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HomeMy WebLinkAboutMiscellaneous - 1478 GREAT POND ROAD 4/30/2018 1478 GREAT POND ROAD 210/062_ 0000.0 10 2 6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING SA US This certifies that .... ... loo -Z 0/1-pe ..... ...... ...........................d.... ............................. has permission to perform ......... wiring in the building of... ........................................... at............ llf..b I ... . North Andover,Mass. Fee.90r 7...... Lic.No. ... 1z .................................................... ELECTRICAL INSPECTOR Check # -4pol— ®epart lth ®fMaSsac • BpARD pF F I�7ent Off`Firms �vsetts APpLICATI ARE PREVENTION R eri,��es Pertnitivo Cfficia]Use Only �PLE�SEP All Work t�� F®R EGV CATIONS Occu RT1►r•� �p razed• ���Api1 T' T® (Rev, 1/07]Y�d Fee Checked r By this City or 71 R TV, �a�Ordance with the P���®� (leave b]�k aPPlicatio �'� O#. �L FQ m (,huse �iil ��v��y Locate®n(Street&fie undersign d® fig AIV ?IOj� tts Electrical '6i RI��g Code(A4—PC) Owner or Tenant Number) s IIOhce�OfhiS r int date: ,sz7 clI 12�o WOR is Address Grp entioII to erfo the lnsPectot Is this permit the electric °flip, Purpose of rn conjunction wit Work described be uddin h ab log,. New Service g �c, �ngpermit? Yes Telephone No N Service Amps• / No Location fiber of Feeder Amps olis Ove Utility A r (Check APPro d. rhend r2ation Priate Bo and Na `�pacity�IVolts � No. x) r c titre Of prop sed Overlie Undgrd Q ° Electrical Wo ad Undgrd N°•of Meters / rk No.of Recessed L C` 'l�C No•of Meters No.of L urraires / / NG o fL ununaare Otrtlets N°'°f�e -Sus cum lehOn ofthe 1 tuuDin a'• to nes No. P'Fuddle "rn tableOF N°.°f ReceptacleOtr S of$otTubs )Fans $ �bewaivedbYthelny e No.°f (lets mug pO A nsforfners ctOr o moire Switches °I b0ve Ge Total s. No. No.of 0,U d, Q �- nerIIt°rjv of Ra Burtr ,, ad, Q o, o ages No. e s A No. Of Gas Baer U Me °f Waste Dis Burners nits g No. Posers No. of Au r - Me °f Dis Beat COI To NO' °fDete 1lTQ•Ofzo. 1 1 'ashers r'uim tal ctio s NO•ofD Totals Number Tons �itiatili D and rYers �._. No. evic No.of SPace/A, _... Tons o fAle� es FaterCal Bead, _.. No.of Self- gD1 1 1 Is . Renters $eatin Deteetio�Ale nta. No.$Ydro KW N°. 'ApP�nces Loc - e ' OTg : massage Bat".. Si s No. X S oral Coil - on vices ! No. °f 1Vo e'llY SYste : otter °f Motors Ballasts. of Devices Estimated Valu Total 4p DaN0'wing: or trivalent >r'SrkUnANrt e ofEle�cal Wo Teleco °fDevices or rk -� �0�� No.oa�umcations E trivalent fD Wir the licensee E CORAG rnSPectio `94ch additional evices°r E tri a e undersi Provides E' trnles to be re When re detarlifdesire nt f b'ned ce Pr°of of ' S waive quest gutted b d, CKECg 01� rtifes that such cobrliiyce Y the ok'xrer ed in accordanceY nitnicipal pol�c as re9uiredbv rhe I cerd ITIS ve mclu no pe With Y) j"'Pector f',under th U AN, e is tri force drag `ion art for d1e MEC Rule I O of IYres F N ares and Bpm 'and has a Pleted oPeratiopeorance of elee and uPon °pnPletio Licensee, ♦ Pen¢Itiesof OTr�R . xhibitedProofo fsn coverage or kcal Work n. (7faPPlica ♦ � !u that the 0 .(Spec• ane to the its substantial mar issue he Address:b1e enY "ex rnpr"in tom' a r tnfornon on flits Permit issuing off7ce equivalent reO eWNER ?_6 a license numbeY Signat►u.e 4Pplic¢dorr is tree ana'co i m 0 gutted bYlaW, B �'CEI�,ecurity work r Lie NOPIet� Siaf/Agent Y mY Signature ,�amneau, es Dau�tnent° LtC;NO., ure below hereby that Lice "Public Sa fe ��, Bus. TeL �Z Y Waiv nsee tY S N . W,,,, this r does not h LrcenSe: Alt. Tel.Na ' Tele equurement rand ave the llabili r ic.No , 6 the(check one rnStu'ance cove O� - -- ----- ) Owner age normall - - - -------------------- pElITF �owner'sagenz ELECTRICAL PERART NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH IN CTION: Passed—[ Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date Z.FINAL INSPECTION: Passed Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'co' meats: (Inspectors'Signature-no initials) F Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ) Re-inspection required($50.00) Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—( ] Failed—[ j Re-inspection required($50.00) Inspectors' comments: Ea (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED Is NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Co '"Onw DePartme e4' th OfM Off Ce Of Of-611 4`I 4,C hdetts V�oeps CJd 640 W"shl e�blatiosrs is A ant lb fCOm�eusatio Bost°n, OZStreet or�tatio� III �$e Business/ j�su�'a�aee Af d mQ. &OVIdi C'ganizailo Address. C rV7ndividu d). tPaCt° a's/�lectrpeian�/ r Cly'/Sta.te/Z1p. G Zg Pleasel'ria hers Are you an a dbl 1 I einAloyer. C �0 OG P 2J!jploye�Ployer With heck the apProAriate b hone#: am a sole (�A and/or�� 4 ox: 6' I s�P and Proprietor opt fie)•* O I am a gen 3 67�6 workin have no em to Panner- have hire eral°pn�acto �No wo is me in aoy aegis listed on ed the sub-contracand I T�e°f ArOJect require °pntp,ins PaQItP These sub; attached s ors 6. (require i 3.13 I am a o, urance 5 workers' attached h eet 1 I Q Neta,construction d). mYself,doep"er doing We are a c 0inP•insuranc ave 8 C1 Rexuodeh g ins workers, an work °�cers °iporation e• QDeuioltiio ur�ce required.]t co�P' Light ofe awe exercised d tts 9' �B n t z,`-rp?irt f. c. xe� their iridin 1 S2 Poon 10, g additi Romeo �.� �__ �I(4 Per MG OElec °n #Co u° ah �who s hox g, entI,Splo ) and�„ L ttical r II�act°rsthatch�k shisa���ir�T out to comP.iuss C'tTo�Vorked�euo 11'OPlumb- epaits°raddition cdoZ f�m rployer an the Sop ovr attached h�an d�oa fiol g word�a �u a�p ed'] 13 °p`rep sePazrs°r addition durance Com rdruK"Porkers,cDm showing the awe hire onhac�y� otic, der Poltcy#or selth f Pavy awe pe°sa x r°suraaceforo6 oon ctors_,and st SlI Mr� 'on affi�vi . Jo f LrC.#, mY emPlo.Yee kers+comp polcmdicatiug such Job Site Ad s Aelolp • Y Wor'M r+ A� dress: �thePolicy� j ach a copy of djob site Failure to the workers,co E fine up to$1 secure coverage as ntpensation xPrrafion.Date: of uP to ­50000 an required POhcY declar Inve $250.00 a mor one- under S ati Ci strgations of day,against Year nnPriso ection 25A of" °n page(sho tY/State/Zip. Ido hereb fife DIA for'nsur'an°eator. Bead well as c• 152 can Ing the poli nuntbe coverage Peri6c aat a copy oVjj f nalties in the ead-Lae uuposition o r�nd expiration d f y �' nil the J Si afore: irs Q aOn• s stateme r�of a ST f criminal ate) Phti one#, Peutz s°fPerjuyy th"tthe ut rnaY be fob,ded th OCR. R and es a f a rnforrn" of-ace of fine �.lficia[use only Don ,��' tionProvrdedabove rs of H,rrte Date: �G' nue and cor ISS City or To" in this are",to be rect: eo � �/. 6mug Authority mPleted by ci 0 oard of$calf (circle ne); tY or to n fr tber h 2 ° t" °f`czal Con Budding DePar(nzen Periait2iceuse tact Person; t 3'Cit3'/T'otyn Clerk # 4 'r -- - Electrical Inspector ------ Phone#. gybing Inspector -------- i Commonwealth of Afassachusetts Official Use Only g Department of Fire Services Permit No. /o j Z BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ii [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Cod(ME527 CMR 12.00 ry®Rn (PLEASE PRINTTZIVINK OR TYPE ALL INFORMATIO City or Town of: NORTH A:NDOVER � Date: III By this application the undersi ed To.the Inspector of Wires; gn gives notice of his or her intention to erfo the electric work described below. Location(Street&Number) Owner or Tenant Owner's Address Telephone No Is this permit in conjunction with a building permit,! Yes ' Purpose of Building / No ❑ (Check Appropriate Box) Utility Authorization No. _ Existing Service_2wAmps_ � o is �� Overhead LTJ Undgrd❑ No-of Meters New Service Amps _Volts Overhead❑ UndgrdNo,of Meters Number of Feeders and.Ampacity El Location and Nature of Proposed Electrical Work: j d , / Com lesion of the f llowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus No.of p.(Paddle)Fans Tota! No.of Luminaire Outlets Transformers KVA No.of Hot Tubs d• Grneratars KVA,. No.of Luminail es Swimming Pool Above El0.o.o mergency Ig No.of Receptacle Outlets No.of Oil Burners nd• ❑ Battle Units g No.of Switches FIRE ALARMS No.of Zones No. of Gas Burners No.of Detection and No.of Ranges Initiatin Devices otal No.of Air Cond. No.of Alerting Devices No.of Waste Disposers .Heat Pump Number Tons ns Totals: �_�"._....�'..........._.-. _..._...... KW........ No.of Self Contained No,of Dishwashers Deteetion/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers Heatin Appliances Connection ❑ Outer Heating pp , Security Systems:* No.of Water No.of No.of Devices or E uivalent Heaters KW No.of Data Wirin • Si s - Ballasts. g: No.Hydromassage Bathtubs No.of Devices or E uivalent No.of Motors Total Hp Telecommunications Wiring; OTHER: No,of Devices or E uivalent t Estimated Value of Electrical Work: ��f Attach additional detail if desired,or as required by the Inspector of Wires. 1 Work to Start: (When required by municipal policy.) i �L� �/ 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 lieensee_provides proof of liability insurance including`°completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND [] OTHER' I certify ❑ .(Specify:) . under th ains and penalties of erju that the information on this application is true and complete FIRM NAME: t tG? Licensee: / LIC.NO.: _Z 2 7 4-_ (Ifapplicable, ente �� 1�� Signature �r mpt"in Ile license number line. LIC.NO.: Z , _ Address: Y Bus.Tel.N .: *Per M.G.L c. 147,s.57-61,security work requires D Alt~Tel.No / OWNER'S INSURANCE W Department of Public Safety"S"License: Lic.No. D5 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/Agent ( ) ❑owner ❑owner's agent Signature Telephone No. PERMIT ELECCTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL I.ROUGH IN CTION: Passed—[ Failed—[ ] Re-inspection requirect($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) , Date 2.FINAL INSPECTION; Passed Failed—[ ] Re-inspection required($50.00) Inspectors'comments: Jr (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors' comments: (Inspectors'Signature-no initials) Date �'•INSPECTION—SERVICE: - DAT i CALLED NATIONAL GRlI): Nom: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ I Inspectors'comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: A Passed—[ ] Failed—[ j Re-inspection required($50.00)-[ ] Inspectors' comments: i (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO RE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigations ..600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): ZGr�/ Address: C U U A. � City/State/Zip:-/4(j U /1/1-64- 0(,706 Phone#:f24) 603- 6726' Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4_ Type of project(required, ❑ I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6' ❑New co:ct ion 2. I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remode ship and have no employees These sub_contractors have working for me in any capacity. workers'comp.insurance. 8. ❑Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required.] officers have exercised their 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no insurance required.] t employees- [No Niiorkers' 12.❑Roof repairs comp.insurance required.] 13.❑ Other ;Any applicant That checks box�1 must also tt out�e secfion below sho%i:ng;heir workers'compensation policy infozmation. 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 Belo informaw is the policy and job site tion. 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. • Ido hereby rkfy nd the p 'ns a penalti s o f perjury that the information provided above is true and correct. Si ature: ` Date: �G t1l 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#• Date..V /.�.1��.5. . . .... NORTH pf 3= O TOWN OF NORTH ANDOVER 9 • - PERMIT FOR GAS INSTALLATION i US This This certifies that . . . . . . .S ?.< U t. �/�c /�G9 . has permission for gas installation . .����. . / f. .`'. . . . . . . . . . . . in the buildings of . . . A C'. l?.��.� �. . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee. P. Lic. No..-24. g . . . . . 'GAS INSPECTOR Check# & ,- C 68 ,� J I 9071 Date. . �4, •� O TOWN OF NORTH ANDOVER 3r A °L p PERMIT FOR PLUMBING SACMUSE� t This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . .�.X k�r4-». . . . . . . . . . . . . . plumbing in the buildings of . . C� c�. . '�.r f!\.s . . . . . . . . . . . . . . . at . . . North Andover, Mass. PLUMBING INSPECTOR Check # d5 I rFF ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �I/��l i� y MA. Date: Permit# � Owners Name: Y^ : Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential on:❑ Renovation: � ❑ Replacement:9__ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED LU z SYSTEMS z z N C4 Ln � U Fes- W ❑ ❑ Q Ln Oy m f- _z z❑ < az z y < a_Q Ln In N l Q �Qw Y0 ❑ w LU _ QLL 06 cuv a ° m O ° ° O Q m o LLJ =0 x- ~FQw- -SUB BSMT. a 3 BASEMENT 1sT FLOOR 2ND FLOOR 3 3RD FLOOR 2,. 4T"FLOOR ST"FLOOR e FLOOR 7T"FLOOR 8T"FLOOR j� n Installing Col„piny Name: n L �/� -t�f�f lr LGL Cheep One O„Iy Csrtificate 3� Address: S—3� � / El Corporation City/Town: ! ( State: Business Te El Partn �`3(/_-ZGG5- Fax: Name of Licensed Plumber: �� �. irm/Company 7„ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142' If you have checked Yes,please indicat he type of coverage by checking the appropriate box below. es No❑ A liability insurance policy- Other type of ind YP emnity ❑ 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 mysignature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's Agent O>+ilneF ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and rr * r Knowledge and that all plumbing work and installations performed under the permit issued for this application will in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of enerai La a""r•an to the best o.my BY 4.� Type of License: Title El PIberSi ure ben Plum er -ity/Town04aster 4PPROVED(OFFICE USE ONLY) Journeyman Licen e Number: MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) I NO ANDOVER Mass. Date JUNE 19 2009 Permit# )/ 1478 GREAT POND RD GEORGE K. NORWOOD JR Building Location Owner's Name Owner Tel# 978-258-9086 Type of Occupancy RESIDENCE New FV7] Renovation❑ Replacement Plan Submitted: Yet No[:] FIXTURES x F U z W on CU w w O F x a b , KD a m E~ ¢ ¢ z z o z w of w w o a w ¢ w w ¢ x �. > z U) w cn w z ¢ x w a �a w OF A U x Z Q W J Q za' F" >4 Cl) M z O z �y O � x W 2 O = w 3 A C¢7 .¢i Ov a > Q a F O WE SUB-BSMT BASEMENT IST FLOOR X e 2"D FLOOR 3RD FLOOR 4T"FLOOR D 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter JOHN LIPINSKI INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yesl ✓ I No ❑ If you have"'cTiTTjcked yes,please indicate the type coverage by checking the appropriate box. A liability insurance policy F� 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in abo application a ue a cc to to the best of my knowledge and that all plumbing work and installations performed under the permit issu d f this appl' ion ompliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen al ws. By Type of License: • 'lumber Signata of i nsed PI er or Gas Fitter Title as fitter •-Master Licens mber 729 City/Town •-Journeyman APPROVED(OFFICE USE ONLY) 1Location No, � Date Siq ©�I a NORTH TOWN OF NORTH ANDOVER + ; . Certificate of Occupancy $ ,SSACMUS � Building/Frame Permit Fee $ —� Foundation Permit Fee $ • Other Permit Fee $ 1 TOTAL $ — i Check # a 3 17 3 u 0 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING or LsA BUILDING PERMIT NUMBER. DATE ISSUED. U� X SIGNATURE: ( 6 A )j Building Commissio ler/Inspector of Buildings Date Z SECTION 1-SITE INFORMATION • 0 1.1 Property Address: .1,2 Assessors Map and Parcel Number: 1'177 ,92 0"Onc p Yo V A, n /r �/A Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fromm e ft 1.6 BUIL DING SETBACKS ft Front Yard n Side Yard 621 Rear Yard 1110, Required Provide Required Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public d� Private ❑ Zone Outside Flood Zone g/ Municipal ❑ On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes—No c/ �I"111 2.1 Owner of Record Na ' t) Address for Service / 25S47UF7(> 4 Signature Telephone 2.2 Owner of Record: Name Prith Address for Service: O Z m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Superviisor:�— Not Applicable Licensed Construction Supervisor: O / License Number s� .� A/ 'a iz-C M Address a D 9 7-e-7 r ," / �y���7 Expiration Date ic Signature Telephone r - Qi- Y- Xe,?z��o2---3 � 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Company Name Registration Number r Address r Expiration Date ^� Signature Telephone YI 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......D/ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition Other �Y Specify Brief Description of Proposed Work: / 0� x /n' c��c !=vee SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed bV permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of c. Construction 3 Plumbing Building Permit fee(e)X (b) - 4 Mechanical HVAC 5 Fire Protection A 07 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZAT ON 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 C/ Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION F I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS i s 2 3 t SPAN DHAENSIONS OF SILLS DfMENSIONS OF POSTS DlIvENSIONS OF GIRDERS ALIGHT OF-FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 17 tACle M FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits frorr Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION APPLICANT C l I ' C�" 4 /'W/G✓UG PHONE ���ZSR J� LOCATION: Assessor's Map Number PARCEL SUBDIVISION / LOT(S) STREET �hS "f'`e �l7 ST. NUMBER. OFFICIAL USE RECO ENDATION OF TOWN AGENTS: CONSERVATION ADMINI ATOR DATE APPROVED U DATE REJECTED COMMENTS TO N PL4NER DATE APPROVED DATE REJECTED COMMENTS--, ,g FOOD INSPECTOR-HEALTH DATE APPROVED — DATE REJECTED f SEPTIC INSPECTOR-HEALTH DATE APPROVE. DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9W jm e , Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3)WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS /DECKS 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN.(MINIMUM) 4) DEBRI REMOVAL DORM 5) WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8)FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGL,E AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION 2) FORM U 3) GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with application. The Commonwealth of Massachusetts ` = Department of Industrial Accidents Office of Investigations Boston, Mass. 02 411 Workers'Compensation Insurance Affidavit Name Please Print Name: C,7• / &1_e v • JIZ- / Location: fY 7� �7reet roAL�' Citv / " 41 GPhone # 61-7 8- Z S 8 %0 Kl,:, 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 workers'compensation for rrry employees working on this job. Company name: \J oil'- E V Address �/ ,Pim ��/I-C City , �cc,� �� it ?� Phone#- /1" v / Insurance.Co. 'b - Poli, # ( Y,3 o/ Company name: /162, 4 'f , !4 S'ce V. Address City / Phone#: Insurance Co. [� ►^��bss' _ c c. fir_ Policy# e-0y:9 9,V 9 e,�.9 Y Failure to secure coverage as required:under Section 25A or MGL 152 cz�lead lathe imposition of c rkninal penalties of.a•fine up to$1.500.00 and/or one years'imprisomient_as_welLas.cbd Penaltiesjoshelorm-d a.STDPWOWDPJIER.and_af e-d-(s1no-jM-aAW--9ainst me I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cerblyyuunder the pains and penalties of perjury that the inhbrmation provided above is true and corrects Signature Date e13 d' Print name 7� dell/7/or r-_. P-tmne.# P— Official use only do not write in this area to be completed by city or town officiar City or Town PermM icensin - ❑ Building Dept ❑Check iiimmediate response is required .D Llcensinq Board ❑ Selectman's Ogee Contact person. Phone A � Health Department ❑ Other JP X POS a i� 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: Lt.C' l C- �'1'LL�r� CLQ (Location of Facility) Signature of Permit Applicant ov- Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector , ra , ' II hand arls c1�j0er' Oec� - f i C teo E ` G c I 1 �O ese- / IOG i U'1c S o, 4 � �g' r MORTGAGE E I PECTION PLAN NORTHERN ASSOCIATES, INC. 401 SOUTH BROADWAY, LAWRENCE MA. 01843-3522 TEL:(978) 837-3335 FAX:(978) 837-3336 MORTGAGOR: GEORGE K NORWOOD JR DEED REF: 3134/014G LOCATION: 1 478 GREAT POND ROAD PLAN REF: 8835 CITY,5TATE: N ANDOVER, MA SCALE: I "=60' DATE: 5/29/03 JOB #: 203.OG 1 85 130' sneo IG POOL O (D r7 CV ,2 STORY 1 NORTH Town of _ Andover 0 No. tL- �` Z __ LAKE dover, Mass., T Q COC MIC KE WICK � x.95 RATED 7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System T BUILDING INSPECTOR rwoe THISCERTIFIES THAT........ .........Nd..........................................R........................................................................... Foundation othas permission to erect.. .7..,� aa.•......... buildings on .......11.9t .....0.4.....76.^� ......�......... Rough Pt. .) �� Ct 0 N A rJr �' ��ti y •� Chimne to be occupied as................................................................................................... .............................�...Z., y provided that the person accepting this permit shall in every respect conform to the terms of theication on file in Final this office, and to the provisions of the Codes and By- ws relating t the Inspection, Alteration and Construction of Buildings in the Town of North Andover. (0 /&8 AS000000 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIONS LARTS ELECTRICAL INSPECTOR Rough � j ............................. .... ...........`::.:...............:.... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Z G (Print or Type) c � , Mass. Date V �coq Permit # 5 � 2 v Building Location net's Names/.! Type of,Gccu�pancy �i S+ "E ti 'I t1 New ❑ Renovation O Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES _ U) N 2 Y Q .. 1- Vf N N O Z > N W Y J W V < N W W Z O 2 a Q X a O _ Z ¢ l6 S Date.is -: •G x d W k Y W = W f O U 2 NORTH •'tic TOWN OF NORTH ANDOVER �+ .. OL PERMIT FOR PLUMBING ,SSACMUSE� This certifies that . . ., . . . . . . . . . . . . . . . . . . . has permission to perform . . . . .w . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . ,!'a 10.6 jt�'. ..... . . . . . . . . . . . . . . . at. . . �. `.�1 :. �./��'%?�.�a. r'. . . . . . . .. North Andover, Mass. Fee. v . Lic. No..9 ? . . . . . . . . ✓PLUMBING INSPECTOR Check # t -heck one: Certificate :�orporation 'artnership 5 L 2 0 ' /Co. -� Name of Licensed Plumber 2r�v� i'T r�rr SA� �Q rr j'-"C- INSURANCE COVERAGE: I have a current flability 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 coverage by checking the appropriate box. A liability insurance policy 21/ 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the oral taws. Title re of licensed Plum er Qty/Town Type of License: Master ,kurneymah ❑ APPW4ED 0 FIC US ONL License Number Iiz� BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED ` DATE 19 PLUMBING INSPECTOR