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Miscellaneous - 149 COACHMANS LANE 4/30/2018 (2)
149 COACHMAN'S LANE 210/064.0-0069-0000.0 1 ,1151 Date...47-2//A.p ,40" TOWN OF NORTH ANDOVER x 16. PERMIT FOR PLUMBING 41 This certifies that �a.....45; .1014.p................................................... has permission to perform.. ................................................................................................ plumbingin the buildings of............................................................................................. at... &..... .............................)North Andover, Mass. Feele,&A.....Lic. No.z?1.fA. .F, ...... a ......... PLUMBING INSPECTOR Check# Date....S./at .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION sSAC c HU This certifies that Mas' mission for ................................................... pe gas i.sta ation .... inthe buildings of........*.......................................................................................................... at/yf obem4 1A W. ..4................ h Andover,Mass. Fee..Oke-t?... Lic. No,? �........ -42IONS .............................. Check# 09978 p '` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT JOBSITE ADDRESS L phi.Ad V"A A„ CyOWNER'S NAME IBM /�s-1rn�l II GOWNER ADDRESS TE — FAx p�T OCCUPANCY TYPE COMMERCIAL[ EDUCATIONALRESIDENTIAL ® O CLEARLY NEW: RENOVATION:A3 REPLACEMENT: PLANS SUBMITTED: YES 0 NOQ 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 FURNACE GENERATOR GRILLE — INFRARED HEATER - LABORATORY COCKS ------ MAKEUP A MAKEUPAIR UNIT - OVEN POOL HEATER ROOM/SPACE HEATER T l ROOF TOP UNIT - TEST UNIT HEATER UNVENTED ROOM HEATER r WATER HEATER OYH—ER � I _ V INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 5 NO n— IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY 0 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 Eli 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 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 compii nce with al eminent provision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. �j PLUMBER-GASFITTER NAME LICENSE# f SIGNATURE MP El MGF ED JP QQ JGF LPGI Q CORPORATION Q# PARTNERSHIP®#�_�LLC®# COMPANY NAME: ADDRESS _ CITYJWJ STATE ZIP �^ TELd$g_ V FAX CELL d�jrly EMAIL p AA4 I OUGH GAS INSP +CT ON NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOXES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ II I I FEE: $ PERMIT# PLAN REVIEW NOTES i i 1 I 1 4 The Commonwealth ofMassachusetts r Department of lndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITI'. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address: City/State/Zip: A&t,, K Phone#:QTir-611 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. E]New construction 2.LKI am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�]Other 152,§1(4),and we have no,employees.[No workers'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 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. r 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: M a(6M44 4 d 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: .� _ Date: Phone#: 6&8'— N 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. 4 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."eveq state or local licensing agency shall withhold'the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cavy 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 - Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia �+ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 3j CITY _ MA DATE PERMIT# -1 l 1 I► ' JOBSITE ADDRESS OWNER'S NAME P f POWNER ADDRESS TEL � JIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL D! EDUCATIONAL © RESIDENTIAL D] PRINT CLEARLY NEW: Ell RENOVATION:® REPLACEMENT:D PLANS SUBMITTED: YES® 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/OIL/SAND SYSTEM ! , _. f _k _ _ __! _._ I __�f µ k DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I 1 .-.._._k DISHWASHER _k --._ � __.. _! J ____k ____ IL__ DRINKING FOUNTAIN FOOD DISPOSER ( .- _-! ___..._� .__. k __. _k l ._ I ._1 .__._._( .__- ! _._.-._k -_.J FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK i ,__.( LAVATORY l _�J ___.__-� ---_._1 ____k _.____i ____.. _ I ___.__t _.-� .--_.._1 k ! _ ► ROOF DRAIN __- SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION i k __.._ _ �._� _ .._.__-_k L_j WATER HEATER ALL TYPES WATER PIPING OTHER 1 _...._.111 .nmm_I _.._.._ ._....__-A I i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESM NO Ell IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY& OTHER TYPE OF INDEMNITY D BOND D 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 R AGENT 0 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 co liance wit II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME , IILICENSE# I w SIGNATURE MP DI JP& S CORPORATION 0# PARTNERSHIPD# t LLC COMPANY NAME ; ADDRESS I CITY STATE ZIP �`%}� II TEL FAX I CELL —' JEMAIL P - -- - .-_ ........ _ -- --- ...--- -------I R GH PLUMBING INSPE ION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION OTES Yes No �2 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department oflndustrialAccidents n r 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Auplicaut Information Please Print Leff-ibl Name(Business/Organization/Individual): 11dA lei I- k4 tM Address: ?i Q 30)c l-c City/State/Zip: a /i/i LAPhone#: q-7,1-xg Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am.a.employer with employees(full and/or part-time).* 7. ❑New construction 2. l I am a sole proprietor or partnership and have no employees working for me in �-- 8. �Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. t 9. El Demolition ❑ g y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions proprietors with no employees. 12. Plumbing 5. I am a general contractor and I have hired the ❑ g repairs or additions h sub-contractors listed on the a ❑ g, ttached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insivance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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#his 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 state whether or not those entities have employees. If the sub-contractors 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: Policy#or Self-ins. /Lie.#: Expiration Date: Job Site Address: /�qa 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert'y un r the pains and penalties of perjury that the information provided above is it a and correct. Si nature: Da te• 02 Phone#: f7k 65f A139" Official use only. Do not write in this area,to be completed by city or town officiar'. 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#: N 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 aor Mre, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial 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 they 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. permit/license number which will be used as a reference number. In addition an Please be sure to fill in the pernut/1 � 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date............................................ CF NOg7M,�O TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that 7- U .6A ...................................................................................................................... has pennission to perform .............................C.'r........ ........................... wiring in the building of (."j ................................................................................................. at ....Zel ..............Nort Andover,Mass. Fee... ...............Lic.No .1. ............................ ..................................................... ELECTRICAL INSPECTOR Check# 240. 4 Commonwealth of Massachusetts Official use Only Department of Fire Services Permit No. 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),5 7 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspe for of Wires: By this application the undersigned gives notice of his or her intention to per orm the electrical work described below. Location(Street&Number) Nct Co %gh Lr& ,-;� , Owner or Tenant 1(kiiq Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check App ropriaterBox) Purpose of Building_�le- Utility Authorization 1q,62 !6 - Existing Service-,1:X— Amps /20y) Volts Overhead❑ Undgrd No.of Meters New Service 2.2) Amps j2,L) Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. 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 Initiatiny Devices No.of Ranges No.of Air Cond. Total Tons No.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 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: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lectrical Work: �� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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 covegge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSUIRANCE BOND ❑ OTHER ❑ (Specify:) I certify,acnder the paced penalties o eriury,that t .gnformation on this application is true and complete. FIRM NAME: . —.l' �� QCi;/l�' LIC.NO.: Licensee: ;,1 -7,AJ Signature LIC.NO.: (If applicable ter "exyt t"ihe license nu r lin ) 4 Bus.Tel.No.--- Y L_ Address: 6 h "d - r Alt.Tel.No.: A pa *Per M.G.L c. 147,s.57-61,security fvork requires Department of Public Safety"S"License: Lic.No. �i`4�� 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 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 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass P Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPEC ON: Pass(N V Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com y The Commonwealth of:Massachusetts Department ofludifstriglAceidiiks Office of Investigations 600 Washington Street .Boston,MA 02111 www.mass gov1dia Workers,Compensation Insurance Affidavit:Builders/Cony°actorsWlectrxc3ians/Pliimbers Applieanti Information Please Print Legibly Name usiness/Or ani'zation&dividual: iu-bA2g F c� . Address: Jill C4,ciket2 in - City/Slate/Zip:NU( Un 444 j Phone#• Are u au employer?Checktbe appropriate box: Type of oject(required): 1. 1 am a ern Io er with 4, ❑I am a general contractor and I ` P y -fir have hired the sub-contractors 6, Now construction employees(full and/or part time). 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.* 7• Remodeling ship M&Iave,no employees These sub-contractors have 8. [(Demolition worldng for me,in any capacity. workers'comp.insurance. 9, r]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.[ Electrical repairs or additions required.] officers have exercised.their 3.E1 I am a homeowner doing all work right of exemption per MGL I L[[Plumbingrepairs or additions myself.[No workers'comp. c.152,§l(4),and wehave no 12.QRoofrepairs insurancere iredemployees.[No workers' � .]� 1311 other comp.insurance required.] xAny applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. I Homeowners who sabmit this affidavit indicating they 2•re doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that checkthis boar must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X 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 ills.Lic.#: oy1 d ExpirationDate: Job Site Address:, � ^J S 1AY,1;7f—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 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 may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. X do hereby cert uncle the ficins pe altles ofpeYjury that the infoPmadon pYOvlded abo a is tY a and correct - Signature: Ph one#: Official use only. Do not write in Mis area,to be completed by city or town official, City or Town, PermlMicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbinglnspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuar t to this statute,an employee is defined as"...every person k the service of another under any contract of hire,• express or implied,oral orwxittemll 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 employes." 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 fox any applicant who has not produeed.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 chapterhave beenpresentedto 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),addresses)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 au LL C or LLP does have employees,a policy is required. Do 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 Dep' artment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain.a*orkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate he. 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 thatmust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"lob 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 to 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 fillgd out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,o.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 co operation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Cox monwalth ofMpssachusP�� 7Duparkent ofT.dwWal Accident Q Face ofIl mst ptious• 6bG Washiug�om S e BQstw,. .02111 TQ1,#61M-27,4900 eA 406 or-x-877-MASS.F`.E Revised 5-26-05 FaX 617"727'7749 www.�ass,gov�c�`a . / 358 Date. !? J.�.... . ... NpR,M TOWN OF NORTH ANDOVER h 2 c Lp PERMIT FOR MECHANICAL INSTALLATION . � �9SSAcwUSEt This certifies that has permission for mechanical installation .HY11.5.1Z .. . . . . . . . . . . . . in the buildings of/ . . . . . . . . . . . . . . . . . . . . . . at . . . ,,,/North Andover, Mass. Fee.( . . . . Lic. No../r �/�.p. . . %� . . . . . . . . . . . . . . . . . . 1`- GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer TOWN OF NORTH ANDOVER 1600 OSGOOD STREET Building 20 Suite 2-36 NORTH ANDOVER MA 01845 FURNACES BOILERS ROOF TOP UNITS AIR CONDITIONERS EMERGENCY GENERAATORS Date: 6/1/15 The undersigned applies for a permit to install the following at: Location 149 Coachmans Lane Owner of premises Pat Grimm Address Name of mechanic Kevin GOrgoglione Address 9 Petersen Rd Brookline NH Building occupied for residential Material of building wood Kind of fuel Elec y NSA NoOf flNSA Chimne . flues Size_ Chimney Thickness NSA Lining NSA If steel stack location NSA Diameter NSA Height N/A DESCRIPTION OF HEATING APPARATUS Kind of heater how many make BTU Input Location in building Protected against fire as required How protected See the State Code(Pertaining to Chimneys, Smokestacks and Heating Apparatus) ROOF TOP UNITS OR EMERGENCY GENERATORS r Make Weight Dimension Length Width Height Location of building how supported Size of roof timbers Material of roof timbers Span of roof timbers Distance on center Protected against fire as required How protected AIR CONDITIONS Kind of apparatus Split System AC make Rheem HVAC FORM REVISED 11.04 ' COMMONWEALTH OF MASSACHUSETTS oCOMMONWEALTH OF MASSACHUSETTS BOARD BOARD OF SHEET METAL WORKERS ( SHEET METAL WORKERS I SSUU..THE FOLLOWING L I CENSE w I SSUES, .THE FOLLOWING LICENSE w AS A: BUSANISS. A,S .A MASTER UNR;E<STR I CTED F Z K:EVfN J GORGOGIIONE ' , a KEVIN J GORGOGLI.ONE �. ABSOLUTE MEC:HAN I CAL SYSTEMS LLC 2 QUIMBY RD ABSOLUTE: MECHANICA`L LLC PO BOX 128 J PO :BOX 128 BROOKLINE NH 03033 0128 BROOKL'INE NH 03033-0128 X04 0�/:25/17<: 399768 1886 ' ``09/28/15 92��;2 YI I 170 3 M 1L-13Li 11% Commonwealth of Massachusetts a • ( H Department of Public Safety License: BU-030733 = y,l• - I ��' . t KEVIN J GORGOGLIONE H g,:._68 i 9GE�C59091 ' +W 190 PO BOX 128 , r1 , BROOKLINE NH 03033'.] - �� � " 3.DOB: 09/09/1959 ���Eye: BR ys �9.Hair:BROt` 4b.Exp: 09/09/2018 1b.Sex: M NE Expiration: Commissioner 09/09/2016 _buN&Nkl„Q0�28; ,•w„ ,�.„ ,. AC<>RJD0 CERTIFICATE °���^ ► OF LIABILITY INSURANCE 07/112014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE SES 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 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,tate policy(ies)must be endorsed if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not coater rights to the certificate holder in lieu of such endorsements. PRODUCER FEDERATED MUTUAL INSURANCE COMPANY NOME:CT CLIENT CQNTACT CENTS HOME OFFICE:P.O.BOX 328 PHONE A!c No Ent:888-333-4949 FA/ No:507-44F�4664 OWATONNA,MN 55060 E-MAIL ADOREss:CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A.FEDERATED MUTUAL INSURANCE COMPANY 13935 ABSOLUTE MECHANICAL SYSTEMS INC 369-774-5 INSURER B: 2 QUIMBY RD INSURER C: BROOKLINE,NH 03033 INSURER D: INSURER E: [;SURER F: COVERAGES CERTIFICATE NUMBER:21 REVISION NUMBER:0 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 TYPE OF INSURANCE OL SUBR POLICY EFF POLICY EXP INSR WVD POLICY NUMBER NMIDDlYYYY NMR]D LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE SO RENTED $100,000 -EREE (Ea Occurrence) CLAIMS-MADE FX OCCUR MED EXP(Any one person) EXCLUDED A N N 9867072 07/11/2014 07/11/2015 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENPOLICY PRO'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $2,000,000 X JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO We accideral ALL OWNED SCHEDULED BODILY INJURY(Per person) A AUTOSAures N N 9867072 07/11/2014 07/11/2015 BODILY INJURY(Per acddenl) HIRED AUTOS RON-OWNED AUTOS PROPERTY DAMAGE r c X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $2,000,000 A EXCESS LIAR CLAMS-MADE N N 9867074 07/11/2014 07/11/2015 AGGREGATE $2,000,00d DED RETENTION WORKERS COMPENSATION Y/C STATIM OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE " CL EACH ACCIDENT $1,000,000 A OFFICERIMEMBER EXCLUDED? "NIA A N 9867075 07/11/2014 07/112015 (MarMatorr in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under $1,000,000 DESCRIPTIOH OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION 369-774-5 210 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845-1048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010!05) The ACORD name and logo are registered marks of ACORD ABSOLUTE Propcsad Mechanical Systems PO Box 128 Date 1/26/20.15 Brookline,NH 03033 Ph 603-249-9800 FAX 603-613-6979 Proposal# 15-117 www.absolutemechanical.COm Customer Phone 978-686-7056 Customer Fax Pat Grimm 149 Coachmans Lane Absolute P.O.No. 15-117 N Andover.Ma.01845 Job AC We Propose to furnish all material and labor to install the following Ga) 149 Coachmans Lane N Andover,Ma.01845 7,900.00 Central Air Conditioning A Rheem 2-ton,R410a,Condensing Unit m#13AJM24 B_Rheem 2-.ton,R410a,Air Handler m#RHSLMH2417AA C_Insulated supply&return ducts D_All necessary registers and grilles. E Digital Programmable Thermostat F_A/C piping G Recycled plastic condenser pad. H_Start-up and adjustments Does not include cost for electrician Ductblast test$400 Advanced Building Performance Solutions 1-Year Parts&Labor Warranty,5 yT compressor warranty Total Installation Labor & Materials Excluding Options $7,900.00 Signature shows acceptance of this Proposal and all terms and conditions set therein. ***NOTE:this Proposal may be withdrawn by us if not accepted within 30 days. All material is guaranteed as specified by the manufacturer.Work to be perforated is done in a timely manner and complies with State Regulations. Any alteration or deviation from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the Proposal.All agreements contingent upon strikes,accidents,or delays beyond our control. Customer Acceptance of Proposal:Signature _` TT Date < The Commonwealth of Massachusetts L Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Absolute Mechanical Systems,Inc Address:2 Quimby Road PO Box 128 City/State/Zip:Brookline, NH 03033 Phone#:603-249-9800 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 7 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 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. employees and have workers' + 9. ® Building addition [No workers'comp. insurance comp.insurance.+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Rqof repairs insurance required.]f c. 152, §1(4),and we have no 13. er Aid A�c employees. [No workers' comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f 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 state whether or not those entities have employees. If the sub-contractors 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:Federated Mutual Insurance Company Policy#or Self-ins.Lic.#:9867075 Expiration Date:7/11/2015 Job Site Address:All locations in 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 hereb cern under the pains and penafties ofperjury that theinformation provided above is true and correct Si ature: Date Phone#:603-249-9800 Official use only. Do not write in this area,to be completed by city or town o,f, wiaL 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#: Project Summa Job: 1 Date: June 1,2015 Entire House By: Kevin Gorgoglione Absolute Mechanical Systems Inc. 2 Quimby Rd.,Brookline,NH 03033 Phone:603-249-9800 Fax:978-423-7122 CELL Email:kevin@absolutemechanical.com roject h,Tormation For: Pat Grimm 149 Coachmans Lane, No.Andover, Ma 01845 Phone:978-686-7056 Notes: ® - e e o Weather: Lawrence Muni, MA, US Winter Design Conditions Summer Design Conditions Outside db 9 OF Outside db 88 OF Inside db 70 OF Inside db 75 OF Design TD 61 OF Design TD 13 OF Daily range M Relative humidity 50 % Moisture difference 31 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 22244 Btuh Structure 13044 Btuh Ducts 832 Btuh Ducts 299 Btuh Central vent(47 cfm) 930 Btuh Central vent(47 cfm) 196 Btuh Humidification 3861 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 27867 Btuh Use.manufacturer's data y Rate/swing multiplier 1.00 Infiltration Equipment sensible load 13539 Btuh Method Simplified Latent Cooling Equipment Load Sizing. Construction quality Semi-tight Fireplaces 0 Structure 1276 Btuh Ducts 598 Btuh Heating Cooling Central vent(47 cfm) 985 Btuh Area ffl 1056 1056 Equipment latent load 2859 Btuh Volume(ftp 8448 8448 Air changes/hour 0.31 0.16 Equipment total load 16398 Btuh Equiv..AVF(cfm) 44 23 Req.total capacity at 0.70 SHR 1.6 ton Heating Equipment Summary Cooling Equipment Summary Make n/a Make Rheem Trade n/a Trade RHEEM Model n/a Cond RA1324AJ1 AHRI ref n/a Coil RH1P2417STAN AHRI ref 7507835 Efficiency n/a Efficiency 11.5 EER, 13 SEER Heating input 0 Btuh Sensible cooling 16520 Btuh Heating output 0 Btuh Latent cooling 7080 Btuh Temperature rise 0 OF Total cooling 23600 Btuh Actual air flow 0 cfm Actual air flow 800 cfm Air flow factor 0 cfm/Btuh Air flow factor 0.060 cfm/Btuh Static pressure 0.50 in H2O Static pressure 0.50 in H2O Space thermostat Load sensible heat ratio 0.83 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. J. 2015-Jun-01 13:44:10 W oghtsC1ftt Right-Suite®Universal 2015 15.0.17 RSU09260 Page 1 ...\Absolute Mechan\149 Coachmans Ln\Pat.Grimm.rup Calc=MJ8 Front Door faces: N Building Analysis Date: June,,2o,s Entire House By: Kevin Gorgoglione Absolute Mechanical Systems Inc. 2 Quimby Rd.,Brookline,NH 03033 Phone:603-249-9800 Fax:978-423-7122 CELL Email:kevin@absolutemechanical.com • • 0 For: Pat Grimm 149 Coachmans Lane, No.Andover, Ma 01845 Phone:978-686-7056 • - • • • ons Location: Indoor: Heating Cooling Lawrence Muni, MA, US Indoor temperature(°F) 70 75 Elevation: 151 ft Design TD(°F) 61 13 Latitude: 430N Relative humidity(%) 50 50 Outdoor: Heating Cooling Moisture difference(gr/ib) 47.9 31.2 Dry bulb(°F) 9 88 Infiltration: Dailyrange(°F) - 18 ( M ) Method Simplified Wetbulb(°F) - 73 Construction quality Semi-tight Wind speed(mph) 15.0 7.5 Fireplaces 0 Lj Component Btuh/ft2 Btuh %of load Walls 5.9 5139 18.4 Glazing 19.4 3365 12.1 v Doors 21.9 918 3.3 Ceilings 2.7 2820 10.1 Floors 6.7 7103 25.5 Infiltration 2.7 2899 10.4 Ducts 832 3.0 Piping 0 0 Humidification 3861 13.9 Ventilation 930 3.3 Adjustments 0 Total 1 1 278671 100.0 s • • Component Btuh/ft Btuh %of load Walls 2.2 1926 14.2 VM Glazing 21.6 3744 27.7 ` Doors 9.1 380 2.8 N Ceilings 2.1 2260 16.7 Floors 1.4 1498 11.1 Infiltration 0.3 315 2.3 Ducts 299 2.2 Ventilation 196 1.4 ` Internal gains 2920 21.6 Blower 0 0 Adjustments 0 Total 13539 100.0 Latent Cooling Load=2859 Btuh Overall U-value=0.160 Btuh/ft=-°F Data entries checked. 2015-Jun-01 13:44:10 wrightsOft• Right-Suite®Universal 2015 15.0.17 RSU09260 Page 1 ...\Absolute Mechan\149 Coachmans Ln\Pat.Grimm.rup Calc=MJ8 Front Door faces: N ABPS Advanced Building Performance Solutions, LLC. John Haithcock Ph: 603 582-0030 119 Witches Spring Road Fx: 603 465-9155 Hollis, NH 03049 john@advancedbuildingsolutions.net TO: Town of North Andover Absolute Mechanical Systems LLC 6/3/2015 Results of Duct System Check The duct system was checked at 149 Coachman's lane in North Andover on 6/2/2015. This system is a forced air system that supplies the first floor. All duct work is located in the basement which is not conditioned. Duct work was insulated to code. The duct work was tested for leakage. According to the 2012 IECC the system must demonstrate total leakage of less than or equal to 4CFM per 100 square feet of conditioned space. This home first floor measured 1440 square feet and had a leakage rate of 48CFM at 25 pascals. This represents about a 3% leakage rate. This home passes the requirements of the 2012 IECC code. If you have any questions, please contact me. Signed Electronically John Haithcock Sr. Energy Auditor Owner ABPS Advanced Building Performance Solutions, LLC. MA Construction Supervisor License RESNET HERS Raters BPI Building Analyst International Ground Source Heat Pump Association North American Board of Certified Energy Practitioners ! Date . ...f. 3. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACHU This certifies that ...................... LG lZ .. has permission to perform ....... ............................... wiring in the building of........... ............................................................... North Andover,Mass. atJ C.'...................................................... ......... ........ Fee(�.................. Lic.No.............. ................ ..... ............. ELECTRICAL INS Check 4 10727 r Commonwealth of Massachusetts Official Use Only _ Department of Fire Services Permit No. ,, BOARD OF FIRE PREVENTION REGULATIONS (Please add zip codes & electrician's cell#; Occupancy and Fee Checked [Rev. 1/07] (leave blank) contract#& bid permit#if applicable.) 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: 3/19/12 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) 149 Coachmans Lane Owner or Tenant Tina Klein Telephone No.9786867056 Owner's Address Same as above Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building House Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps Volts Overhead❑ Undgrd x❑ No.of Meters 1 Number of Feeders and Ampacity 248 thhn 1#10 thhn 40 Amps Location and Nature of Proposed Electrical Work: Install one(1)electric car charging head(evse)in the garage e 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 K-VA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.A�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: .......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Securi oy f 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: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 400.00 (When required by municipal policy.) Work to Start: 3/19/12 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: J.Lee Associates DBA J.Lee Electrical Services LIC.NO.: 20687-A Licensee: Alden Losee Signature LIC.NO.: 14674-B (If applicable,enter"exempt"in the license number line) Bus.Tel.No.: 508-597-1330 Address: 753 Forest St. Suite 110 Marlborough Ma Alt.Tel.No.: 781 913 6103 *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 PERMIT FEE: $ Signature Telephone No. 1 �, ;, R{ �. f 7_ 147" 02- 6 vldl 5 m.7 �7�4 T- r- [T.(7,1— ITT,e ase Lez,bry NM-P_P_ (Business/Organization/Individual): F ele Address: T-�),S City/State/Zipp4krl Phone Are you an employer? Check the appropriate box: Type Of project (required): i.rC''4'1 am a enTloyer with 4. 11I am genera] contractor and I I(H employees (fall andJo5a.�_timo-* have hired the sub-contractors6. New Cons—Liucrou 2.11 1 am a sole proprietor or panaer- listed on the attached sheet 1 7. ❑ Remodeling ship and have no employees These sub-comiractors have Demolition worl,-ffi,(,- for inc in any capacity. workers' comp. insurance. P40 workers' comp. insurance 5. ❑ We are 2 corporation and its 9. Building addition required.] officers have exercised their 10-0 Electrical repairs Or additions 3.El I am a homeowner doing all work Tight of exemption per MGL I I-El Plumbing repairs or additions myself [No workers' comp. C. 152,§](4), and we have no 12-El Roof repairs insurance required.] f employees.--a. [NO WDrkel`S' I comp.insurance required.] I ❑ Other ';Any applicant that checks box#I must also fill out the section below showing their ivoikers,compensation I i tl:orj policy-,n xo,ma tion: Homeowners who submit this affidavit indicating they are doing all work SM(d IfieU,h-,Te outside contractors tractoys must submit a new affidavit indicating such. lContractars that checl,this box must attached an additional sheet showing the:name of the sub-contnictors and their WOfI[erS'comp.policy information. am,an employer that is providing workers c amDensation N s zF rE ncefio r my employeei Belcw, _,*�the policy an,7jgb sUe information. Insurance Cop-7any Name: Sr Policy#or Self-ins.Lic. Expiration Date: ZIJII Job Site Address: CCity/Stare/Zip: Attach a copy of the workers' compensation policy declaratfom page(showing the policy number and expiratlou date)° failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pemalties;of a fint up to $1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORI,,ORDRp, and a fine Qf up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of&,t of Investigations of the DIA for insurance coverage IeTifi , canon. 1 de,hereby e En En i penalties qj'perlury that the information D, ovided above � true and col-rect is Date: W Phone T'74: Y7 /33t) Offlicial use only. Do not write in this area,to be completed by cizV or town ofjj"cIaL 1 01tv or Tovm: ISSLFir�a _'k TT�_�� Cr-fty(CI cle on l° Ce U eer di Denald '.Board of z-l'L'-; 2.B u fil d I a gg D ep art m at 3. C,tt7ffl mim C e,r k 4. EFIL p ect o r S.P u n-, jnEne 6.Ot"er p Contact Person: Phone#° I— A .7... MORTM t Of4,.ao .°1y0 3? ° TOWN OF NORTH ANDOVER 0 • - PERMIT FOR GAS INSTALLATION ,e 9SSACH USEt This certifies that . . . .`"-. . . . f.G . . . . . . . . . has permission for gas installation . . . . :k1. . .". . . . . . . .. in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . s at . . Z/* .`.�. . . , Norah Andover, Mass. Fee. .a�4. L Lic. No.. A??.1 �. .�.�``�.`.� �. . . . . . GAS INSPECTOR' Check# 1( 1- 6232 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS , Building Locations .1, 3 Permit# fJ o AaL� Amount$ 3 1�V � Owner's Name fw� �//� e New Renovation Replacement M Plans Submitted Lai- � a w v�' U vi w O F+ C ;D O z F w W z u w a v, > w Q x a o� w t- F x w u a z d w z E• F w O > ct, Z O v, O o x 3 c ° °a > o a F o SUB-BASEMENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR LIE rt (Print or type) ,j,�J Check one: Certificate Installing Company Name �r p 1 Corp. Addr ss ` Partner. Business a pone ® Firm/Co. Name of Licensed Plumber'or Gas Fitter lzj�lu eel, INSURANCE COVERAGE Check one: I have a current liability Insurance"policy or it's substantial equivalent. Yes13 No13 If you have checked Les,ple a indicate the type coverage by checking theappropriate box. 13Liability 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 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 pe rmed under Permit d for this application will be in compliance with all pertinent provisions of the Massachusetts tat Code a Chapte f the General Laws. By: Sig ature of Licensed Plumber Gas Fitter Title Plumber X40 City/Town, Gas Fitter (cense Number Master _ APPROVED(OFFICE USE ONLY) � Journeyman { fi • y. 40 :'�o TOWN OF NORTH ANDOVER '= PERMIT FOR PLUMBING. . , LIZ . ,SSACMUSE� This certifies that . . . !"' . .� . . .n. �' ? . . . . . . . . . . . . . . has permission to perform . . . . ..-f.,9 plumbing in the buildings of . . . . /. . . . . . . . . . . . . . . . . . . . . . . at. . . . e . . . . . . . . . , North Andover, Mass. Fee 1 �. . .Lic. No. 1 a . . . . . . . . . . . PLUMBING INSPECTOR Check # It/ L 7573 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS / � � 'Fa(Al. Date Building Location Owners Name 6,1 Permit# Amount Type of Occupancy New Renovation E] Replacement Plans Submitted Yes No P . 1:1 rl FIXTURES F H xz O z z U W �+ F O ot z p v� W W x r a A A a r~ A a C St�I� BASEY NI' ` IST Rfm M HAOR �l 110M 4M11fM 6M HO R - nH>tiMM gm wt (Print or type) — Check one: Certificate Installing Company Name pig ❑ Corp. Address 1 ❑ Partner. usmess Telephone Firm/Co. Name of Licensed Plumber: --� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 12 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 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 install ' ns perfo ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass chus tate PI ng Code and Chapter 142 of the General Laws. By: a e o icense er Title Type of Plumbing License f • D City/Town icense MumDer '� Master Journeyman ElAPPROVED(OFFICE USE ONLY j0RTN `` °:,�`'° '•1"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4 This certifies that ��. ` has permission to perform wiring in the building of......Ez r" #...61,x/..4 . at..... . '..4444A.41,11......L..'ev.............. . orth Andover,Mass. Fee.. ���......... Lic.No. 3 .................. i; CALCAL IN . Check # r 10699 Clowwnweah i of Madlaclucaeffa Official Use Only AparfinenE o�}ire�aruicaa Permit No. Gj' BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM! ELECTRICAL WORK All work to beerformed p in accordance with the Massachusetts Electrical CodeME (MEQ 5.. CMR 12.00 (PL ERSE PRINT IN INK OR TYPE INF MTION) Date: 3/ 1 Z City or Town of: v2/ 0 UC,r To the Inspector o Wires: By this application the undersigned gives notice of his or her intetrtion to erform the electrical work described below. Location(Street&Number) / Co�� A Owner or Tenant ¢ Telephone No. Owner's Address (� Is this permit in conjunc on with a builPZ1, mit? Yes ❑ No (Check Appropriate Box) Purpose of Building_ it, Utility Authorization No. Existingm Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: iWCn Com letion of the ollowin table inay be waived by the Inspector of If7res. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans f Total T.o farmers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. d. Batte ry Units No.of Receptacle Outlets t No.of Oil Burners FIRE ALARMS No,of Zones No.of Switches No.of Gas Burners o.oI Detection an InitiatingDevices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g Heat um umber ons K No.of Waste Disposers p _ -go—.of Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipa [IOther Connection No.of Dryers Heating Appliances KW ecurity Systems: No.of Devices or E uivalent No.of Water KW o.of No.of Data Wiring: Heaters Sl s Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiringg: No.of Devices or Eciuivnlent p OTHER: ® hmg 717:u j Attach ddditional derail if desired,or as required by the Inspector of Il"ires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ®- Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the Iicensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of s e to the pe it issuing o ce. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ,�appl �� /Z 3� I certify,ander the aims and pen°f�of erjrrry,tl t the in rnration on t rb'f is true autl otu t FIRM NAME: v s a iC LIC.NO.: Licensee: jjP,PAe y1 <✓c 64 Signature i✓ -t LIC.NO.: (Ifapplicable,ent "exempt"in the Acense number It Bus.Tel.No.•1.� Address: `i r A vUet !C�Alt.Tel.No.: / *Per M.G.L.c. I47,s.57-61,security w requires Dep ent 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 Signature Telephone No. PERMIT FEE:S The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly -J� Name(Business/Organization/Individual): �� �j/�� �`vim Address: � �-� City/State/Zip:�& Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. El am a general contractor and I � have hired the sub-contractors 6. F1 New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g 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.❑Roof repairs insurance required.]t employees.[No workers' 131iOther 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 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. be Insurance Company Name:. 114 3)71S / , Policy#or Self-ins.Lic.#: ® /VS(p Expiration Date: r Job Site Address: S 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby cer fy tl pain a d penalties of perjury that the information provided abo a is rue and correct. Simature: L Date: �J 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#: r 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 ...eve ry 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 2 SC 7 states `Neither the comm P � § commonwealth nor any ny 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 permittlicense 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: The Commonwealth ofMassachusPtts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tel,#617-727-4100 ext 406 or 1-877:MASSAFB Revised 5-26-05 Faze#617-727-7741 wwwaxzass.govfdxa Date,$ - A N° 4431 ':'tic TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SSHusf� This certifies that . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . P. ( .r . . . . . . . . . . . . . . . . . . . . . . r plumbing in the buildings of . . .!'. . . ". .-�. . . . . . . . . . . . . . . . . . . . . . at . . .f Y 5 . . . . . . . . . . . . .. , North Andover, Mass. r Fee!�. Lic. No.. . . . . . . . . . . . . . i PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FO PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location /y� ���1� M �/t /- Owners Name T / 1(/!`� �,/i!/P Permit Amount Type of Occupancy 5')A)&-Le F y4M 11-- New LTJ Renovation E Replacement El Plans Submitted Yes No El FIXTURES z a a .a zx w w a a W F A14 x p, A E. d dW SL rA d A S03-MMC � Pro F � r� ` !1 u F /MM CIR 3M FL 4M 'IZR 6M HIM 8W MOOR (Print or type) /+ Check one: Certificate FR Installing Company Name ( R s !' N Corp. Address L CPAJ I /�� Partner. () it e e S O / Business Telephone ��� if Firm/Co. Name of Licensed Plumber. % I f'� Iy �'� 5^6 U c Insurance Coverage: Indicate the Me of insurance coverage by checking the appropriate box: Liability insurance policyn/" Other type of indemnity El 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 F1 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus a Plumb' g Cod and Chapter 142 of the General Laws. By: bignature of Licenseaum er Type of Plumbing License Title j f t( 3 City/Town tcense Numoer Master Ti Journeyman F1APPROVED(OFFICE USE ONLY u 7 C 1 N° 1 J v Date...... ...�. .. , t NORTH, 3?�•_`,r�l�-+',e�OpL TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACYIus This certifies that ....... �.. .�!........., 5..0 4............................................... cP � �, fZ has permission to perform .........:�................�F.......1...:n..s:'.�.:�.......�........ wiring in the building of...... ................................................... c at... .. ..7....rv.� � ... . North AAndover;Mass. • Fee. j. Lic.No.A.7.3,... tea... /.. �..... ELECTRICAL INSPECTOR 03/26/99 08:44 35.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer (� �� office use only fit LfamIIIIIIIll mill of iiar4 lsrEtts Permit No. r� 3t;mt nxni of ilubilc _*nfttIq occupancy& Fee Checked BOARD OF"FIRE PREVENTION REGULATIONS 527 CAR 12:00 2M (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All 'Mork to he performed in accordance with the Massachusetts Electrical Code, 527 C41a 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date or Town of NORTH ANDOVER To the Inspector of Wir The uderslgned aoclies for a permf it to perto m the electrical work d scribed 5etow. Lccation (Street & Number) owner or Tenant J121CIA ,nl b" in Cwner's AdCress Is :his permit in ccniunctien 'Nith a ' iIding oe It: Yes _ No = (Check appropriate Box) _, .cse cf �uiiCinc Utility Autrcnzation No. Existing Semite Amos Vcits Cverreae _ Uncgrne ' No. of Meters ! Ne'.v Sel-Ace /O d Amos �J 0/pits Cverneac Uncy:^c No. of Meters Numcer ct Feecers arc Amcac:ty k. _....c,.,.,. anc `latae .f ?.cccsec Eec,.:cal .Vera No. _. -••^ :ut:e!s NO. _. _=s No. ct 'ranstcrmers TOtat _.c. ....c K`.A No. at t_cnnnc .xtures Swimming r•Col AOOve.— in- No. _ a-mc. _ Generators KVA 1 No. at ^ersency u5nurg No. at �___c.ac: e Cutlets No. at mit Bur.^.ens i 3arery Umts No. at Switcn Cutlets No. ar Gas = rrers I FIRE ALARMS No. at tines Total I No. at =etec::an arc I No. cf Ranges No. z! Air _ r.c. I tcr.s Initiating cavlces -!eat Total Total No. at Oisccsals No.= +^ys ;ars K':J I No, ct Stunting 'cevtces t I No. at Sett Cantalnee I �- No. at 7.snwasners - ScacerArea rearing <%V Oetec::onrSouncing cevtces i No. at -:^:ers Neat:rC 'Cewces C+v I .scat '_ Munlc!=al —Otn@r _ Ccnnecccn _ NC. Ct No. of Low vcriage i No. at '.Yater heaters CYI I Sicns Ballasts 'Nir:nC No. �4yero massace acs NO. of %iotcrs TOtat I-+P INSURANC= ?_rsuant :a tre recutremenis zt ssac-:se-s ;er•eral '_aws I nave a current _;acuity Insurance ?Cnrl nC:uC;ng Ccr. c Ccerauens Coverage cr -is suostannai ectavaient.ool Ya NO nave suaml-ea vau cet ct same to Me Chips. YES _ NC = it •:cu nave / cxee `.'ES. cease tricicate :ne type of c verace _y c-ecx,ng :ne accr prate pox_ �iJ °/ 3 N INSURAC= _ SCt07H ER_ CER __ (Please ace:ty) t ptranon eater _sumatec 'value of E:ectncat Warx 5 WCrx :o Star. Inscec-min Cate Pacuestec: Rcucn =Tnal Stgnee anter :na Pena of ry^rry ,I q Y =:r•I;I NAME � IJ � C � G LIC. 1140. L.censee Signature ' 'C. 14C (/�9 1( Bus. Tel. No. TTT��777.7� ACCress _ Alt. -ei. .`to. OWNER'S INSURANCc WAIVER: I am a are !Mat :-e !;pensee pees got nave :ne insurance coverage or Its suostanUat eeutvatent as re• culrea :w Massacrusetts General Laws. ane :hat rty signature an :-:s ::erm:t aceticatlon ,valves :nts reeutrement. Cwn Agent (Please cnecx cnef BteC^Cn@ No, ?E-RMIT FE_ q 3J� V SiCrature ct Cwner cr.Agent1 t+f_91 Location / 14`r C-0 A C No. n 02 Date TS TOWN OF NORTH ANDOVER to 9 Certificate of Occupancy $ Building/Frame Permit Fee $ cNU Eco Foundation Permit Fee $ s� s 'Other Permits Fee $ tt� w�t1S�eewer Connection Fee $ BY if annection Fee $ 9199TOTAL $ Ladmu cwl _f Building Inspector iyt51fo' Div. Puhlir.Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 1� PAGl; 1 MAP dd0. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK :PAGE ZONE j I SUB DIV. LOT NO. LOCATION / Q Cj1/k p J4/ PURPOSE OF BUILDING l._f j ®d C OWNER'S NAE /'-/A/� 7q A � pe Q/� NO. OF STORIES V SIZE OWNER'S ADDRESS C004C# yl**S ,C AJ f BASEMENT OR SLAB ARCHITECT'S NAME T '•-7T �'/'r SIZE OF FLOOR TIMBERS IST"? 2ND 3RD BUILDER'S NAME !/1 �^ SPAN --J,(—� DISTANCE TO NEAREST BUILDING !00 + '^-r DIMENSIONSOFSILLS --- DISTANCE FROM STREET {sE © '� POSTS l �/ DISTANCE FROM LOT LINES—SIDES /_Q�� REAR 1®a 4:"T-+ GIRDERS l AREA OF LOT R( -% , ((�� FRONTAGE HEIGHT OF FOUNDATION A / THICKNESS / e C .1 IS BUILDING NEW No SIZE OF FOOTING I' X ® // ('D^14 oz l) IS BUILDING ADDITION SE c 14 MATERIAL OF CHIMNEY J IS BUILDING ALTERATION / 1 p—s IS BUILDING ON SOLID OR FILLED LAND / WILL BUILDING CONFORM TO RE6UIREMENTS OF CODEIS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY 1� IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE / INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED ANDAPPROVED /PPROVE/DyBYryBUUILDING INSPECTOR DATE FILED JA W (7 / T 7 / BOARD OF HEALTH r SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE a�—d PLANNING BOARD PERMIT GRANTED is OWNER TEL # CONTRACTOR # CONTRACTOR LIC # BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S DRIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW'D f PIERS PLASTER DRY WALL UNFIN. 3 BASEMENT AREA FULL I FIN. B'M'TAREA _ '/. 1/7 3/, FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDVV D _ ASBESTOS SIDING _ COMMGN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR POOR ADEQUATE _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) _ GAMBREL I MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN, TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING NORTH Town O 6 OL ®ver No. 00 rt R. a [/ �: f1 ' ®". "'A—V.-v�Y�,9 R r aeC37. _. - y1V!/ C!°2i ®. 6 C np 6' .a.6 K�, er Man... 7A 19 0 Al C N NEWICK oR P� SS PERMI LD BOARD OF HEALTH THIS CERTIFIES THAT.. JI.. � �....#4.. ®. �.qs .................. UILDING INSPECTOR has Per ionot�.CC. ..... buildingson /f�OvAcA�o-o . Rough to be occupied as... i '144���.W1!`....40-A-,,�� „ -Am-A . . . Chimney ...................... ... .. Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS CONSTR ION STARTS Service Final ... . . ....... ...... . .... ..... BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE 1 - 9 - 91 �. -JOB LOCATION I ' 9 Co4CN M,4,ts LAN,, , Number Street Address Section of town ','HOMEOWNER" �r(N4T"K 4 gas- Name Home Phone Work Phone " PRESENT MAILING ADDRESS L4 N City Town I ? State Zip code , ,''The current exemption for "homeowners"occupied dwwas extended to include owne ellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided (,Ii, that the owner acts as supervisor. (State Building Code, Section 109 . 1 . 1) DEFINITION OF HOMEOWNER: 'Person(s) who owns a parcel of land on which he/she resides or intends reside, on which there is , or is intended to be, a one to six familydwell- ing, attached or detached structures accessory to such use and/or farm pstructures . A person who constructs more than one home in a two-year eriod shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official that he/she shall be responsible for all such work performed unde building permit . (Section 109 . 1 . 1) r the The undersigned "homeowner" assumes responsibility for compliance wit State Building Code and other applicable codes , by-laws , rules and h the . ,regulations . The undersigned "homeowner" certifies that he/she understands the Tow .North Andover Building Department minimum inspection procedures and n of requirements and that he/she will comply with said procedures and ; requirements . HOMEOWNER' S SIGNATURE .APPROVAL OF BUILDING OFFIC AL Note: Three family dwellings 35,000 cubic feet , or larger, will be required to comply with State Building Code Section 127.0, Construction Control . (00 ail ,G l` re �$ Floor i �f • �X � off+. � pi)c titter pv� ,e 6J , o f v •"" r Ain V ; t �k y y� lady ccfun� pQs� - TO �9 Co,4cA M T4s C4l(C e tle f'/