HomeMy WebLinkAboutMiscellaneous - 143 MASSACHUSETTS AVENUE 4/30/2018 I 143 MASSACHUSETTS AVENUE
J 210/006.0-0033-0000.0
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Date......
AORT"
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that .............................................................................................
has permission to perform ................ ......
wiring in the building of.............. . .........................................
........ .. ......... ..
.......I.q
at . ......s. .... r' .. .... North Andover,Mass.
.0
Fee 31P............. Lic.No.. ...... . ........
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ECMTMRIC L RSPECTOR
Check: #
0807
c.� 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 �J
electrical permit shall be issued to the$erson,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-1hspector_o 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: /2 Z- ***Dote:Reapply for new perm
0 Permit Extension Act—Permit/Date Closed:
• l r I
Commonwealth of Massachusetts
Official
it
Permit No 10907
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: Z� /17
City or Town of: NORTH ANDOVER To the Ins ector of Wires:
By this application the undersigned gives notice of his or her int tion to erform the electrical work described below.
Location(Street&Number) T
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes [J No � (Check Appropriate Box)
Purpose of Building 1� �. 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
4 Location and Nature of Proposed Electrical Work: GAS )D6111 PA
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 Total
Transformers 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 I No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p 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 No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: e--- Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of s e It the rmit issqjng Office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) :
I certify,under the pains alttes of .er'ury,th the information on tis application is tru an complete ��
FIRM NAME: . I�. LIC.NO.:
Licensee: Signature LIC.NO.:
(If applicable,e r "exempth lice a umber line) Bus.Tel.No.:
Address*. ';2 Tel.No.:
*Per M.G.L c. 1 7,s.57-61,security work r ires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
if
4
• �J-.�l.r 'V�.R J�/J.RI�J-R.J.i{®� .`-yl1.JJfJ:1V�V...7.1.eY�®J�'.J.� .y `
INSPECTOR-
�..L40U►3�,1..-lYl'7.Ci"+L J.tLOJ.Y[ �• •• - '
Pwset -�[ - +'ailed�[ �e-xnspeetzonxe uzze�( �D.nn%..
�ns,�ectoxs'cop�zne�fs: _ ,
QCusp ectore sign.atuxe-xto Awals) Pate
3'assea-[ +aiTet�--[ ate-nspectzottxecuzze�($ O.OD) [ '
3Cnsp ectoxs'comm enfs; )
(ffis&dors'gignature-no WHEN) date
Passed—[ I wiled--r � ?fie-fns�eetionae4uixe�($�0.40)�[ ]
rasp efors'comments:
(lnsp ectoxs'signatureo initials) Pate . '
P'e-Inspectionrequired($50.00)-[
tspecfoxs'eoXnm.eptfs: .
QCnspectoxs,slga�turo-io Wflals) Date
�sed�[ � �`ailer�--[ �. 'fie xnspectionxeguired($50.00)-'[ �
]ECtoxs9 coT)1ments: ,
' S
�Lsspectoxs' ignafure noznivaTs) Pate '
]tiEED m17 'AO MFT ON MITE IF TM APXA TO 3E MMUCTE3D Xg NOT
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CX The Commonwealth of Massachusetts , -
Department oflndustriglAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractor6fFIectricians/Plumbers
Auulicant Information Please Print Legibly
Name(Business/Organization&dividual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
�+ 6. New construction
employees(full and/or part-time).* have Hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.x 7• Remodeling
ship andEl no employees These sub-contractors have 8. Demolition
working forme 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.[1 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 wehave no 12.❑Roofrepairs
insurance required.]i 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.
I Homeowners who submit this affidavit indicating they Ere 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.
X am an employer that 1s providing workers'compensation insurance for my employees. Below is the policy rind job site
information.
'Insurance Company Name%
iPolicy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy tleclaration 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 wellas civilpenalties 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.
Ido hereby cert under thepains andpenalties ofperjury that the information provided above is true anti correct -
Sigm.ature: Date:
one#:
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#:
V
Information and Instructions '
Massachusetts General Laws chapter X52 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 shallnot 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 Jin the commonwealth for any
applicant who has not produced.aceeptable 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." J
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 certificates)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 fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed 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 y
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 stamp ed or marked by the city or town may b e 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.More 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 Gommonwcalth ofmassachvsotts -
Dop.aftont of Mustidal Accidents
(Jf£�ce oFluestiatXo
600 WashiWoa Street
Boston.,MA.02111
Tel,#6x7-727,4900 ext40G oar-1-877�MASSAFE
Revised 5-26-05 Fax#617;,727-7749
'c W-W—Mass,g-ov a
Date.. . /.�1.�9!!.Z.. ... .
NpRTH
of ..to ^,ti0
3? TOWN OF NORTH ANDOVER
• - PERMIT FOR GAS INSTALLATION
h
�9SSACHUSESS
This certifies that . . �7.a?�!?. . .�1 . /7. . . . . . . . .
has permission for gas installation . .G'�-�. •�Q . .�r
in the buildings of . . . .,/t!Q? 9d. . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . .�--? .11 . /� . . , North n over,,/Mass.
Fee.A rqq. Lic. No.7�5/ . . . . . . . .
GASINSPECTOR
j
{�Check# Zy /
$ 129
ti
T MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town.-AlPUZ MA. Date: Z: Permit#
Building Location: I'A� Owners Name:.
Moos
Type of Occupancy: Commercial ❑ Educational ❑ Industrial❑ Institutional❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
- - - - - - - - - - -
w H
z
Q UO F-
m x OF Lu _W U � ~ 0 w uj
O z 9 o W O a 1=-
Lu CO W m 0 p 0
vW cn c� w (n a0
W w f- o
> V W Z O -� P h O Z .J O u_ N = W H W W
O Q fY W W m W O Z O r j H' > Z F =
U 93 m u_ t9 C9 = Z J O a W E- > > > O
SUB BSMT.
BASEMENT
1 FLOOR
2 NuFLOOR y
3 FLOOR
4 FLOOR
6THFLOOR
6 FLOOR '
7 FLOOR
8 FLOOR
Installing Company Name: Check One Only Certificate#
Corporation
Address: CitylTown: State:
❑Partnership
Business Tel: LI"74:; 3�Z4. Fax:
❑Firm/Company
Name of Licensed PlumberlGas Fitter: 7TA04ti,
INSURANCE COVERAGE:
I have a current Iia- bility insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A 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.
Check One Only
Signature of Owner or Owner's Agent Owner El Agent El
By checking this box❑,1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By ❑Plumber
Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑Master
CitylTown ❑Journeyman License Number:
APPROVED(0§FICE USE ONLY ❑LP Installer -
�/2rClG h
% Ztf/L
y/ /
The Commonwealth of Massachusetts
rn Department of IndustrialAccidints
Office of Investigations
kvi. 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lelzibly
Name(Business/Organization/Individual): GQ �,
Address:
City/State/Zip: IlY'� Phone#: Q°7�r'� ' �t�?`� ' `"t Z-L-A
Are you an employer?Check the appropriate box: Type of project(required):
1.01 am a employer with_1�-7 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.I ? ❑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.❑Elec ical repairs or additions
3.❑ 1 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.❑Roofrepairs
insurance required.]t employees.[No workers' 13.[i Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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.
lam 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: ` `n
Job Site Address: 4A!2 City/State/Zip: I
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 ce un a #1 e i and penalties ofperjury that the information provided above If true and correct.
Simature: Date: �L-
Phone#: ��Z
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitUcense#
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 ofhire,•
express or implied,oral or written."
An employeiis 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
or on the P w mg house
rounds or building appurtenant rtenant thereto »
g g pp 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."
9
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivi;sions 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,
j please do not hesitate to give us a call.
i
The Department's address,telephone and fax number:
The Commonwealth.of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
I
Boston.,MA.02111.
Tel.#617-727-4900 ext 406 or 1-877,7MASSABB
Revised 5-26-05 Fax#617-,727-7749
www.mass.gov/dia
Commonwealth of Massachusetts ��
Pel,nit No. f2
Department of Fire Services
Occupancy and Fee Checked
x BOARD OF FIRE PREVENTION REGULATIONS [Rev.<) 051' (Icac blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
.SII '.eork to he performed in accordance eeith the\Ip>SaclnlSctts I.IC06CA COC(\IEC). i'-'LAIR 12.00
i 1'LE.I,S'E PRLN T I- IAA OR TYPE,1L AT.OR 1 L ITION) Date: -3-/0 "06
City or Town of: NIver AM— TO 1Jlc' hISIx�001' uJ l6`irr.�:
13y this application the undersigned ores notice of his or her intention to perfi
i
c9
:
Location
No. 174 Date
NORTH TOWN OF NORTH ANDOVER
3?
O
�. •
A
Certificate of Occupancy $
CMust<�•' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ e 110
Check #
18547 �Y�� End
Building Inspe,6
TOWN
OF NORTH ANDOVER
• BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED. /
94
-V
SIGNATURE:
Building Commissioner/12gxdor of Buildings Date
SECTION 1-SITE INFORMATION Z
1.1 Property Address: 1.2 Assessors Map and Parcel Number: O
t-)t
0
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
-Zoning District Proposed Use Ld Area Frorrta ft
1.6 BUILDING SETBACKS fit
Front Yard Side Yard Rear Yard
Required Provide RegWred. Provided Required Provided
1.7 Water Supply M.G.L.C.40.§34) 1.5. blood Zone Infomntion: 1.8 sewernge Disposal System:
v
Public ❑ Private ❑ zone Outside Flood Zane ❑ Municipal ❑ On Sita Disposal System ❑ D
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT FlIsToric Ulstrict es o rn
2.1 Owner of Record
,-`j- Dcp)�o
ameP t
� ) Address for Service:
Sighature V Telephone
2.2 Owner of Record:
�Q In Q-V e
Nam Print Address for Service:
Si ature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable
Licensed Construction Supervisor:
License Number
Address' A
Expiration Date
Signaturb Telephone r
3.2 Registered Home Improvement Contractor Not Applicable ❑ 0
Company Name
Registration Number M
Address
ass
Expiration Date ^
Si nature Tel Z
Telephone V
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......0 No.......0
SECTION 5 Description of Proposed Workcheck all a Me
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
a
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be ;`_ 0,M' CIAL USJ�ONE.SI
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)X(b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf,i u• rs r ive o rk authorized by this building pemiit application.
Signature of owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property .'
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Si ature of Owner/Agent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDMERS I 2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
F NH
ORT
Town of : 10Andover
No. 17(o = . -
-
0 LA
dover, Mass., �` d
COCKICKEWICK
7�A0RATEO PPa\ ��
`S BOARD OF HEALTH
Food/Kitchen
PERMIT . T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT- 1................................................................................................................ Foundation
has permission to erect ...................................... buildings on . ............... ...............................�............ Rough
to be occupied a o.....�...... �i�..., chimney
provided that the person accepting this permit shall in everyTrec�'co nform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Lawsg 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 CONSTRUCTION S r Rough
.................................................................................
......................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Bumer
Street No.
SEE REVERSE SIDE Smoke Det.
NORTH TOWN OF NORTH ANDOVER
Oe4+��n •�,�•y0
: .�.,, •. a o� OFFICE OF
o
BUILDING DEPARTMENT
400 Osgood Street f
North Andover, Massachusetts 01845
Asa^CHU5�1
D. Robert Nicetta, Telephone(978)688-95454
Building Commissioner Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: 0 b
JOB LOCATION: 1 3c,S• Q V
``Number Street Address Map/Lot
HOMEOWNER%i�'ha�,�a ��x(��n ti'10DYYA
Name Home Phone Work Phone
PRESENT MAILING ADDRESSI�['3 r?1ci&S-(,, Ur( , n n V143 n�-a Cjt ' -S
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended
to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
_;tV,6A�,/ 2A"OcId,
APPROVAL OF BUILDING OFFICIAL
110.\M OF A1T1:,.AI S()$8-9541 CONS]�R VNI]ON 689-9530 1W ALH16'{X-9540 11,.ANNING(,)"-0535
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: r,��- is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
(Loc 'on of Facility)
24,
Si tore of Permit Applicant
Fire Department Sign off:
Dumpster Permit
Date
Location + 3
Nd. Date n X�) A-4
NORT1y TOWN OF NORTH ANDOVER
Certificate of Occupancy $
41
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
m
Building Inspector :9
1 2662 Div. Public Works
ocation �( --� /L _j
�E-�—�-
No. � nit
'`� r) Date
NpRTN TOWN OF NORTH ANDOVER,
n Certificate of Occupancy $
* Building/Frame Permit Fee $
Foundation Permit Fee $
s�cMusE
Other Permit Fee $
Sewer Connection Fee $
r
Water Connection Fee $
a+
TOTAL $
Building Inspector
i `- J Div. Public Works
Z"_PERMITIVO. AI'1'LICATION FOR PERMIT TO 13011.1)**** **NORTII ANDOVER, MA
AI\P NO. 1 OLNO. 2. RECORD OF OWNERSHIP DATE BOOK PAGE
Z((N k: SUB DIS'. LO'f NO.
LO( A I ION PURPCEYE O:81111 DING
OWNER'S NAME ° NO.OF SIORIES SIZE
OWNER'S S ADDRESS BASEMENT OR SLAB ST NO RD
ARO.I It I ECI'S NAh1E SIZE OF FLOOR TIMBERS I 2 3
BI IILDER'S NAATE SPAN
DISI ANCF TO NEAREST BUILDING DIMENSIONS OF SILLS
DIS TANCE FROM STREET DIMENSIONS OF POS IS
DISI ANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS
AREA OF LOT FRONTACE IuoIf OF FOUNDATION THICKNESS
IS 81111_Dimi NEW SIZE OF F(X)IINC, X
IS BUILDING ADDITION ' MATERIAL OF Cl IININEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR Flt I.EDLAND
Wil 1.BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECI ED'IO TOWN WA'I ER
BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECI ED TO TOWN SEWER
IS BUILDING CONNECI ED 10 NA I URAL GAS LINE
INS FUCTIONS 3. PROPER TY INFORNIATION LAND COSI.
ESI. BI.ix;.COST
PAGE I FILL Ot I r SECT IONS 1-3 EST. 13 D6.COSI`1'ER SQ. FT. �
s
EST. BLIki.COSI I'LRROOM
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEI'l"IC FERMI F NO.
AITACIIEDGARAGES MUST CONFORM'TOSTATEFIREREGI.)LATIONS a. API'I(O�'EDBI"
PLANS MUST BE FILED AND APPROVED BY BI111.DING INSPECTOR 111111.1ANG It C'Mit
DA I E FII ED OWNERS IFl. /x Q 7
COKI RAEL/I 1� /
COM R.LI('a
SI(iNA I t IRI:01:OWNER(N(Al l'I I TORI ZED AGENT
Ft I.
11:11KIIT GRANTED
19
,j"a
W4
a
TOWN of NORTH AINDOVER
AFFIDAVIT
Hne C actrr Law
' < t
�iicatiaa
R
MSI.c. 142 A regmxes tint the al.t�al, M300atICC4 rep<nr, mai �, i,
t i y Lsszral, dwaUtirn, or ca-s= of an aiE f-n to any P:e- aastag a' bald-
+:r C IIIIg a least a'Y?'but not I I d-M fax daell7rg Urjz ._xr tD stx rims �nd1 aie'a3�ac�s� tD
r�d°sz�e or bAl�rg" be d❑ne by rEV—<.ed onus, wLth Main as, altrg with otl7ec
£ J 7t�cl
T1 10
+Pe of Work: o: Est:. as '
1�1 6c�
Yr k Address `of Wo, ��` GLU U (�
Owner Name: ,�
t7ate of Permit Application:
hereby certify that: y
Registration is not required for the f 0 Llowing. reason(s) Far office Cbe call, "
Pb
• �
Work eRmitxcluded by law '
Job under $1,000 D3ie
Building not owner-occupied
7 ` Al
IL owner. pulling awn
Other .(specify)
aa
.Notice'. is hereby given that:
OWNERSPUII.Il3G 04''N PM-Or OR DFAU% To= IIIatEGIS'TIIZID CXk1ZRAC1t� _ 4
FOR APPLICABLE.HCw,, WORK DO NOT HAVE ACCESS TO Ta ARBrIItA-
TION PROGRAM OR GUARANTY FUND UNDER ISI. c. 142A_
A:.
`r r Si e3 U-e-- pa-alt:Less of per �-
p . } Y PP Y pe agen t of the owner:
1.
hereb a 1 for a' rmi t as the
Date Contractor dame Registration No.
' OR
' I apply the for a permitas
Notwithstandinthe above notice ,
owner of the above property :
, Date er Name ,
.II ;
o - _ over
Town
o rn
No. 2. 6 a
_ dower, Mass.,
O S LAKE iy;1�
'9A_C0
CH'"" K
H'" WK
0 r. V
'9S Aq T E p
BOARD OF HEALTH
Food/Kitchen
PERMIT T
Septic System
BUILDING INSPECTOR
/,, . l
THIS CERTIFIES THAT X .`:.................. ����/�1ll.Y............................................................... Foundation
..................................... ...
has permission to erect,...' .... buildings on ......1.`7.2.............. .. .. .........j�-v. .:... Rough
..................................................
Chimney
to be occupied as.....................................................xef• ey
provided that the person accepting this pbrmit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST S Rough
................................. . ... ... . .. .....................................................
Service
UILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Location � 93 AS:St t )-$-
No. a C7 Date a a
NORTIy TOWN OF NORTH ANDOVER
3? � _ • OL
Certificate of Occupancy $
cMus
CHUS ' Building/Frame Permit Fee $ So�
1w4
Foundation Permit Fee $
Y
Other Permit Fee $
TOTAL $
Check #
q 5 L i I/ building Inspector
't U /
3 f
TOWN OF NORTH ANDOVER
"BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE ORTWO FAMILY DWELLING :
BUILDING PERMIT NUMBER: ,�j DATE ISSUED: /
SIGNATURE: ,
Building Commissionerfinfpectoi of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1:2 Assessors Map and Parcel Number.
Map Number Parcel Numbce -
1.3 Zoning Information: 1.4 .Property-Dimaisions-
Zonin:..District Proposed.Use Lot Area Fronto _ ft
1.6 BUILDING SETBACKS ft
Front Yard -Side Yard 'Rear-Yard
Required Provide , . Provided R Provided
1.7 water Supply MGI-C.40. 54) t.s: Food Zoue Infoiroitioa 1.s". Se v—p Disposal SnKem:
public ❑ private ❑ Zone Outside-Nood.Zone ❑ M—iapal D. On�site_Dispos.system ❑
SECTION 2-.PROPERTY OWNERSHIIatAUTHORIZEDACENT
2:1 Owaer of Record
/ /X3.3 OX>-5 ilz �o47 �� t/o<
Name(Print) Address for Service:
Si tore 70 Telephone
2.2 Owner of Record: .
Name Print Address for Service:
Si ature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 'Licensed Construction Supervisor. Not Applicable . ❑
Licensed Construction Supervisor.
License Number
Address; -
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
j I SECTION 4-WORKERS CON PENSATION.(M.G.L.C 152 § 25c(6) `
Workers Compensation Insurance affidavit must be completed and.submitted with this application. Failure to provide this affidavit will result
j in the denial of the issuance of the building permit.
I
Signed affidavit Attached Yes.......0 . No.......0
SECTION 5 Description of Proposed Work check all applicable).
i New Construction 0 Existing Building. ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
i '
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
IBrief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be
Completed by t a lieant
1. Building (a) Building Permit Fee
gQpO,00 Multiplier
2 Electrical (b) 'Estimated.Total Cost of
Construction
3 Plumbing Building Permit fee(a)x(b)
4 ,Mechanical AC i—�
5 Fire Protection
6. Totals. 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the.statements and information on the foregoing application are true and accurate,to the best of my knowledge.
and belief '
Print Name
Si ature of Owner/ ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
No RD
SIZE OF FLOOR TIIvMERS ]sr 2 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
.': Town of North Andover ;.•,
Building Department
27 Charles Street , z
North Andover, MA. 01845
D. Robert Nicetta
Building Commissioner
(978) 688-9545
.', 978 688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print
�y
DATE
JOB LOCATION 7-3
Number Street Address Map/lot
HOMEOWNER � Ak) -- Y,94Name Home Phone Work Phone
PRESENT MAILING ADDRESS /y3 bti►r4 s S U
�uio vzCity Town Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings
of two units or less and to allow such homeowners to engage an individual fot hire who does.
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Persons)who owns a parcel of land on which helshe resides or intends to reside,on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be'considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned"homeowner'certifies that helshe understands the Town of No.Andover
Building Department minimum inspection procedures and requirements and that helshe will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
7Z
APPROVAL OF BUILDING OFFICIAL
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid.waste disposal facility as defined by MGL
c11, S150A.
The debris will be disposed of in:
L 11S oS/f Z- Ut ST
(Location of Facility)
Sig ture.o Permit Applicant
o�
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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aooa
-i= L over, Mass.,
COCMICMEWICK V
%d ADRATED P5
S H BOARD OF HEALTH
PE.
Food/Kitchen
Septic System..RM, IT T D
- w
I.. " I..t.... f /V......
BUILDING INSPECTOR
THIS CERTIFIES THAT........ .. .............a ............. .Q..Q.N..a ...................................:......................
Foundation
has permission to erect....F0.h......... buildings on / .J 4A Av.� Rough
C r m� .* ��* Chimney
to be occupied as /r! a Z �l.../I!1....................... ........................... y
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 In ion, Alteration and Construction of
Buildings in the Town of North Andover. / &VENOM PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTION STAR ELECTRICAL INSPECTOR
C Rough
........... �/ ...... Servize
BUILDING INSPECTOR
Final
Occupancy Permit Required t0 Occupy Buffing GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
• Street No.
s
SEE REVERSE SIDE Smoke Det.
!a �,�
Date... ...........................
e of`NCRTH'��O TOWN OF NORTH ANDOVER
- A PERMIT FOR WIRING
41
SACNUSEt
This certifies that ....,/ ....... .. .
....................................................
has permission to per .......
{L�.+ ...4a� .........r..................................
wiring in the building of........ ....................
fat...� � � . ...
..............................JNorth Andover,Mass.
Fee..P7=.... Lic.No 4W.FAI.............. . .. .. . .... ..........
Q ELECTRICAL INSPECTOR
Check #
64 `. 5
Commonwealth of Massachusetts
f2X Permit No.
Department of Fire Services
OCCLlpancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 905] jjell�el*lllk)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All .%oi-k to he iwi-tnnlied in accordance with the\L1-';Si1ClIL1SCtt1,FICCII-ic,11 C'OdC 527(AIR 121.00
(PLE,ISE PRIIN T LN JAW OR TYPE,IL LYFORH ITION) Date: 3-10 -06
City or Town of: — 1?9911ff AM TO 117C 0/ 4'71TS..
By (his i1pplilatioll the undersigned gives notice ot'llis or her intention toperform the clecti-ical work described below.
Location (Street& Number)- Ale,
Owner or Tenant D!zk4..,, 00V Telephone No.
Owner's Address 1113
Is this permit in conjunri ion with'th a building permit? Yes RRr No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Anips —Volts Overhead F1 Un(IgrdE:] No. (of Meters
New Service Amps volts. Overhead ❑ Undgrd F] No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: el 4-r-
Complelioll a/111c.fiXott ilig table nual he it an Cd by the 111spet.10P ol It"W.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle) Fans No.of Total
I Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
❑ No.ot'Emergency Lighting
No.of Luminaires Swimming Pool Above ❑ In-
rnd. grad. Battcr 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 I No.of Alerting Devices
Tons
"eat Pump Number I Tons I KW—!No.of Self-Contained
No. of Waste Disposers Totals: . I .I I I Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KWLocal 01vilunicipal - El Other
,
Connection
No. of Dryers "eating Appliances KW Security Systems:*
No.of Water No.of Noof No.of Devices or Equivalent
KW I . Data Wiring:
"eaters Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No. of Motors Total lip telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Estimated Value of Electrical Work: (�Nlien required bymunicipal polic
1k ork to Start: Inspections to bc requested in accordance with MEC Rule 10, and LIP011 C01111PICtiOn.
INSLRANCE COVERAGE: Uiluss waived by the owner. 110 permit for the performance of electrical work may i.SSLIC 1.1111CS.'
flit: licensee provides Proof orliability insurance including"completed operation"coveras.,e or itS.AlbSt'llitial cqtliyalcflt. 1 If,,:
Cel-tirICS that such Cif) farce, :111d hasU•dlihited III-oof of :aIne to the Permit of rice.
I. IIECKONE: INS(.'RANCI-"' 1)
I C*t'1-1q.j,, wider 1he gwins I ld p nolf S J)1'j;erj*u;1;);,3,fal lite hifin-nuidon Jul this"llpficalion 1'1 11we ev'(1 vo.'I'plefe.
FIRM NAME: 15 ,A'Jj Vi�' LIC. il,o.ZAV-7
Licensee: rc atul
rp V44 i vt 5 I'MI, ' 4 ..AC. .�qO.:
�ille.' I
'ills
Address: Tel. No Wzf
T e 1. N o
"Security System -ontr,-'L�tor I iLqLiicd for this apIicble,enter the license num i
OWNER'S INSURANCE 'AAIVER: l ;.fill aw:il'C that the L iCCll,',eC d0f.�',nal have the liability iI ISL1111I ICC I'.J c 11C 1,1711111
iquired by law. By nly:,ignatUrc below, I hereby waive this requirement. I ;fill the(check one)❑ owner s lgicnt.
Owner/Agent
":"ignjture No. P1FR,V11T FFF. i
Date-3).
O'<".� TOWN OF NORTH ANDOVER
10 6mma-1,90L
PERMIT FOR PLUMBING
,SSACHUSE�
This certifies that .11�. . . . . . . . . . . . . . .
has permission to perform . . . . . . !. .S . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . ."}. . . -. . " .r.r'�.�`^.I .. . . . .
at . . . . el�?. . . . . . . . .. North Andover, Mass.
Fee. . Lic. No.. . . LL,�. . . . �:�-�-..... . . . ,
PLI�MBING INSPECTOR
Check #
6878
i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS Date
Z4
Building Building Location 613 ZVX 17W Owners Name �/�°� ��/�/�� Permit#
Amount a
Type of Oceupanc�" y
New Renovation Replacement 0 Plans Submitted Yes No ❑
FIXTURES
irr
cn w a o CC
a
o w w w z a
z �' z a a o
w 3 A Cn
" 04
A A x w
Q Q
z o x
3 a ca A H A a -<
SL13-1M
a�snv>avr
Ll I
mHAOM
MWM
41H HAOM
sHiHJXR
6M HDOM
MHAOM
(Print or type) , Check one: Certificate
Installing Company Name 17 fJ G� !n ❑ Corp.
Address �5- ,e Partner.
Business Telep one Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the pe of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent El
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performeq under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachus s ate Plumbi Code nd C 1420 the General Laws.
By: igna ure o icense um er
Title Typeeoo��Plumbing License
City/Town i_c1en�se u'm eT�rMaster ❑ Journeyman ,
APPROVED(OFFICE USE ONLY
Z�D6
`. Date..................................
f 14 RTof
f°.';�``°-.' TOWN OF NORTH ANDOVER
o
PERMIT FOR WIRING
2 C64USE�
This certifies that ...............P / LEST
... ........... . ... ..... .........................
has permission to perform .........../..Q Sw�G�
................. ..................................
wiring in the building of.................... .. �
....................................................
at �!
� ........L...b��.��SS....... . ....................... .North Andover,Mass.
Fee..6. ........ Lic.No.J..4.1'W........... ......... ..
LECTRICALINSPECTOR �'�%�
Check #
Commonwealth of Massachusetts Official Use only
Permit No. C4 w
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: /(164rrt 14.4Aez 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) A4W A,6- W'-' 9 2.`g
Owner or Tenant vfl.9 w elAg) Telephone No.
Owner's Address 16!Y A4 *,61
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building`` Utility Authorization No.
Existing Service &/0 Amps /2F) / 2qJ Volts Overhead 2--- Undgrd ❑ No. of Meters
New Service /'0-0 Amps /7p / ZVI) Volts Overhead u Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: P644/ s"�l�� —
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 Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
J Above In- o.o Emergency Lighting
No. of Luminaires Swimming Pool rnd. rnd. Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS TNo.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: I 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.o No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 27-t,(— Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such Covera s in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains an enalties of perjuty,that the information on tl ' pp1. t/on ' lrue and complete.
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FIRM NAME: 6Z�> �?E�i ��'9{ LIC. NO.: 3
Licensee: XXV/jam Sig:;;;;
LIC. NO.:
(If applicable, enter "exempt"in the license number line.) Bus.Tel. No.: a,>- 626 Z
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Address: i Alt.Tel. No.:
*Security System Contractor License required for this work; if applicable,enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
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