 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent " OTHER: AV Attach additional detail if desired,or as required by the Inspector of Wires. Es'imated Value of Electrical Work:�j C��fs (When required by municipal policy.) _ Work to Start: 1\ 0 Inspections to be requested in accordance with MEC Rule 10,and upon completion. IN URANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless thelicensee 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:) I certify,under the pains and penalties of perjury,that the information on this application is true anti complete. FIRM NAME:.. LIC.NO.: Ci G 16 License N Signatur LIC.NO.: (If applicab e,enter "exempt"in the license numbe lin NN,�,,��,��,�.q{�� Bus.Tel.No.• Address: y �c��1 N (►rte I a`'►�`i Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent pE RMITFEE:$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the = permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an ct ' 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 EN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors CommenpN 2--, 1 Inspectors Signature: Date: FINAL INSPECTION: Pass F 'ed Re-Inspection Required($.) ❑ Inspectors Co ents: Inspectors Signature: Date: —7" DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com � 11 i L • The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations UV 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le •bl Name usiness/Or anizatiorAndividual : (E g ) V 1 Address: LQ City/State/Zip M( C\-JUA_vZ-N IYYU� G 14�� Phone#: `3 2 Arepu an employer?Checktheappropriate box: Type of project(required): 1.10 I am a employer with 4. ❑ I am a general contractor and I 6 ` F1New 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.1 7• ❑Remodeling - ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g 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 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Arty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they aie 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � Insurance Company Name:. �. �.� l `�,,e, a Q Policy#or Self-ins.Lie.#: ��`� Expiration Date: �( A. Job Site Address: \ City/State/Zi9Q_* Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 her and tb� a d penaIt' of perjury Aat the information provided above is true and correct. - Si at�re: n QQ t Date: c)'' 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#: i Information and instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." 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 ceitificate(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 maybe 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 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, r please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Gonmonwealthofassa husPtts DepartlaGnt of Industrial.Accidents Qfte of Westigatlons 600Washington Street Boston,MA,02111 Tel,#61.7-727-4900 ort 406 or 1-877 MASSAFB Revised 5-26-05 Fax#617-727;7749 wwmass,gov1dia I _ 4 I f jr✓rTr r �,y � �.� rl $ p r r r, i' Date.Al....41................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING gSwCHU This certifies that ......................................................................... has permission to perform .. u— ...... ........... .............................. ............................................ <Ivlmg in the building of........1 C�,�j ................... . ... ... ....................................................................... at .................................. ..................................................................North Andover,Mass. .........Lic.No. ............................... tit ELECTRICAL INSPECTOR Check U) I AL*d rs.Re O�Ci�t i�ati— BOARD OF FMPREVEN'tK*REOElLATI =d%e APPL"7= FM PERT TO . PERFORM ELEC %ad�fsbep cfi- dme000z3s�xa SY1odRJ3m (PLEdSFs PBIIitI l €lA€KOR TPS�£L { Daft Y l 3 ►6�T�ra tJoR+�. A�o�eR Ttl0ebs":Wr . P � �des�a'14edbetos. I.ea�es�Sg+eet&N �3� OWWWTeWS SLA-?.R e_ mc> ti. Tfthno Nwro -say-o Is vi I OwsaftAddmas �s p�tbt wise= P� Yes .` No. Amps YACom&mdoaf C� �... _� � Sertiaee Aat 1 Y � g►s�� N�e€ s __ '.Wtstbs�$eedeEs aad A�s�► , efB edL es eC - g -10 XVA afRot Tubs HFA TOM afi +pa p © Q CWhis S[tt. s AI�lBS a[Zes� 3 .rte eE�asSas aiAie Cess. Tam OfAbdbgbwim adWaioeHseesum Tomb:pi -p upi aa °"s mss KW cJ Appbasm lcW acwmw HW at Sim Bs s Tattle �ia�'i��i�'�Sir+ecT,araeraq�edbpdis 'afWa�as. 1 �EsE edYe aE Wadc00 (Wl� b9 Mumma P 9 3 WO&aS� I (� Imbe odivaoombmcvAildE Rub 1%aadmpmamoWn DWROCEWMAM IIatessvmhWbg9evws�saPmkfWdda afea ica3 �iaa� tbcSomsaspm�vi3ezp afti y • °aaumg-arris a Ibe t6atsschaoeisieaadi�eebedpaoofaf se�e �ebaa4Soe; CB=0M- 21SUXANMjI. DOME] ' 113101 t3opnW.) F miff eeprlas ssdpaa�es�F�1S�tJee ae�qv a ,Iis�rs ast�+asp� S A � �vKrma�['�tlieliammosasesb�l�j BmT4LNo-meq p'74b-'7 l AILFd-s 'yo., �es3d�G�..a 147,s.57.61,se��elcs��ese€ S '`�' Lic.33'o OWMIS DISGRAM WAWM- I a�a +et�f�e lsoe�ma saes lb s e tsaoe as ea�Y C� lwpwbyb m B1'mys4asemseb916I aa;�0 fitsavbme L I g.ffe aak OWL P 'F •i Ste' The Commonwealth of Massachusetts Department of IndustrW Accidents Office of Investigations 1 Congress Street Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADulicant Information Please Print Legibly E Name(Business/Organization/Individual):Northeast Electrical Services Inc Address:40 N. Main Street, P.O. Box 361 City/State/Zip:Bellingham, MA 02019Phone#:50&966-7467 Are you an employer?Check the appropriate box: Type of project(required): C 1. ✓[] I am a employer with 24 4. ❑ I am a general contractor and i employees full and/or part-time).* have hired the sub-contractors 6. New construction i ( P ) 2 I am a sole proprietor or partner- listed on the attached sheet. 7. [✓ Remodeling .❑ PrP ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance Comp'insurance.* 10. ✓ Electrical re or additions requite] 5. ✓[] We are a corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required]t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tConuactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-omtradw have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for MY employees. Below is the policy and job site information. Insurance Company Name:Guard Insurance Group Policy#or Self-ins.Lic.#: Expiration Expiration Date:?/29/14 Job Site Address: 137 MriCerSj— City/State/Zip-M.-AnCjdUf',` AM 01aD 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 the pains amfpenaU4mqfperjtzU that the in ormatwn provided above is true and correct Si J13 Phone#:508-966-7467 2 Official use only. Do not write in this area,to be completed by city or town offw-kL 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#• R �- :. I �. � � �k �*¥ "t�� I �� +� � �5. �"� I ., ,�' i � �, . .� �� "� �. � `' i i ,r ��° a ;� . :,t. ..�...-„� � �� u ., � .� .� _�„r. s aw w �. .... � � � i ��. � � s x � ,'. � � ”' `^”' ar" � 1 w? �u 1w &� � �� a,„ *, � � � �� .." „Y S �� .w, w �., � "u s 1 J 1 I II r Date. .!.!- .i.l. ............ OONTq TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ACNUg� This certifies that r• �� .- ` has permission to perform ....Yre-.�-.r �`! ........... 1- . li! ......"�"� .r!0-2,...... wiring in the building of.......!...... ..u :. ............................:....................................:.... at ......��, ��- -,� -- North Andover,Mass. ............... Cl Fee.... ....... � !..........Lic.No.� .. .. M.� ............. ��::�!....... ..... ELECTRICAL INSPECTOR Y Check# ? ,► �* Commonwealth of Massachusetts Offti�cia/l�U/se0 y Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] blank) (leave APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),527 R 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: .3 //`Z / /!!Z 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) 3 rj�,a K e j- S�3n 2 Owner or Tenant 2 bS1n 'X\0 t.1 Telephone No. Owner's Address SOrv,- f Is this permit in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Purpose of Building Q �2am/f y Utility Authorization No. - Existing Service-LtV Amps t-0 / 4V 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: f� `a J�1� m H yl� !40S no j-ey— Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA ' No.of Luminaire Outlets No.of Hot Tubs No.of Luminaires Swimming Pool Above ❑ In- ! N 4-o `Q' No.of Receptacle Outlets No.of Oil Burners Q No.of Switches No.of Gas Burners No.of Ranges No.of Air Cond. Total Tons No.of Waste Disposers Heat Pump Number Tons KW ...................................... Totals: J)etectionlAlertm tuevices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:Y No.of Water KWNo.of No.of ' Heaters Signs Ballasts No.Hydromassage Bathtubs No.of Motors Total HP OTHER: _ Attach additional del Cl �� G Y 3 Estimated Value of Electrical Work: UU,AU (When required by J Work to Start: Inspections to be requested in accordance w `-' / INSURANC C VE GE: Unless waived by the owner,no permit for the the licensee provides proof of liability insurance including"completed operatio undersigned certifies that such coverage is in force,and has exhibited proof of CHECK ONE: INSURA=NCE ❑ BOND ❑ OTHER ❑ (Specify:) � X certify,tinder the pains and penalties of perjury,that the information on thi, FIRM NAME: A1C ✓� t � E�2C�'f�C L-.�-� Licensee: Y11gC�_p Signature_y�/, (If applicable,e r "exempt"in the license{umber line. , Address: 0 A✓i �� lC?,I f t J I 2�ICyt i� _- *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: J 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: s � Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed `, ) on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for 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. El.Rule 8—Permit/Date Closed: Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed ❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ h Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: j Inspectors Signature: Date: FINAL INSPECTION: Pass ? Failed IN Re-Inspection Required($.) ❑ Inspectors ments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r ' 1 r The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly Dame usiness/Or anization4ndividual Address: 0azile T 4-7 -e City/State/Zip: , I !,R n �� a(9 Phone Are you an employer?Check the appropriate bog: Type of project(required): 1.0 I am a employer with 1 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. ❑ 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'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] 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 aie doing all work and then.hire outside contractors must submit anew 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. 01*V U0 6 Expiration Date: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 cert and ains and penalties ofperjury that the information provided abov is true an correct. Signature: e� Date: 71y Phone#: / , ^g� 7 ��?p, j Official use only. Do not write in this area,to be completed by city or town official. I. 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#: 1 • 1 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 loeal 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 employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation 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 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: Tho Go a.onwaithofMossaclausPtts Department of Industrial.A,ccidonts Office of Investigations 600 Washington Sheet Boston,MA.02111 Tel,#617-7274900 oxt 406 or 1-877-MASS.AFE Revised 5-26-05 Fax#617-727-7749 WWWMUs,gov/dia I • i I I MA C"1 ANS S CC `' S A "a MtU MASTER, L. 1 C E f CTR IC LtC C ; i Commonwealth of Massachusetts Official gi use o y Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank 'M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK f All work to be performed in accordance with the Massachusetts Electrical Code C),527 12.00 I (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: �J 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 i cal work described below. Location(Street&Number) 1Y7 Q \{2 � 02 g ,. Owner or Tenant psi ID k3 q a N Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Purpose of Building �in�rj /f y Utility Authorization No. Existing ServiceaCV Amps I Co / Lyp Volts Overhead fl Undgrd❑ �4o.of Meters f I New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Vi^Ce CQ_ on en H Zones, d1 o S 10 el I ►-ems tj Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El No.of Emergency Lighting rnd. grnd. Battery Units j No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas BurnersNo.of Detection and I 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 ❑ Other p g Connection No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: U(I,P& (When required by municipal policy.) Work to Start: // Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCCCOVE GE: 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: INSURA=NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FHM NAME: . CILIC.NO.: 1,13 Licensee: � � � , 1M C(Gj_,iZ Signature LIC.NO.:f7 2:9&LJL7 (If applicable,e r "exempt"in the license timberline Bus.Tel.No.:9��c� Address: ! q✓� 2 IQ'✓1 Q �t I e nc12 M/1 d 19 a Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 `� ) 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 entitystated 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. 0.Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: i 1 Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass ? Failed 0 Re-Inspection Required($.)❑ Inspecto s ments: r Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Date.... � 7 ) n f NORT/q, �f 3? 6D ,tiao� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING * t BsgCHUS� This certifies that..2)n-?...-.f......./..-/. ..J� ..................................................... has permission to perform.5".-5". ,........�..,..P.{...s�'.t- -.. .... plumbing in the buildings of...:......1... ..t:.f�. - ...................................................... at....... .3... ...................................................... 7..........17 ,North Andover, Mass. Fee.....................Lic. No. .�.?�77 ... �................................................................ PLUMBING INSPECTOR Check# 9+�- 14 v-, i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY a r vy e R- MA DATE[ ]PERMIT# O 36iv JOBSITE ADDRESS OWNER'S NAMEhead POWNER ADDRESS TEL 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL 0I PRINT CLEARLY NEW: D RENOVATION:9 REPLACEMENT:Q PLANS SUBMITTED: YES Q NOD FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM I _ [ � ( j DEDICATED GREASE SYSTEM f _-__� ___1 DEDICATED GRAY WATER SYSTEM I ( _ � � DEDICATED-WATER RECYCLE SYSTEM DISHWASHER ^ _.__� __.__� -___ _i _� __� � ---J ..w_l DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I F___! LAVATORY I _ J 1 _. ( i _.l _( i 1 I 1 1 - I ROOF DRAINSHOWER STALL ..j ---JI 1 -+ SERVICE/MOP SINK TOILET i URINAL ! — W SHING MACHINE CONNECTION _ I - i __._ S I _ ' � _.__.l ._ S i .__ _3 -A_ __( WATER HEATER ALL TYPES '�"' TER PIPING _ I i ! _-- -J I OINER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the S Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _i AGENT 10 L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge �^ and that all plumbing work and installations performed under the permit issued for this application will be in comp' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. HWQkPLUMBER'S NAME �cd d LICENSE# � j �� SIGNATURE Mp JP CORPORATION D#PARTNERSHIP D_1# s LLC ^A i COMPANY NAME v[.�S /rte ho! !jie ; ADDRESS ,30 vv-e CITY yipOV A --.._f STATE ®ZIP d/$ TEL y' .f - X33 FAX $ y j CELL f ',37 � EMAIL i I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i i I4 i M f P � The Commonwealth of Massachusetts - Department of IndustriqlAcci6nts Office of Investigations quo 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print LeLyibly Name(Business/Organization/Individual): Ave, S e- Awl I-e I" j Address: City/State/Zip: M 9 v/f f1- 'hone#: S ��6 S` f�?3 Are you an employer?Check the appropriate box: Type of project(required): IzQT-am.a employer with 4• ❑ I am a general contractor and I 6 e . ❑New construction employees(full and/or par-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.0 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.E]Roof repairs insurance required.]t employees.[No workers' 1311 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 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.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 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 cert r the pains and aloes of perjury that the information provided above is true and correct Sinature: Date: l 7/ V Phone#: �f G �- 7 5 33 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#: c r-y 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 retained 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple ermit/license applications in any�v,en 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 Massachvse is Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA,0.2111 Tel#617-727-4900 ew.t 406 or 1-877:MASSAFE Revised 5-26-05 Fax# 6177727'7749 www.Mass,govfcHa - I I I i n, DAVID ", ✓ 27 HOB`x $� 7 at. a VVIL mI,V N4a8.1e;�RlUtIff PL15877,-iVl 05101/2014' p _ 0 4623 Lica 55e.htQ. inviar•x - _ �P t7ate eriafilVb. I I 1 I Date...... .. ...�.?........... °F Nonrh,� TOWN OF NORTH ANDOVER O � p PERMIT FOR GAS INSTALLATION 88�cMua� J This certifies that ......... ............... ......... . ................................................ has permission for gas inthe buildings of.......IrJq. .a.. :........................................................................ at.... , ..7........ ..... ....................................................... North Andover, Mass. Fee...III - Lic. No. .. 44.../.�I... 1.�!sl..................................................... GAS INSPECTOR Check# y 5Z, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `L r/ CITY 9-- MA DATE } PERMIT# JOBSITE ADDRESS / OWNER'S NAME G, I G. OWNERD A DRESS TE _ FAX I'YPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Pg1NT ® RESIDENTIAL CLEARLY NEW: RENOVATION REPLACEMENT: PLANS SUBMITTED: YES 0 NO F APPLIANCES 7 FLOORS- BSM 1 2 3 4 —5 -6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER { DRYER FIREPLACE FRYOLATOR I FURNACE - r�n I—._I GENERATOR GRILLE INFRARED HEATER _ - LABORATORY COCKS _MAKEUP AIR UNIT OVEN POOLE - - H ATER ROOM/SPACE HEATER ROOF TOP UNIT TEST �VIT HEATER UNVENTED ROOM HEATER I NATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES ANO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EA_ OTHER TYPE INDEMNITY [j BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER © AGENT Eil I hereby certify that all of the details and information I have submitted or entered regarding this application are trueand accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl. with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP dMGF El JP D JGF Q LPGI Ej CORPORATION©# PARTNERSHIP Off=( LLC E]#= COMPANY NAME: - ✓ C4 ADDRESSU__ �r•�`c _ _ �� CITY STATE®ZIP TEL FAX CELL cj _� EMA t� _ Z Sr I . i ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOWES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r I I . The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations VV 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individual): � \S C, Address: o ,D-e ".t-G yt City/State/Zip: Ull ,# p/F f�'Phone#: Are you an employer?Check h appropriate box: Type of project(required): .1.9"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.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp,insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certi nde lee pains:n9daMes o pe jury that the information provided above is true and correct - Simature: Date: Phone#: �7r�(Wr 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 Investigation 600 Washington Street Boston,MA 02111 Tel,#617-727K4900 oyt 406 or 1-877MASSAFB Revised 5-26-05 Fax#617-727-7749 www.xnass,govfdaa k L - ' � a DAVID F � � 27108 S t H:1 WILM(N i ' s 01-15877-M 05'10 112014 Jp4623 Lics a5e.1a1�. ' r _ Expiration ddtP,. r� Date. 12 �.`-k.......... 0 �r2 7 �►OR7h TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING g`QAC/1Ug� This certifies that.....'t...P..... t" has permission to perform. b-4..P L.., .:....�....74-..�'..�?N!"P.e--t- plumbing in the "buildings of... Urn .L:. ............................. at...�..�-� .......�C.�1►2�cp ... 2 a.�. -...................... North Andover, Mass. Fee cna t32c`U M ..............Lic. No. ..................... ......... ..................................................................... PLUMBING INSPECTOR Check# l/� A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �—q CITY MA DATE' J I PERMIT#— R G JOBSITE ADDRESS OWNER'S NAME ti OWNER ADDRESS' TELI FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EntiCATIONAL El RESIDENTIAL PRINT7t PLANS SUBMITTED: YES NovCLEARLY NEW:E] RENOVATION:CI REPLACEMEN .'� C o FIXTURES 1 FLOOR BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 161 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ' — ,; S DEDICATED GA !0IUSAND SYSTEM � T�� DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM '_I DISHWASHER -�' DRINKING FOUNTAIN FOOD DISPOSER ��'_T� FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK -- -1 - { �—�� '-- - �I ----- LAVATORY ROOF DRAIN -�� - - � SHOWER STALL SERVICE/MOP SINK TOILET URINAL — WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -- L—j` --JIL— INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[( NO L_j i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY%; OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. l CHECK ONE ONLY: OWNER i _i AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate o the best my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with rtin vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 1 Kevin Scott (LICENSE#;13258 SIGNATURE M P E JPS CORPORATION][#[2:4:3:8--1 PARTNERSHIP# LLC'�j#� COMPANY NAME; Kevin Scott Plumbing&Heating INC. i ADDRESS I P.O Box 446 CITY Wilmington j STATE ZIPS 01887 — TEL X978-988-3632 FAX 978-694-9977 CELL 978-479-8966 EMAIL kevplumbing@comcast.net ve Date.... �.�Z: �.-L........:........ €... NORTH TOWN OF NORTH ANDOVER PERMIT FOR O GAS INSTALLATION HUs� 1 ' This certifies that ....... v ....................................................` . . ............. has permission for gas ' stallation ..: o! .......... inthe buildings o/f�.............. ��G..-?...................................................................... at..........`.��.. .........;4`..?' �c o r' -� fNorth Andover, Mass. ................................................... Fee..?R. ....... Lic. Noi3,� ?......... ........�..................................................... GASINSPECTOR Check# cI �� 0 I f � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q1111 Y CITY MA DATE: PERMIT# JOBSITE ADDRESS. C!,{` _ OWNER'S NAME � � I ; ��'aq -- I+TE4 '�� Q.7..lFAX� OWNER ADDRESS ! ' TYPE OR OCCUPANCY TYPE COMMERCIAL]-1 EDUCATIONAL:_ RESIDENTIAL ( PRINT CLEARLYNEW: RENOVATION:L i REPLACEMENT: PLANS SUBMITTED: YES N(}✓i APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 s 10 11 12 13 14 BOILER - I----; ; -._.-` _-`---,-------+----I-- --,- E----------,�-_�---_ BOOSTER --�_�=J.- __I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER —_],— ! - -i`� ._ DRYER FIREPLACE ; _ 1-?----`-•-.- _. .._ ! :—-1'��_—��_. I FRYOLATOR FURNACE 1, t_ l -__� l - l -�:. _ _-I GENERATOR 1 — --_ —_--�__--,:--- ----�_rte-____ ---;- - ---� GRILLE _�INFRARED HEATER ---I {_----�.._.__-:----,- -�;--- I;—,------}=� -T _�_—i - _ -- -- LABORATORY COCKS ..._.. MAKEUP AIR UNIT _ _-�_ !' -- _ OVEN POOL HEATER ROOM!SPACE HEATER :__...-? ROOF TOP UNIT • TEST UNIT HEATER vim_ _ . t ) UNVENTEQ ROOM HEATER __� :�_�: WATER HEATER - !_____ : �j i- _j�� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO �> I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' % OTHER TYPE INDEMNITY - BOND ( _ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER :—-" AGENT '!____-] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the beof my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with Pe ' rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASF17ER NAME; Kevin Scott __ LICENSE#: 13258_- SIGNATURE MP; . !! MGF;Y_ JP JGF%� LPGI CORPORATION v!#,2438 PARTNERSHIP - _ __ LLC COMPANY NAME:,Kevin Scott Plumbing&Heating INC. ADDRESS'P.00.Box 446 CITY ;Wilmington �- r T �i STATE MA_ZIP 01887 'TEL_978-988-3632 - NP FAX 978-694-9977 -� CELL;978-479-8966 1 EMAIL;kevplumbing@comcast.net �I p�I�„ [7-7jqwL-- 3-1 may I gill 4 r COMMONWEALTH OF MASSACHUSETTS PLuzm,bk ER-5 LICENSED A 'A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: . = ` KEVIN :A SCOTT ` PO BOX 44.6 WILMINGTON ' MA 01887-0446 13258 05/01/14 148017 WNIONWEALTHASSAHSE"TTS REGISTERED , PL I CORP ISSOES THE ABOVE L ESE ro: KEVIN A SCOTT KEVIN SCOTT PLB & HTG INC IPO BOX- 446 N 4 WILMINGTON MA 01887-0446 f 2438 05/01/14 - 139385 IN i Date 11.�i2I� ....... ............ o, IaORT#4 A TOWN OF NORTH ANDOVER . 7- PERMIT FOR PLUMBING �8�►CMUSE ,'1 �V\Y�-�C:-�G� This certifies that.. .r ............ has permission to perform........ ........................................................................... plumbing in the buildings of.....H.(J.( �.C-.,-j..................................................... . ............n......... a 2 .......................... North Andover, Mass. t.A.Z.A....6 6!�...***"*........'...* Fee3.7.0........Lic. No. 416:kn... ...%................................................................... PLUMBING INSPECTOR Check# TIM OK =19 mm mm mw mm am am MK mm mill mAM Mik i� OK r: _- r o 117 i #11Y�3d :33.4 C3 . ON geA The Commonwealth of Massachusetts Department of IndustrW Accidents Office of Investigations 1 Congress Street;Suite 100 Boston,MA 02114-2017 www mass gov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant:Information Please Print Le 'bl Name(Business/Organizadon/Individual): Address: A / City/State/Zip:zG. AA APhone#: Are you an employer. eck the appropriate box. 1. 1 am a employer with J 4. [] I am a.general contractor and I Type of project(required): employees(full and/or part-time.).* have hired the sub-contra ti. ❑Yew construction p ) dors 2.❑ I am a sole proprietor or partner- lis:.ed on the attached sheet 7. emodeling ship and have no employees These subcontractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp, insurance., 9. ❑Building addition requited.] 5. We are a corporation and its 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.15 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.]+ c. 152,§1(4),and we have no 12.❑Roof repairs employees.[No workers' 13.❑Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T1.lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubmit anew affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have cmploycts. If the sub-contractors have employees,they must provide their workers'comp.policy number. I air an employer that is providing workers'compensation insuran information. ce far my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins, Lic.#: !(l/ Y Y"� i �,+ 2 Expiration Date: ` Job Site Address: i r r 'R+ City/State/Zip: affW— 0 i$t}� Attach a copy of the a workers compensation . p n policy declaration a e shown the page(showing e 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb cern the painv and mollieso er'u that the information provided above is true and correct Si tit e: .. nn Phone#: 0000 + (q' 3070 Official use only. Do not write in this area,to be completed by city or town of1iciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#• : COMMONWEALTH OF MASSACWUSETTS- OF MASSACKUSET;'l ° .- PLUMBERS AND GASFI • • NWEALTH .•. . Mfl 'LtC 17E '�CflM • LICENSED AS A JOU RS _ •• PLUMBER B ERS. ssuEs THE 1=R • SFI P UMBER E ABOVE LICENSE T0: ►:tINIBER 5 ANSA TER . .PHILLI.P J LICE1dSED A DURFEE ISSUES THE ABOVE LICENSE TO: i E STDiJRF =� E - T. MA 02638-242 ..',: fLAX ST17 : 2632 ' MA X263$.": ..:;: ` . 05lQI/14 :':f3ENR Is Ig09 ' ' • .. Fes:Then Detach Along All Perforations.L3T74 •05101/14 ._ .. _ - • Alt PertOratlons Fold,Then Detach Along i .COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITfiERS. REGISTERED AS A PLUMBI G CORP ISSUES THE ABOVE LICENSE TO: PFI:IL .IP J DURFEE t)URFEE 'PLUMBING 8HEATING,. LI:C 5.I,. VAX ST "::DENNIS MA 02638= 17 3152 05/01/I4 18093 :: 10151 Date �. • - TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform 1 plumbing in the buildings of. . rr} �AA. at . . . . North Andover, Mass. . . . . . . . . . . . . . . . . . . . . . . . v PLUMBING INSPECTOR Check#_�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY J 1 MA DATE ( PERMIT# JOBSITE ADDRESSOWNER'S NAME POWNER ADDRESS TEL 6 AX TYPE OR OCCUPANC PE COMMERCIAL © EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES ]( Nod FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ( [ __f I —. i [ _.__ DEDICATED GREASE SYSTEM _-r-_I f _ I }_-__� DEDICATED GRAY WATER SYSTEM ! DEDICATED WATER RECYCLE SYSTEM ( J I __—_i DISHWASHER DRINKING FOUNTAINf . __.._1 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) f 1 f i i _[ _.__-[ KITCHEN SINK __._._J ____._I _ ._J __.__1 ____1 ___.._J E-7-1 _ _-_J ► _.__ LAVATORY 1 ._._ __—f l ( .-._...._) J _._i ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL - IVASHING MACHINE CONNECTION ; _ ._ WATER HEATER ALL TYPES WATER PIPING OTHER _f __.._._._i f .._.___I f ! I F-7-jr-71 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _ NO IF YOU CHECKED YES,PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE OF INDEMNITY D, BOND DI OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT �I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accuraje to the best of my kno ledge and that all plumbing work and installations performed under the permit issued for this application will be in compli Pertinent provisi o he (Massachusetts State Plumbi Code and Chapter 142 of the General Laws. PLUMBER' NAME nn�n _ Yom— (LICENSE# S ( SIGNATURE MP7P JP Q CORPORATION E1# PARTNERSHIP EN LLC [ COMPANY NAME j v, E ADDRESS CITY w, ,STATE ( ZIP ( TEL [ FAX �._( CELL j EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I I� r i j • The Commonwealth of liPassachusetts - Department o,fIndustrigl Accidents Office of Investigations UqV 600 Washington Street Boston,MA 02111 www.mass gov/dia 'workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledb Name(Business/Organization4ndividual): r J Y' Address: ,v b City/State/Zip: !�,A Phone Are yA an employer?Check the approliriate box: Type of project(required): 1.V I am a employer with 4. ❑ I am a general contractor and I 6. 0 New construction employees(full and/or part-time.),* have hired the sub-contractors 2.❑ I am a sole proprietor orpartner- listed on the attached sheet.x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance'. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.Q E ctrical repairs or additions 3.El ream.a homeowner doing all work right of exemption per MGL ILV lumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.QRoofrepairs insurance required.]i employees. o workers'• quu'ed] � 13.❑Other comp.insurance required *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they Lire doing all work and then hire outside contractors must submit a new affidavit indicating such. i ?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 Policy#or Self-ins.LIC.0: Expiration Date:� 1XV. Job Site Address;_ /J UWP t) 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 requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office sof Investigations of the DIA for insurance coverage verification. Ido hereby certto under the pain an n LeS ofperjury that the information provided ab0 is true and correct Si ature: v Date: 0 /n 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): i 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: V .L Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint 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 "everystate or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill,out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LL C or LLP does have employees,apolicy is required. Be advised that this affidavit maybe 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 andprinted legibly: The D epartmerit 11as provided a space at the botEom 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 Min the permit/license number which-will be used as a reference number. In addition,an app licant 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 o of that a valid affidavit is on file for future permits or licenses P p . Anew affidavit must be filled out each ear.Whe e y r 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 bur 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: Tho Gommolm-alth off-assaohusetts Depa imciA ofJadustdal Accldouts Office ofWestigatious 600 Wasb gtou Stzeet Bostw,MA02111 TO,#617-727=4900 at 406 ox 1:-877-MASS.AFB Revised 5-26-05 FaX#617-727-7749 v y , I I I I - - - -- - ! COMMONWEALTH OF MASSACHUSETTS LICENSED AS"=A MASTER PLUMBER i ISSUES THE ABOVE LICENSE TO: KEVIN 'A SCOTT PO BOX 446 WILMINGTON MA 01887-0446 13258 05/01/14 148017 E I '- . COMMONWEALTH OF MASSACHUSETTS -:PLUMBERS AND GASFIJ I ERS REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: KEVIN A SCOTT KEVIN SCOTT PLB & .HTG INC PO BOX 446 1 , WILMINGTON MA 01887-0446 2438 05/01/14 - 139385 � .,LICENSE NO. N SERIAL NO. I i I I I Date......!.. .A�..�,........................ 40R'rh TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,8`QgCHU5 S�� This certifies that ......i�..Q. ...l: !......"L.�°.u!.1........ ..... ..1�........ .................... has permission for in the buildings of gas�installation . "G � VOW......., . . . . .......................................................................... at............ .. .... ..!.co(......................................, North Andover, Mass. Fee...�.P........... Lic. No. l,. h ........ Rb.'.......................................................... GAS INSPECTOR Check# St �-I.- - ie�iJ5, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY MA DATE P—ERMIT#- &15 JOBSITEADDRESSIIOWNER'SNAME .�_�_ I `OWNER ADDRESS Gam, TE 0- a ,vIJ J FAX TYPE OR OCCUPAN TYPE COMMERCIAL I EDUCATIONAL E] RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:D REPLACEMENT:[j PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _TJ CONVERSION BURNER COOK STOVE 1 _. ( . - DIRECT VENT HEATER DRYER J FIREPLACE FRYOLATOR I _ _ FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _. f ��_ __ I. MAKEUP AIR UNIT OVEN _ POOL HEATER I ROOM/SPACE HEATER _ I ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER -OTHER � _1 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YE IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE INDEMNITY ® BOND �]( OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurst to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit - Pe ' n ovision of the Massachusetts State Plumbing Code nd Chapter 142 of the General Laws. PLU7MGF ASFITTER NAME _ _ LICENSE# 3oU`�_� SIGNATURE MP El JP 0 JGF LPG] CORPORATIONS®PARTNERSHIP( # _ LLC®I#= COMPANY NAME: ADDRESS CITY _ ,) STATE Crr 1ZIP[ FAX JCELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i .r- w it COMMONWEALTH OF MASSACHUSETTS PLU-MRFR-S A.NU 'GA5FlTl"b LICENSED AS'-A- MASTER,PLUMBER ISSUES THE ABOVE LICENSE TO: } r KEVIN 'A SCOTT d I� r PO BOX 446 WILMINGTON MA 0-1887-0446 13258 05,/01/14 .. 148017 :COMMONWEALTH OF MASSACHUSETTS REGISTERED AS A PLUMBING CORP I ; ISSUES THE ABOVE LICENSE TO: I KEVIN A SCOTT m KEVIN SCOTT PLB & .HTG INC PO BOX 446 WILMINGTON MA 01887-0446 WIL i 2438 05/01/14 , 139385 I i i i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: 1 MPORTANT: Applicant must complete all items on this page n n LOCATION PROPERTY OWNER ff'[- 1�5t�f ► t ��. Print 100 Year Old Structure yes no MAP NO:C PARCEAq ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non= Residential ❑ New Building ttl.06e family ❑AOdition ❑Two or more family ❑ Industrial 1,21AIteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIP ONS F�R TOJE PE R ED: nn^^ 13 r o� Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: 1 _- Phone: Address: 1 Supervisor's Construction License:_eS- 1 0a Zf 2... Exp. Date: 'S Home Improvement License: -sl( - Exp. Date: 11b l ARCH ITECT/ENGINEER-�4T— �1 Gcy�US Phone: ��SZ' Z� J Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ 0�r Check No.: /.2 Receipt No.: �0' NOTE: Persons contra;* withft unr istered contractors do not have access o t g ra fund Signature of Agerit%Qvvn _ Sig?ature of contractor' Plans SubmittedLi Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The fo!<<Hwang is a list of the required.forms to be filled outfor:the.appropriate-permit to.be obtained. J Roofirg, Siding, Interior Rehabilitation Permits ❑' Building Permit Application ❑ Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or-C.S.L. Licenses o Copy of Contract D Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire'Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the aprn,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui!ding Permit Revised 2012 Location Z? 7 1 )G l' ham' l` f No. 4/ — e-jr Date / /l TOWN OF NORTH ANDOVER Certificate of Occupancy $ /,/)0- Building/Frame Permit Fee $:Z0 Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# A 2 � �� / Building Inspector 1 l Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 58,987.00 m $ - $ 707.84 Plumbing Fee $ 88.48 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 88.48 Total fees collected $ 984.81 137 Barker Street 549-14 on 1/15/14 Family Suite ZBA#2013-015 ,` _ __ _ _ ___ ;: /. f I i I 4 I i .� 1 I I l I� I r i NORTH Town of t Andover O - 0 LI h , ver, Mass, _ xy coc KlcolwlcK y1. S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System SG S� �. .�4. :....................................................... BUILDING INSPECTOR w THIS CERTIFIES THAT ... has permission to erect buildings on .7 �� 71�o� S� Foundation .......................... .. 3 ................................................................. Rough to be occupied as .................. ...: ........zl-�1�.: ...�...................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE Arihitedh rat-6 Ct. P.n.rt mNa. +tixWi'. M�iil�c+.l:Bill�n„ 4 rciRD�I�IH��uxvF 5 sn9a I\/\// x�n lN SnocT .,JW Iw 0 RMSWN Y1 PCR ORMCD RiN ACGORDANO —� Mu PND 5FP E GOC 5 AND ICCORDINc 10 E DES'PRACIICCS OF nIE PA C5. ].+'A DIM[HSIONS END CO NNCNIS THSF BC IED N AN ESS LL AMG GH'RvnNCIEpF'WL 1 OFC HE CMI' �C�101 E CLP rICATIONrtSEFORE PROEEDIND. D,-DIMEN51ONOS ARE FD:M Of M J� OIN 11CO1 INFOD. RM ARE L 4t,nRCD 10 INDRS THE eSELVES FULLY WIFH i� CON+BIONS UNDER1"l*1111 WHICH PFR 0RMED'S FAC E CON WC70R MUS'EMPLOY 1.1'AP AS POSSIBLE. A h! L100PS PND CAUSE 1N y'H CAP ND OU 1HEIR WDPR AS-LILu rv0i GORUSC AIN WE I0"pERCONCE WIiH ANY GAP GE ECR 1, D A. NOR SHOWN UNFINISHCi ARE REZRIG`0 WHENn DASEMENF c l A O uNCF1O FUR sPi1CN E)N BE IDL FUR ISHCD PND-ENISEE1 .T NO OWNER. E%CENSE T( F S DFOCR. vG,ON Br —^�� NCAl,REsEv[R OwNEa SNEI. `CRN RAC10P FROM O SHWA SPFIgFPCTDRr t B w0i RAILS ML SHiALL EaoM 1; C01.'LERNC R 1 WE RN 1.E I INE[PPED R HE E OPPWINCS I------------ Ex sting Baseme It Fl(or Plan EXI`,'TING BASEMENT PLAN II,v' M.Bill,IRS Urawi Ng Numhxr: 1.E t.LEx15TINC GC iprt10rv5 AND FY ALL ii NS 1.INFERIOR r M E%iEROR WALL D4:NNE55 A, INFEPIOO D PERIMETER LL OD DO 15 ARE PRY IN 1 IE F CLD.VERIfY ALL MAY VAR/FR'Ml DIMCNSS AN DFIRE HATING ^ROMO FR DATION WALL AND DO NOF OIMCNSONS AN)E%ISTMC CONOBIONE CONFIRM WPl CNNESS AND FIRE RATING U as well fRPMIrvG. E FEPKJR BEFORE PROCE'DING WITH CON5IRUC�ON I WALLS PRwf..�R EO NOT IN's.SO E Of PNCCEO Rt 3WALLIN5UL.11N�1'ON SHNL A2 . 0 END/Oa—R-TIONS. pRE SuOW Et 5 OP SO DEORFC'. OPt2: l BR Aa ©R>D DATE(MM(DDIYYYY) ..- CERTIFICATE OF LIABILITY INSURANCE 01/1312014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to I the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the I certificate holder in lieu of such endorsement(s). f PRODUCER CONTACT , Durso&Jankowski Ins Agcy LLC PHONE I FAX 198 Massachusetts AvenueArc No F: : ArC;Nod: North Andover,MA 01845 E klm -- Durso&Jankowski Ins.Agcy. ADDRESS: PRODUCER PREV1�4 CUSTOMER ID#: INSURERIS)AFFORDING COVERAGE NAIC# INSURED Ace Home Medics LLC INSURER A; 57 Harold Parker Road Andover,MA 01810 INSURERS: INSURER C:Utica Mutual Insurance Company INSURER D: ) INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR PO LTR i TYPE OF INSURANCE - INSR"YM POLICY NUMBER MMIDDP(YYY I M�MILpDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE i$ 1,000 00 C X 1 COMMERCIAL GENERAL LIABILITY j 1,4687243 1 09/2712013 s 0912712014 PREMISES IEa ocrunenees $ 500,00 r—f i r CLAIMS-MADE :X i OCCUR 4 i fI MED EXP(Any one person) 5 10,00 --_ I PERSONAL&ADV INJURY 1,000,00 i GENERAL AGGREGATE s 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. I ` j PRODUCTS-COMPIOP AGG $ 2,000,00( POLICY PRO-JECT LOC ( $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I I (Ea accident) $ ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED AUTOS BODILY INJURY(Per accident) S _ SCHEDULEOAUTOS i f i PROPERTY DAMAGE $ f HIRED AUTOS if !(PER ACCIDENT) NON-OWNED AUTOS Ig j UMBRELLA LIAB I OCCUR ! EACH OCCURRENCE $ EXCESS LIAB -- CLAIMS MADE i AGGREGATE I — ---- - S DEDUCTIBLE I RETENTION 3 j ( S #WORKERS COMPENSATION I I VJC STATU- flTH- AND EMPLOYERS'LIABILITY Y I N i X O Y LI ITS C !ANY PRCPRIETORIPARTNERIEXECUTiVE 1 4687246 09{2712013?09127/2014 f E.L.EACH ACCIDENT 5 1,000,00 i OFFICERIMEMSER EXCLUDED? N I A{ ; {Mandatory in NH) E.L. ISEASE-EA EMPLOYEEI$ 1,000,00 If yes,describe under f —.---_----._ i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,00 { DESCRIPTION OFOPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) Carpentry— CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street North Andover,MA 01845 AUTHORED REPRESENTATIVE I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD I Town of North Andover ZONING BOARD OF APPEALS Albert P.Manzi III Esq.Chairman �.��'� Associate Members Ellen P.McIntyre,Vice-Chairman °'` " Michael P.Liporto Richard J.Byers,Esq.Clerk Doug Ludgin D.Paul Koch Jr.,Esq. Deney Morganthal Allan Cuscia °r = Zoning Enforcement Officer s "11 Gerald Brown Legal Notice North Andover Board of Appeals w Notice is hereby given that the Board of Appeals will hold a public hearing at The North Andover Town Hall, 120 Main Street, North Andover, MA on Tuesday, December 10th, 2013, at 7:OOPM to all parties interested in the petition of Joshua and Elizabeth Moughan for property located at 137 Barker Street (Map 35, Parcel 99), North Andover, MA 01845. Petitioner is requesting a Special Permit from 4.121.17 of the Zoning bylaw to build a Family Suite in the R-2 Zoning District. Application and supporting materials are available for review at the office of the Zoning Department located at 1600 Osgood Street, North Andover, MA, Monday, Wednesday and Thursday from the hours of 8:00-400, Tuesday from the hours of 800-5:30 and Friday from 8:00 to 11:30. By order of the Board of Appeals Albert P. Manzi III, Esq., Chairman Published in the Eagle Tribune on: November 26, 2013 December 3, 2013 i I I I ZONING TABLE: i ZONING DISTRICT. R2 REQUIRED PROVIDED MAX. HEIGHT 35 FEET < 35 FEET MIN. LOT FRONTAGE. 150 FT 150.00 FT MIN. LOT AREA: 43,560 S.F. 46,119 S.F. MIN. FRONT SETBACK 30 FT 101.2 FT r MIN. SIDE SETBACK (L) 30 FT 52.3 FT MIN. SIDE SETBACK (R) 30 FT 32.1 FT MIN. REAR SETBACK 30 FT 159.2 FT OWNER IS SEEKING ZBA APPROVAL TO CONVERT BASEMENT AREA TO INLAW APARTMENT. NO FOOTPRINT CHANGE TO EXISTING STRUCTURE. s54°03'23"w 150.37' FOR REGISTRY OF DEEDS USE ONLY N (5% UTILITY EASEMENT ZONING INFORMATION: o o-- ' 0. 146_.53, �..._. ZONING DISTRICT. R2 " S48 53_54 W ASSESSOR INFORMATION: MAP 35 LOT 99 OWNER JNFORMATION• JOSHUA & ELIZABETH MOUGHAN LOT AREA 137 BARKER STREET 46,119 S.F.f 159.2' NORTH ANDOVER, MA 01845 DEED REFERENCE. BOOK: 13531 PAGE. 326 v r: ZNx NORTH ANDOVER ZONING nw BOA OF APPEALS w N� ��3 o ar `N�'� N d 32 13•G4 mow►. Rpfeo orch111 � p "r story EX 2 Frame Wood tore 34 5 c f StrU � 1A �x r o APPROVED20_ a 00 A S 101.2' 102.5' GRAPHIC SCALE SCALE.• 1"-40' FEET 40 0 20 40 I.R. 94.68' FND 55.32' N53°35'15"E "I HEREBY CERTIFY THAT THE PROPERTY LINES N53°43'05"E SHOWN ON THIS PLAN ARE THE LINES DIVIDING BARKER STREET EXISTING OWNERSHIPS, AND THE LINES OF THE STREETS AND WAYS SHOWN ARE THOSE OF PUBLIC OR PRIVATE STREETS OR WAYS ALREADY 137 BARKER STREET ESTABLISHED, AND THAT NO NEW LINES FOR DI"VISION OF EXISTING OWNERSHIP OR FOR NEW plpT pl, OF LAND WAYS ARE SHOWN AND THIS PLAN CONFORMS TO THE RULES AND REGULATIONS OF THE REGISTRY OF DEEDS." LOCATED IN I DECLARE, TO THE BEST OF MY PROFESSIONAL NORTH ANDOVER, MASS. KNOWLEDGE, INFORMATION, AND BELIEF, THAT ESSEX COUNTY THIS PLAN WAS PREPARED IN ACCORDANCE WITH THE RULES AND REGULATIONS OF THE PREPARED FOR REGISTERS OF DEEDS JOSHUA MO UGHAN OF Fes, e SCALE: 1 "= 40' DATE: NOV. 7, 2013 I � PREPARED BY SULLIVAN ENGINEERING GROUP, LLC � — 40 22 MOUNT VERNON ROAD a. �J BOXFORD, MA 01921 I PAUL FINOCCHIO, PLS DATE (978) 352-7871 Cell:978-604-5243 143 Main Street Office: 978-207-0326 North Reading,MA Fax: 978-207-0329 mat(dacehomemedics.com Proposal Submitted To: www.acchomemedics.com Asko �►.�� Janet Hopkins&Josh Moughan 137 Barker Street r # 153165 Construction Home Medics LLC North Andover,MA 01845 Conuction Super.Lic.#100212 C:978-979-6004 Estimate/Agreement#:2062C PG 1 of REMODEL + BUILD • REPAIR EM:toslunoughan(&,yahoo.com Date:December 2,2013 We Accept.Mastei Card&Visa r - Job Location: j a 137 Barker Street $ �9` North Andover,MAO 1845 Cost Estintate/Agreement for Services ae" - MR! Basement In-Law Construction Scope of Work Renovation to basement space to create new in-law suite with 3/d bathroom,laundry closet,galley kitchen,open living room/ bedroom,(2)additional storage closets,(3)utility closets or access panels,(1)enlarged window,(1)new egress window,(1)new entry door from garage to exterior,(1)new entry door from garage to basement,an acoustical ceiling,tile&floating stele floor and a relocated set of stairs to the first floor.Proposed stairs will lead down from first floor to new landing and will turn 90 degrees o end facing the front wall of the house. Foundation 1/2 wall will have a finished wood cap with trim detail.Bathroom ceiling will e plastered. Carpentry,Construction All carpentry,construction,and administration for new basement renovation per plan;demo(minimal)and prep of existing space; 315500 Administrationframing;insulating;rework framing at/around stairwell and proposed landing;framing and install of windows&doors,cabinetry, flooring(tile in bathroom,floating floor in remainder of finished space),all finished millwork and bathroom accessories(including new fan/light kit vented to exterior),build pressure treated steps leading out of egress area and wood safety rails on front and back walls. Proposal is inclusive of proactive communication with clients and suppliers as well as permitting,administration, coordination and supervision of entire project.Stairs will be prepped for carpeting and will have mopboards and base.Shower will have an acrylic base and walls(without a seat). TBD:Existing AC opening;will be filled with concrete or a new window can be installed here if utility room walls are not in the way. jElectrical Electrical work to provide electrical to proposed basement in-law bedroom to include:wiring for electric range,microwave,fridge, 96225 dishwmh ;provide and install(12)recessed lights;wiring only for mini-split;(2)sets of 3-way switches;(1)GFI in bathroom; wiring for vanity light,light/fan combo and(3)single pole switches in bathroom;wking for steekable waghen4ye;(1)single pole witch and wiring for laundry closet;switches and receptacles in bedroom and living area to code•,(1)cable line in bedroom;(1) cable line in living area;kitchen counter receptacles;(2)smoke detectors;wiring and switches for(3)closet lights;(3)keyless porcelain lights in utility closets;(3)are fault breakers;(1)subpanel to replace existing; provide all necessary permit and inspections;test all work for proper operation.Homeowners will supply all appliances and finished electrical fixtures(except recessed lights). Plumbing Plumbing work to supply and install drainage,waste,vent and water piping to new fixtures(1"copper main and future vent exists 11650 in bsmnt);supply and install large 60"W Aker fiberglass shower stall and valve,standard faucet and toilet(Shower model#KDS- 3060 RH or LH without seat);install lav;disconnect existing laundry;;"' ""` 'ter;install kitchen sink;supply and install contractor grade kitchen sink faucet;install dishwashe;remove existing 1-1/4"gas line(approx.40')and raise to be above roposed acoustical ceiling;disconnect Modine heater and use existing zone to pipe in a toe kick or equivalent heater near bedroom;supply and install a 12000BTU JG mini-split heat pump with a 20 SEER on front basement wall;provide all necessary l permit and inspections;test all work for proper operation.Homeowners will supply kitchen sink and lay. All plumbing to be installed on main drain and wet wall. Hang&Plaster Hang all new wall board over all wall areas in proposed finished lower level bedroom,bathroom,kitchen and adjacent areas.Not 4300 including interior of unfinished utility rooms.Interior of closets will be textured. Irime and Paint Prime and paint walls,ceilings,trim,doors-,two coat finish. 1900 Acoustical Ceiling Allowance for the installation of an acoustical ceiling throughout all finished areas of proposed lower level in-law except the 2000 bathroom ceiling which will be plastered.Actual cost to be determined when personal ceiling tile selections are made or approved. Building Materials Framing lumber,insulation,finished window/door/base millwork,doors/frames/hardware(split jamb,hollow core,6 panel slabs, $6600 standard hardware for the entry to mudroom,BR,BA,(3)closets,(3)utility closet;allowance of$175 each),(2)new entry doors and locksets(allowance of$500 each),(2)windows(one to be egress window;total allowance is$700),thin set,fasteners, adhesive and other related,mist.materials necessary.Homeowners will supply kitchen sink,lav,electrical fixtures(except recessed lights),flooring,grout,grout sealant,cabinetry,counter tops and other bath accessories unless otherwise preferred and specified by omeowner. isposal Pisposal of old building materials,packaging and other related debris(an on-site disposal container will be used). 550 Subtotal: 48725 Please see Page 2 of 2 for estimate#2062C Thank you very much for your consideration. We greatly appreciate your business and look forward to providing you with exceptional quality, in a professiona4 neat,timely and efficient mann Our number ne goal is your complete satisfaction. Accepted: The above prices, specifications and /r/ conditions are satisfactory and are hereby acceptedn ate Ace Home Medics, LLC is authorized to do the work as specified. Payment will be made as outlined Signature N Dat iS above. iI i ' Cell:978-604-5243 143 Main Street Office: 978-207-0326 North Reading„MA Fax:978-207-0329 mat( acehomemedicsxom Proposal SubmWed To: www.acehomemedics.com Janet Hopkins&Josh Moughan HIC Lic.# 153165 137 Barker Street Home Medics LLC North Andover,MAO 1845 Construction Super.Lic.#100212 C:978-979-6004 fl Estimate/Agreement#:2062C PG 1 of REMODEL • BUILD + REPAIR EM:ioshmoughanAyahoo.com Date:December 2,2013 We AcceptillasterCard& Visa Job Location: _= 137 Barker Street F A"g P North Andover,MA 01845 4•\ Cost EstimatelAgreement for Services BBB. I Basement In-Law Construction oncrete Cutting lCutting of concrete foundation for new entry door from garage to exterior and for(2)enlarged window openings(one egress,one $900 �on-egress but larger than existing). Masonry-Retaining At the rear wall of the garage: $5050 Wall Construction -Remove existing rail road tie wall -Excavate earth from rear of existing wall back approx.3' + -Build new retaining wall approx. 19'L by 4-5'H plus a section approx.9'L by 4'tapering to grade -Install geo grid and crushed stone behind wall Rework existing patio area with existing pavers at base of new wall -wall to be built of Genest Pro-Cut Gray wall blocks Masonry—Egress Area At right side of house,at approximate location of existing basement window: 3700 -Excavate approx.6'x 6'by 4'deep -Form&pour(3)concrete walls for egress area -Install crushed stone at base of a ess area for proper drainage Permit Fee Allowance Allowance for building permit fee;based on$12/$1000 of project cost. 612 Total: 58987 Additional Terms and Conditions:1/3 due upon start;1/3 due upon completion of plaster-1/6 due prior to completion;balance due upon completion.Prices are based on standard removal& installation.Additional work may be required due to conditions that we cannot see or predicx changes to the scope of work or to the finalization or modification ofspecifications.Any work over + and above that described here will be billed accordingly.Proposal is valid for 30 days from submittal We may take pictures of our work Ifyou do not want these pictures shared please initial here. Payment terms can be changed if the masonry is postponed until spring. i i I i I Thank you very much for your consideration. We greatly appreciate your business and look forward to providing you with exceptional quality,in a professiona4 neat,timely and efficient manne. ur num one goal is your complete satisfaction. Accepted: The above prices, specifications and / if conditions are satisfactory and are hereby accepted. Date Ace Home Medics, LLC is authorized to do the work as specified. Payment will be made as outlined Signature Da e above. Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑ ;TYP "DF-8EWERAGEDiSPOSAL '.. Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco.Sales 0 Food PackagingfSales ❑ k t ti Private(septic an ,:etc.- l - � =Permanent Dempster on-Site ❑ • • THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS (CONSERVATION Reviewed on Signature •y f� COMMENTS HEALTH Reviewed on Signature COMMENTS ZoningBoard of Appeals:.Variance Petition No: pp Zoning Decision/receipt submitted yes Planning Board Decision: Comments ' Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit JL DPW Tow;z Engineer: Signature: Located 384 Osgood Street FIRE DEPART(l�ENT -Temp Dump'§ter on site yes.. . no Located-at 124tMair,Street- =" �FireDepartme►�f signature/date `" - ,ti - . .;,�t• -, t, ; ,• .•. , 4 ' COMMENTS_ ` ' Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Tota[land area; sq. ft.: ELECTRICAL: Movemento.f Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL-.Chapter-166 section 21A-F and G min.$100=$1000..fine NOTES and DATA— (For department use ® Notified for pickup - Date [ E E Doc.Building Pennit Revised 2010 Date..... ... ��10NT�y 1 3a°O:"'.;':�•��pt TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that '.. . ... a.. ................................ ....... ...... ....... . has permission to perform ...`,..rnol ......A.1pr.(LA . ....................................... wiring in the building of.........Cjo.c..O at ......�..�J......r.........±- rt�r�-{ct+c' ��'�'..........................:"Andover,60 Fee,5 Lic.No......... ........... 1.t!�....ELEC Check# 4. r ? SPC E ' Commonwealth of Massachusetts Official Use Only ' Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [R ev.1/07 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC 527 C IR 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the lnspalctoT of Oriies: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1 -2 Owner or Tenant G rte/c�,e,.. /�n�h Telephone No.y 7g-(_a9.co(, Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 5,,,, << �j ,, �_ 1.a, 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 Locati n and Nature of Proposed Electrical Work: ��fL Oh ScavH Vo r 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 Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency.Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.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 No.of Waste Disposers Heat Pump Number TonsKW No.of Self-Contained .......... ''"""""............. Detection/Alerting Devices No.of Dishwashers Space/Area lro.,* - 17" - _ - - --` Other No.of Dryers Heating App! uivalent No.of Water KW No.of Heaters Si ns uivalent IX-0.Hydromassage Bathtubs No.of Motor. ;ring: uivalent OTHER: y Estimated Value of ect tspector of Wires. al Work: 9co Work to Start: Inspections to be requ Y Jetion. INSURANCE C VE GE: Unless waived by the ow. ay issue unless the licensee provides proof of liability insurance includinj ivalent. The undersigned certifies that such c v rage ism force,and h CHECK ONE: INSURA=NCE BOND 11OTBE: I certify,under the pains and p nalit s o per'ury,that tl e. FIRM NAME: ES a� Licensee: 7,zG Sigr. (If applicable,enter "ex" t"in the cense um er line.) v Bus.Tel.No.•J 7?r•2507-,2�`S' Address: �G� tj o! n a 1� r e Alt.Tel.No. 'Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$ —� Signature Telephone No. s ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the t bb permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed f' 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[fl Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: l Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ 6Y Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass F71 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com J t 1 The Commonwealth of Massachusetts Department of IndustriqlAccWnts Office of Investigations qu 600 Washington Street Boston,MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i Applicant Information PIease Print Leizibly Name,(Business/Organization/Individual): Lj6. P. r Address:— City/State/Zip: 6'u', AMP. aila� 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 employees(full and/or part-time)." have hired the sub-contractors 6. ❑New construction 231 I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.KfElectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy 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.Lic.ff: Expiration Date: 'i Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Facture 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 violat r. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins anc overage verification. �do hereby certt under It d penalties of perjury that the information provided abov is fru and correct.i ature: Date: p 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#• ' I I COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS ASA RfG JOURNEYMAN ELECTRICIAN I ISSUES THE ABOVE LICENSE TO: J MICHAEL G RAYMOND v ' 24 TRUMBULL AVE HAVERHILL MA 01832-3. 51208' E 07/51/13 887418 . =i . I c E r i i f ' Commonwealth of Massachusetts Official Use Only Permit No. LQ Department of Fire Services Occupancy and Fee Checked „ BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC 527 C IR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the lnsp ctor of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 -7 Owner or Tenant rGl er. n�h Telephone No,h 7g-G&&C2 � Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building �r,,6<< !�6 9r� �,, Utility Authorization No. - Existing Service Amps / Volts Overhead[IUndgrd F1No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Locati n and Nature of Proposed Electrical Work: djeo aa— oh Uo r Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o mergency ig tmg rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices A No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: -".'".""'�"'"""....I "''' 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 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: ! L Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of ectr'cal Work: 9C0 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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 suchc v rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and:27 nalti s of per'ury,that the nforntation on t plication is true and complete. FIRM NAME: . LIC.NO.: ESJa Licensee: G Signature LTC.NO.: (If applicable,enter "exem t"in the 'cense ttm er line.) Bus.Tel.No.:� `S— Address: �L� '_Inn �u �� U� . Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 3 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 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . J Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r Location No. r Date HORTh TOWN OF NORTH ANDOVER F n Certificate of Occupancy $ Building/Frame Permit Fee $ �'7b''••°''<�' Foundation Permit Fee $ Ss�C U Other Permit Fee r -1 $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ a• Building I Wector 0812fi/9� 12:28 54.00 PAID Div. Public Works PERMIT NO.' &X� APPLICATION FOR RMIT TO BUILD***** **NORTH ANDOVER, MA MAP NO. ( LOT.NO. 2. RECORD OF OWNERSHIP DATE BOOK PAGE 'LONE �l SUB DIV. LOT NO. LOCATION I'3� PURPOSE OF BUILDING OWNER'S NAME NO.OF STORIESSIZE 2 1 OWNER'S ADDRESS BASEMENT OR SLAB 102, ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1 ST 2ND t 3 D BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BO;,RD OF APPEALS ACTION,IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTUCTIONS 3. PROPERTY INFORMATION LAND COST n EST. BLDG. COST pl PAGE I FILL OUT SECTIONS 1-3 EST.BLDG.COST PER SQ. FT. EST.BLDG.COST PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4." APPROVED BV: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR I O DATE FILED OWNERS TEL# 6/,7 Fr/ 7 2-2- Y UQQ 2 3 CONTR.TEL# (� s /►1� B � b(.0119// V t �� CONTR.LIC# / o O1 1 (�l SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE $ ,6-0, PERMIT GRANTED — 19 Revised 11/97 JM A w • S�� ; o � S : .:� f ``.. .. �.. ..,r.n.. .o scem�.�..a+.�.`.. ertutratic of �O REGISTERED 4 of �(I ISSUED BY Date of Manufacture / > APPLICATION ANCHOR INDUSTRIES INC. 2/13/97 NUMBER EVANSVILLE, INDIANA 47711 _ Order Number MANUFACTURERS OF THE FINISHED F121,4 Re �►� TENT PRODUCTS DESCRIBED HEREIN 151166 This is to certify that the materials described have been flame-retardant treated f� (or are inherently noninflammable) and were supplied to: a in ►nI, PETERSON PARTY CENTER INC 139 SWANSON ST yia WINCHESTER MA 01890 7nr m� 'moo> Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant . approved chemical and that the application of said chemical was done in conformance ni MV9 with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109 m� The method of the FR chemical application is: M PP o: Serial#: 8040000C (0001) Description of item certified: FI EXP 25X45 VL WW 4PC(2)10'MD m� O �o Flame Retardant Process Used Will Not Be Removed By 6 . .•ll Washing And Is Effective For The Life Of The Fabric • OHP SOYLESZU0 STATES ILLS,RC-- \ O O Name of Applicator of Flame Resistant Finish Signed: TENT ARTMENT—ANCHOR INDUSTRIES INC. I►% fat O .... ,C�••rO�rO�iOwO�iO�sO�iO�r i ��.,�.. .. .- r- . . `.., `.. `.. �._ y\.. ,..y`. •�� • - yam" . y�"yam ,�\ •y1 w 011.1ertirtrate of Niame ilestatance /11 ISSUED BY 0! REGISTERED v of uciF Date of Manufacture APPLICATION �� : ANCHOR INDUSTRIES INC. 11 NUMBER J F' EVANSVILLE,INDIANA 47711 5/03/96 Order Number 11 FFj MSP P MANUFACTURERS OF THE FINISHED 70> F121.4 �iF REi�`av TENT PRODUCTS DESCRIBED HEREIN 11532 MAE, This is to certify that the materials described have been flame-retardant treated yp` (or are inherently noninflammable) and were supplied to: rrii O1> uOlta ao PETERSON PARTY CENTER INC 139 SWANSON ST lO O� ' to1> WINCHESTER NIA 01890 ro Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance iii fan with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109 0; application The method of the FR chemical a is PP � : Serial#: a� 8000300 (0001) O \�1 Description of item certified: O; FI TOP 12W X 12 VL W W tat "o Flame Retardant Process Used Will Not Be Removed By Ogg Washing And Is Effective For The Life Of The Fabric ' �aOpN ' Signed: Name of Applicator of Flame Resistant Finish O�t�• O TENT ARTMENT—ANCHOR INDUSTRIES INC. �aN �rU�`�(1r.rU�rO�rO�ro� �rO�rO�rO�r �ro� O�rO�if'O�.rO..rO�rO�rO�rO�ro�'$ � O�ro� � O�rU .L• J/ I i 1 i � Z � � G 1 Z. � i .� i �� s �. - , � G �� i -' J�. � ^ - .�1/� 1 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 060219 jet, Birthdate: 04/27/1954 Expires: 04/27/2001 Tr. no: 8508 Restricted To: 00 MARK TRAINA 6 RYANS PL BEVERLY, MA 01915 Administrator - -, I he Commonwealth of Massachusetts Department of Industrial Accidents 600 Washington Street Boston, Mass. 02111 -~ Workers' Compensation Insurance Affidavit location* - I Cw phone# U I am a homeowner perform, ing all work myself. 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. Company name: ic�(JJ (N f <. nddress city ',�� l MA oI t o Aho.ne 4- insurnnce c - 1 v D I am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' comoensation polices: c m any name: address: fifty 3�itone# insurance co policy# ` company . a address: city Qhone# .• . - insurance co �olicvY + .�►t� t�aM ad dittona MR=arct9sa _ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a TOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. /do hereby cervi under the pains and penalties of per ury that the information provided above is true and correct Signature Dau Print name vim, �,v ' v �`- Phone# 2-q — official use only do not write in this area to be completed by city or town official r city or town: permittlicense# r;Building Department C3Licensing Board G+ check if immediate response is required OSelectmen's Once Cf{ealth Department ' contact person phone#; 1'1Other t' (revied IM PIA) .� � �� `� i '2�� Y i NORTH T 0 own of dover No. CP0COCHIII dover, Mass., ORATED 61 BOARD OF HEALTH Food/Kitchen Pk� nMLT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ........ ....... ...... Foundation has permission to erect. ...(jR2.*-'........... buildings on .0...7_4 . .............. ........... Rough to be occupied as......pry........ .........1610901110-40;*........................................... Chimney p6�_ s_i ...... provided that the person accepting is permit shall in every respect conform to the terms of the application on file in Final Phis 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 ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TA,&R-jS. T71_� Rough .............................A tq.*.**.r... .... ...........................i6... Service 4B il��N�GIN INSPECTOR Final -rmit Required to Occupy Building Occupancy N 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. SEE REVERSE SIDE Smoke Det. 1 Location 13 2 ' No. Date --�I'D y ? i �oRt� TOWN OF NORTH ANDOVER 09 Certificate of Occupancy $ Building/Frame Permit Fee $ �ss+cHust< Foundation Permit Fee $ _ Other Permit Fee T, $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Sol — ,141 S of ,,141 -" Building Inspector i05 �/99 11:29 50.00 PAID Div. Public Works PERMIT NO. / -6-0 APPLICATION FOR Pf RMIT TO BUILD********NORTH ANDOVER, MA NIAP NO. 3 LOT.NO. ! 2. RECORD OF OWNERSHW DATE BOOK PAGE ZONE SUB DIV. LOT NO. LOCATION i 3 Kn �tjp PURPOSE OF BUILDING D ! Z X ��Fr�� OWNER'S NAME "�✓ �! NO.OF STORIES SIZE OWNER'S ADDRESS / Y BASEMENT OR SLAB ARCHITECT'S NAME ` SIZE OF FLOOR TIMBERS 1 S f 2ND 3RD BUILDER'S NAME P /„`�I SPAN DISTANCE TO NEAREST BUILDING IU`C DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS I IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION-jgy,7f 1v� !,(! MATERIAL OF CHIMNEY IS BUILDING ALTERATION 70 bp_ c l IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE (f� IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION,IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE IRISTUCTIONS I PROPERTY INFORMATION LAND COST EST.BLDG.COST PAGE I FILL OUT SECTIONS 1-3 EST.BLDG.COST PER SQ. FT. I EST.BLDG.COST PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: C PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR tLi DATE FILED L I� G OWNERS TE L# �' LS 2GI- �� MAY 1 8 10 9 CONTR.TEL# ry �1��►�l/ !L'Q CONTR.LIC# �I 4 SIGNATURE OF OWNER OR AUTHORIZED AGENT `D H.LC.# FEE v , PERMIT GRANTED a 19 Revised 11/97 JM ' %ORT#q Town . of over 15o o C01A r CN,CC7( dover, Mass., i S H BOARD OF HEALTH i PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT......441A9.........1S.`./4 vA^ .................................................................................... Foundation has permission to erect........................................ buildings on ..... . ... g ............. Rough to be occupied as.7- t .......... S I" So 7O f /`'Z O10�.0.#........A y Chimney .... .. ................................................. ............ .... . . ...41. ............... 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. - j VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Location /,317 i !� PERMEXPIRES IN 6 MONTHS Final No ��a IT UNLESS CONSTRUCTI Rough S TS EL � M�RTh TOWN / 3o� 1�c .................................................. Service Certificate oma: BUILDING INSPECTORp Final : Building/Fa Occupancy Permit Required to Occupy Building i fi��s'�CMUS tom; Foundation Other Pem Rough Display in a Conspicuous Place an the Premises — Do Not RemoveFinal I Sewer Cor No Lathing or Dry Wall To Be Done F Water Con Until Inspected and Approved b the Building Inspector. TOTAL P P P Y 9 P Burner Street 1312.0 - SEE REVERSE SIDE Smoke j I i 1 I a nn i I y i c'L I 1 1 j ; OD Q�D Certificate of iname Rtqt"�taure REGISTERED ISSUED BY { FABRIC JOHNSON WORLDWIDE ASSOCIATES, INC. Date of Manufacture NUMBER BINGHAMTON, NEW YORK 13902 _ Manufacturers of the Finest April 1997 F-140.01Tent ProdtIcts Described Herein This Is to certify that the products herein have been manufactured from material Inherently flame retardant as here after specified by the material supplier. NAME: Peterson Party Center CITY Winc--hesfer STATE MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701", Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. i [Type,color and weight of material:l SO Z Vinyl White i Genesis 50x50 2pc. Description of item certified: Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. Manufacturer of Flame Retardant Vinyl Laminates TENT EPARTMENT,JOHNSON WORLDWIDE ASSOCIATES,INC. 'Large Scale Q O� �O i } In �P�tIfIL tP of fflante PSI t�I�LP I i REGISTERED ISSUED BY FABRIC JOHNSON WORLDWIDE ASSOCIATES, INC. Date of Manufacture NUMBER BINGHAMTON, NEW YORK 13902 Manufacturers of the Finest April 1997 F-140.01 Tent Products Described Herein This Is to certify that the products herein have been manufactured from material Inherently flame retardant as here after specified by the material supplier. NAME: Petreson Party Center CITY Wi nr-hactar STATE D4 Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701', Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type,color and weight of material: 16oVinyl White Genesis 20 ' Mid for 50 ' Description of Item certified: Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. Manufacturer of Flame Retardant Vinyl Laminates TENT EPARTMENT,JOHNSON WORLDWIDE ASSOCIATES,INC. OO "Large State Q b0 i I a PC �n�r��n�n��r� j ��r IMPORTANT DOCUMENT .,,,, i n�,rMM��L3pr �nj o 5 55 5 C tift,rate of irtame 5 5 5 REGISTERED ISSUED BY 5 o- F a /� 5 APPLICATION \i.HOR� Date of Manufacture — NUMBER— ` NDUSTRIES INC. 3/31/99 Qj5 5 F121.4 y� M��or EVANSVILLE, INDIANA 4771 15 Order Number 5 C ezt+ MANUFACTURERS OF THE FINISHED 216101 5 TENT PRODUCTS DESCRIBED HEREIN 5 i 5 5 This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to: 5 5 PETERSON PARTY CENTER INC 5 5 139 SWANSON ST S 5 5 5 WINCHESTER MA 01890 5 5 5 Certification is' S 5 hereby made that: 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 chemical and that the application of said chemical was done in conformance with California Fire 5 Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109.5 5 The method of the FR chemical application is: 5 5 Serial it: 8001500 5 5 (0002) 5 5 Description of item certified: 5 FI TOP 20W X 20 VL W W 5 ' S5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 JJpp� pp ( p Signed: Dj Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. 5 � [J�CPLICP[PCPCPCn�[PC1�CP[J�CPCP[PCP[1�Lf�CPC.1�C1�CP[.Pc1�CP[_1�CP[1C.1�Ll�GPCPCPCPCfCP[P[PCPCP[1�L(L(�CPCP[P[PCPCPGPCPCP[PCPCI�CPC1�LfGP[1�[1�[PCP[J�LI�LI�[1�CP[J�[nC1�C1�L(�LI�CJ�CI�LILfC1�[J�CPLl� �7 } i PERMIT NO. APPLICATION FOR IfiRMIT TO BUILD********NORTH ANDOVER, MA MAP NO. vl-51- 1 LOT.NO. / 2. RECORD OFOWNERSHIP DATE BOOK PAGE ZONE S111)DIV.LOT NO. LOCATION , �n PURPOSE OF BUILDING D I �� , OWNER'S NAME jTai me"'�✓ V NO.OF STORIES SIZE OWNER'S ADDRESS 13r2 BASEMENT OR SLAB ST ND RD ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1 2 3 BUILDER'S NAME p , lA SPAN DISTANCE TO NEAREST BUILDING NY DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION > -fo /„ MATERIAL OF CHIMNEY IS BUILDING ALTERATION'D` 'v cEN uvs IS BUILDING ON SOLID OR FILLED LAND Taal WILL BUILDING CONFORM TO REQUIREM`J TS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION,IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTUCTIONS 3. PROPERTY INFORMATION LAND COST EST.BLDG.COST PAGE 1 FILL OUT SECTIONS 1-3 EST.BLDG.COST PER SQ.FT. EST.BLDG.COST PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: C PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR DATE FILED l OWNERS TEL# l { /ALJ V rVV ' i�......_ IR CONTR.TEL# $ ZGI— DV MAY ► g I� g 1 ` CONTR.LICb�=i ! f SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE $ H.I.C.# e 'i1._ _ibV lei=C's IL�-',J.S P I PERMIT GRANTED a 19 Revised 11/97 JM NORTH Town of ndover 0 0% 15o 24L 0 CoC�,� dover, Mass., lAr A0R? TE D Pk? 5 BOARD OF HEALTH t PERMI D Food/Kitchen I Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......;!;/.Ar......... ........ vA N Foundation has permission to erect..........Q2.............. . . buildings on ..... ... d�` !h 4- p g , I ....� ........................... Rough t0 be Occupied as.. dr/V....•��...... s0 70....rt i`......d..... a*........�Ir' — Chimney t .................... .. ......'+..... provided that the person acceptin is permit shall in every respect confor to the terms of t application ile in Final this office, and to the provision the Codes and By- s relating to the In ection, Altera and Co ction of Buildings in the Town of fo Andover. P1.1– VIOLATION of the Zoni Building Regulatio oids this P it. Rough Location 1,3? PE ' EXPIRES MON S Final No. R 3 L S CONSTRUC S TS ELF RoughI f NQRTf, , o , ,• TOWN .......... .... .. .... ... ............................................................................ Service o � = - • �� Certificate c BUILDING INSPECTOR " Final ! : s Building/Fra Occup Penn.it Required to Occupy Building J } �s R� w t 1',`• •'tom Foundation sACMU`� Rough Other Permi Display in a Cons 'cuous Place an the Premises — Do Not RemoveFinal + Sewer Conn N Lathing or Dry Wall To Be.Done Water Conn Until Inspect and Approved b the Building Inspector. TOTAL p p p y g P Burner Street N 13120 SEE REVERSE SIDE Smoke I GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stonelfabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip- Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '/"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min. 22x30 w/3'headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0'clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage I FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging,clean joints, 8"solid @ combust. Surf. DECKS: Separate permit required: Lag to house, provide flashing. Rails min. 36"high, Baluster max space 6"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48°, Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside opei �" 1 Exterior grading complete. 0- Certificate or occupancy required r W Q a Temporary Stairs required for inspection. > 0 C Re-inspection fee-$25.00(Be Ready). O W o Z v, a Certificate of occupancy required prior to occu64 V� eg to 6-, 64a o - �. m u_ � � '" ami � y � Q Q. E u_ u_ u- Z a E aD o 0 0 U Location f. 13,4�� S No. �� Date t I 14ORTol TOWN OF NORTH ANDOVER Of .•° C Certificate of Occupancy $ _ *Argo Building/Frame/Frame Permit Fee $ �S s4cNust 9 � I , Foundation Permit Fee $ Other Permit Fee $ j TOTAL $ — Check # Building Inspector PERMIT NO. ®�- APPLICATION FOR PERMIT TO BUILD********NORTH ANDOVER, MA 11AP NO. LOT NO. 2. RECORD OF OWNERSIIIP DATE BOOK PAGE ZONE: Still DIV. LOT'NO. LOCATION / 3 -q- P[IRI'OSF:OFBlI1LDINC, 0WNER'S NAME: � � � /— n i /^0 C O NO.OF STORIES l SIZE 2� c f s OWNER'S ADDRESS ''� C� BASEMENT OR SLAB i ILS ARC HITE•CT'S NAME SIZE OF FLOOR TIMBERS 1ST 2ND 3RD 111111.DER'SNANIE: Pro - J4StlN PSPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POST'S DISTANCE FROMLOT'IANES-SIDES REAR DIMENSIONS OF GIRDERS It EA OF 1.01' FRONTAGE IIEIGIII'OF FOUNDATION THICKNESS IS BUILDING NEW 7 SIZE OF FOOTING x IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDGNG CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED T'O TOWN SEWER i IS BUILDING CONNECTED TO NATURAL,GAS LINE INS l'UCFIONS 3. PROPLRT V INFORMATION LAND COST � EST. Bl.nc. cosr / / r(D o a PAGE I rILI.Our SECTIONS 1-3 EST.BLDG. COST'PERSQ. FT. EST. BLDG. COST PEI t ROOM ! ELEC"TRIC p1E;T1iRS MUSTBE ON O[ITSR)E OF BUILDING SEPTIC PERAIrr NO. ATTACHED GARAGES NIUSTCONFORIII TO STATE:FIRE REGULATIONS 4. APPROVED BY:/W PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR i DATE FILED 1 OWNERS TEL# CONTR.TEL# SIGNATURE. OF-O\VN ER OR AUTHORIZED AGENT cONTR.I.Ic# it PERMIT GRANTED _ 19 Revised 5/5/99 .INI W Doc REQUIREMENTS FOR TENT PERMITS Name of City/ Town: � I Address: Phone: (q A�) qs; 5 Hours available: CX'" r),.— Fee Structure: Circle One: Mail :InPe:rson wttL 11,Qd on� A i Items needed to submit with application: /Flame Retardant Certificates /Sketch in Azo 1(Tti_`tD hUugoe, /Copy of Construction Supervisor's License /Workman's Compensation Certificate Signature of Client (authorized agent not enough) Other Requirements: Fire Department Approval: Inspection Required: Any Other Comments- (978)688-9545 omments-(978)688-9545 Town of Fax(978)688-9542 ` M NORTH ANDOVER DIVISION(H COMMUNITY DEVELOPMENT&SERVICES BUILDING DEPARTMENT MICHAEL McGUIRE Local Building Inspector OE ict �ns 1830-to XM +-I-Q PM 27 Charles Street•North Andover•Massachusegs•01845 . ✓1�e �anvino�uveal!/a�/�aooac/uvedtd E BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR • Number: CS 060219 j !' Birthdate: 04/27/1954 i, Expires:04/27/2003 Tr.no: 9111 ResMcted To: 00 MARK TRAINA 33 HANFORD RD STONEHAM, MA 02160 Administrator i I i i I I I I ==__ The Commonwealth of Massachusetts (rib Department of Industrial Accidents . office of1fiY9S iyaUoos . -- 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit i - .s... easy _eQ1 � _ ..._ ,. i name* location- city Rhone# ❑ I am a homeowner performing all work myself ❑ I am a sole proprietor and have no one working in any capacity I am an employer providing workerscompensation for my employees working on this job. comoanv name* address Cj4X 1. !�;� . � rte#•• insurance coy :` ?� :!!► "7 3.::�3 t�✓ :.. :':.. ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: ...:: .:...:... comoanv name: - address: city: .... phone#= ...::..:.....: ;... . company name:- address- dress: city: ........ . .. . ...: insurance co. .: ........ ... . >ZQlicy# XttacFaBdifionall-shiRtIhnecessarr Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition 8 q position of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify undo the pains and enalties of perjury that the information provided above is true and orreci Signature r � Date OVP ? � ~ rint name official use only do not write in this area to be completed by city or town official ;J city or town: permidlicense!{ I—tBuilding Department OLicensing Board ❑check if immediate response is required OSelectmen's Office Health Department contact person: phone#; I—(Other (remed 3195 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law",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 :he 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 . .:welling house of another who employs persons to do maintenance, construction or repair work on such dwelling house i or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. ;MGL chapter 152 section 25 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 zpplicant who has not produced acceptable evidence of compliance with the insurance coverage required. :additionally, 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 in the workers'•compensation affidavit completely, by checking the box that applies to your situation and Supplying company names, address and phone numbers as all affidavits may be submitted to the Department of ndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The ffidavit 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. '��.►5L'w�d:.6ifYw id t:': s'+ MR. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of ne affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please )e sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to .he Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 fax#: (617) 727-7749 phoneJ': (617) 7274900 ext. 406, 409 or 375 e ice a , REGISTERED ISSUED BY D ua of �� : � � ate of Manufacture APPLICATION s_ ANCHOR INDUSTRIES INC. NUMBER EVANSVILLE, INDIANA 47711 2/13/97 Order Number MANUFACTURERS OF THE FINISHED F121.4 � R1E C�`p� TENT PRODUCTS DESCRIBED HEREIN 151166 n, This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and were supplied to: PETERSON PARTY CENTER INC 139 SWANSON ST frim ! WINCHESTER MA 01890 i 3 Certification is hereby made that: n// The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance a Xm with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109 Iii �� The method of the FR chemical application is: '1Q. n, Serial #: p// 8040000C (0001) : si I/d Description of item certified: FI EXP 25X45 VL WW 4PC(2)10'MD u Flame Retardant Process Used Will Not Be Removed By o Washing And Is Effective For The Life Of The Fabric yin _ __ " o; � Signed: �. O Name of Applicator of Flame Resistant Finish p� — --------------- TENT ARTMENT—ANCHOR INDUSTRIES INC. t\Q ! �O O 0 O O �O O O 0 O O O .\ .\ 1♦ � O N\ .r r.► r ..r � .r ♦ .r .r �r w �r � �r � .r .r ♦ r � ♦ ♦r ♦r rr J,/, I I � I i 1 vi I oc e-s � � L� s� i i ��r )ee r S WORTH Town . of Z 1 - r Andover 0 No. 2o o- COC MIC ME WICK a dover, Mass., A � ORATED P'P�'� S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT �..��. G.... 00.6..... �.......................... ........... .................. .. ........................... Foundation ' ' has permission to erect..�Qs... . buildings on .......f ....... Id' Rou h ........................................ ...... � g to be occupied as....7T- T.........1.:: +.r........3.......rD.....e�.,�......4Fu�c.� ►.�................ 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. M 3 S7 PTCY � 407;16` PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST ELECTRICAL INSPECTOR Rough . .......... Service ... . .. . . . .... .............................................. BUILDING INSPECTOR ' Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough F nal 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.