HomeMy WebLinkAboutMiscellaneous - 15 MAIN STREET 4/30/2018 anion
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ORTM
°! Mt«`°:•�"a TOWN OF NORTH ANDOVER
3a �!.r ' .'• 0
PERMIT FOR WIRING
ti s c _
�sSACHU �
This certifies that
.........
has permission to perform ....... '�.-- ......................................
wiring in the building of................ ....... ..................... ....................................
at ....:. ..... .. ....................North Andover,Mass.
Fee'---�t;?............. Lic.Nog `
. ......... .... ..................
1 ELECTRICAL..MPE OR
Check #
7249
Commonwealth o�///adaace `� Official Use Only
2eparl o }ire�ervice� Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07]
(leave blank)
APPLICIATIONwork to be NeFORrformed 1 PErRnMIT TOce with the asPERFORM ELECTRICAL WORK
(MEC),527 CMR 12.00
(PLEASE PRINT IN INK ORAPLALLjKFOrTION) Date: ' ? t;City or Town of: J To the Inspector of Wires:
By this application the undersigned Ives notice of his or her intention to perform the electrical work described below.
Location(Street&Number)_ 4t-,D, 0.r' k-
Owner or Tenant , (,
Telephone No.1N
Owner's Address
Is this permit in conjunction with a building permit? Yes No
❑ (Check Appropriate Box)
Purpose of Building Utili Authorization No.
Existing Service Cil, Amps �t7 / y v Volts Overhead Und rd
g ❑ No.of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Com letion o
hefollow' table m be waived by the Inspector of Wires,
No.of Recessed Luminaires 1 No.of Ceil.Susp.(Paddle)Fans No.of Total
Transformers KVA
No,of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Poo
Swimming l Above ❑ In- o-o mergency digmg
�. rnd. rnd. ❑
No,of Receptacle Outlets No.of oil Burners Batte Units
FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners ilu.of Detection an
Initiating Devices
No.of Ranges No..of Air Cond. To-al-
Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump umber Tons KW No,of elf-Contained
Totals: Detection/Alertin Devices
I No,of is
Space/Area Heating KW '1 j Local uniectlo
❑ Cpnnection ❑ other
k No.of Dryers Heating Appliances Kir Security ystems:* i
No.of Water No.of No.of Devices or E uivalent
Heaters KW Si ns Ballasts Data Wiring:
No.of Devices or E uivalent
No. Hydromassage Bathtubs No.of Motors Total HP Te ecommunications Wiring:
No.of Devices or E uivalent
OTHER: �v
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work (When required by municipal policy.)
Work to Start: S- YS-0`� Inspections to be requested in accordance with MEC Rule 10,and upon completion, -
I
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 j
undersigned certifies that such cov
age is in force,and has exhibited proof of same to the-permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:)
I certify, under the airs and penalties ofperjury,that the information.on this applicationis true and complete.
FIRM NAMSC� . t`t��CS�
LIC.NO.:
Licensee: t,.r� Signature
(If applicable,enter " empt:'i the li nse number ' e) LIC.NO.:I;: j,��
Address: 01__ c. j t 10 v Bus.Tel.
ti 0t `1`� Alt.Tel.No.:'
*Per M.G.L.c. 147,s.57-61,security work requir artment of ublic.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/Agent ❑owner's a ent.
Signature Telephone No. PERMIT FEE:9 C
oda Pte.
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Location /� �--�_-•i
No. H J Date01 der
"ORT" TOWN OF NORTH ANDOVER
• s
�o s Certificate of Occupancy $
MUs t� Building/Frame Permit Fee $
'° Foundation Permit Fee $
Other Permit Fee $
TOTAL $ �
Check # 14 1j/
17106
//��uilding Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED: a
ic
SIGNATURE:
Buildin Commissioner/I for of Buildings Date
SECTION 1-SITE INFORMATION I O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
383 Johnson Street Lot #2 Of PS
aka f77777a ap Number' Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
R 3 Single Family 25, 220 125 +
Zoning District Proposed Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
31 as >
35
1.7 Water Supply M.G.L.C.Q.1 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public BV Private ❑ Zone Outside Flood Zone ❑ Municipal X On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn
2.1 Owner of Record
911,3
383 John-,on Sup=t- R T 44 Michell Road Ipswich, Ma 0193€i
Name(Print) Address for Service: 1
Joseph Pelich fir�k-Sfck- ( 978) 356-4664
Sigpture Telephone
2.2 Owner of Record:
Name Print Address for Service:
rn
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
Li nsed Cons ruction Supervisor: CS 07� O
` l License Number
mn
Ad res
ic
7 ()7" 7ha 1 Expiration Date
rgna a Telephone r
t
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name
rn
Registration Number
Address r
Z
Expiration Date A
Signature Telephone V)
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building rmit.
Signed affidavit Attached Yes.......OX No.......❑
SECTION 5 Descri tion of Proposed Work check all applicable)
New Constructions Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg./ ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
f
Booloo-S, o2 `/a 23A714")_ 64-w
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Completed by permit applicant
1. Building _ (a) Building Permit Fee �q.0e K
0 Multiplier P
2 Electrical 3 ^� 9 0 6 (b) Estimated Total Cost of 3
Construction
3 Plumbing R o _
Building Permit fee(a)X(e)
4 Mechanical HVAC ,j 5 Cr o
5 Fire Protection .3 9 q O
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BURIDING PERMIT
- T
I, Joseph P e 1 i c h Trustee as Owner/Authorized Agent of subject property
Hereby authorize Stephen Maiuri I to act on
My behalf,in< in ers rela ive to�yor Guth 'ze by this building permit application.�r 6 O #►
Signature of Oy±er Date
SECTION 7K ---AUTHORIZED AGENT DECLARATION
1, I ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR 1TVIBERS Isr2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY j
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that allnecessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance With any applicable requirements.
APPLICANT jcseA4 ;ZlejIcL �r,14(fke PHONE Y``y
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION LOT NUMBER
STREET �l S A L R�,P"e— STREET NUMBER
OFFICIAL USE ONLY
REC M1VV1)3E NDATIONS OF TOWN AGENTS
Boom WEEME0O.E .mm M■ %. ..................�.........'...E..MM.■ ■■f�ME MO...■
� DATE APPROVED � �✓� _
CONSERVATION ADNIINISTRAT
DATE REJECTED
CONIlVIENTS
r,
DATE APPROVED G
T
DATE REJECTED
CONWIENTS CDl Gtr OJ�IC�i G�
�y
DATE APPROVED
FOOD INSPECTOR-HEALTH DATE REJECTED
DATE APPROVED
SEPTIC INSPECTOR-HEALTH
DATE REJECTED
COMMENTS
PUBLIC WORKS-SEWER/WATER CONNECTIONS
ArfIRE
Y PERMIT
71
ATE APPROVED
R
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
FROM Fastern Land Survey FAX NO. : 9785315920 Feb. 05 2004 01:45PM P2
Professional Land SLfrveyws & Civil Cingineen;
ESSEX SUFIVLY SUiVICL 1958 - 1986
OSBORN PAIWER 1911 - 1970
BRADFORD & WFF-17) 1885 - 1972
ITOT PLAN OF LAND
L.=Ef) IN
-'A
MASS.
7,1
7.7
ZZ
IVEMA",
7�
71
'Oki ,
-1 hero-by CertilEj, to the AM711,,A>MZ-
7CNE:
-Bu"d'mg bWeCtor that the pr,)-
IAT 2
AREA.- -:11 ZZ, LOT IIRUUA(;E: P038d construction shown conforms
FRONT YARD: '3& SIDE YARD: REAP, UM: to the dimmiorlal Zoning of
Hass.
SCALE: ''
DATE:
REFEREWZ: EK
LiY Christopher R. Me110 PLS 313 .7
104 LOWELL STREET
PEABODY.MASS,01960
(1978)531-8121
FAX:(978)531-5920
— j
�' ✓lze �a7ro7wncuecz�li a��/lataaclzuael�i
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 073482
Birthdate: 03/02/1967
Expires: 03/02/2004 Tr.no: 17622
Restricted: 00
STEPHEN M MAIURI-
36 CAVENDISH CIR
SALEM, MA 01970 Administrator
N
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
9w Boston, Mass. 02111 j
Sy
Workers'Compensadon.Insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
1 am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity•
l xx t am an employer providing workers'compensation for my employees working on this job.
Company name: Eddington Place Realty Trust
------------
Address 44 Mitchell Road.
City: Ips-Wich, Ma. 01938' Pttione#: (978) 356-4664
Insurance.Co. Weston World Policy# NPP 871006
Company name:
Address .
Insurance.Co. Policy_#t
Farre to secure coverage as required under Section 25A or MGL 152 can lead tvthe imposition of criminal�fpenof arfa,erie up to
and/or one years'imprisonment as_vmLw-cnai pefla&ie:S�o�elomo�l��S?3?P' fiaea0iflQ br '
understand that a copy'of this statement may be forwarded to the office of lrrvesfigations of the DIA for coverage verification.
/do hereby ceridy under the pains and penalties of perjury LW the kAymatiorr provided above is true and correct
Signature pate
Print name Joseph Pelich Trustee phone.# ( 978) 356-46
Official use only do not write in this area to be completed by My or town dficidr
City or Town Pem� Eq.
Q Builc ng l
❑Check rf immediate response is required -❑ Licensing
❑ Selechnar
Contact person: Phone A ❑ Health pe
❑ Other
1
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
The debris will be disposed of in:
LA��-L Rte►
(Location of Facility)
QA:nA d&A —Jk4.
Signature of/Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
This form shall be used to assist the Building Department in their determination of exemption under section
8.7.6 of the Town of North Andover Growth Management Bylaw.The applicant shall provide all of the
necessary information as requested below.
3 83 Jo k040IJ St cal a
Permit Applicant Property address Map/Parcel
5:V8- �)S(O • q�6q ✓
Applicant's Phone Number Single Family Two Family
I the undersigned applicant for the above property attest that the attached building permit for which this form is completed
does comply with the EXEMPTION section 8.7.6 of the Growth Management Bylaw.I also understand providing this form does not
absolve me or any,party to this permit from the requirements of obtaining other permits required prior to the issuance of the building
permit.Further I understand that my interpretation of the exemption status is subject to review by the Building Department and is only
officially accepted when the building permit is issued.
Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot,in the building
permit application and associated attachments,complies with one or more of the following sections as indicated by a check mark.
This is an application for a building permit for the enlargement,restoration or reconstruction of a dwelling in
existence as of the effective date of this bylaw,provided that no additional residential unit is created.
The lot(s)was/were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the
Zoning Bylaw.
This application is for dwelling units for low and or moderate income families or individuals,where all of
the conditions of 8.7.6 are met and or represents dwelling units for senior residents,where occupancy of the units is
restricted to senior citizens through a properly executed and recorded deed restriction running with the land.For
purposes of this section"senior"shall mean persons over the age of 55.
This application is part of a development project which voluntarily agreed to a minimum 40%permanent
reduction in density(buildable lots)below the density permitted under zoning and feasible given the environmental
conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open
space or farmland.The land to be preserved shall be protected from development by an Agricultural Preservation
Restriction,Conservation Restriction,dedication to the Town,or other similar mechanism approved by the planning
board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with
an adjacent parcel on the effective date of this Section 8.7 and shall receive a one time exemption from the Planned
Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit
on the parcel.
_/This application represents a lot which is ready for a building permit(all other permits from all other boards
and commissions have been received and the project is in compliance with those permits),and the Development
Schedule does not accommodate issuing a building permit in that year.One building permit will be issued per year per
Development until such time as the development schedule accommodates issuing building permits.Applicant must
submit an approved FORM U with this EXEMPTION.
PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A
DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS.
BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED
BUILDING PERMIT IS ALLOWED AN EXEMPTION AS CITED ABOVE.
FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE
CHECKING OFF OF A ABOVE EXEMPTION WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR
N OUNDS FOR REFUSAL BY THE BUILDING DEPARTMENT TO ISSUE A BUILDING
PERMIT.
,KLICAXTS SIGNATURE DATE
/flIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION
i
Name GZ YL. G /✓
Location
Check# Z 61 Date 12'��
Note:
TOWN OF NORTH ANDOVER
o °m Sewer Mitigation Fee $
9
`; =•�'; Sewer Connection Fee $
,SSACHUs�t Water Connection Fee $ 0495:�'+ zn
Meter Fee $ �d
Other $
RECEIPT NO. TOTAL $
1142 /
Div.Public WoTks
WHITE: Applicant CANARY: Department PINK: Treasurer GOLD: File
k
i
I
i i
TOWN OF NORTH ANDOVER, MASSACHUSETTS
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET, 01845
J.WILLIAM HMURCIAK, P.E. Telephone(978)685-09:
DIRECTOR Fax(978)688-9573
F µoath
0 "G o ,e 9ti
O T
H D
5
9SSACµUSE�
DRIVEWAY PERMIT
DATE Z
LOCATION 1 in
BUILDER phone
OWNER �q phone2 76 -SSG-
THE NORTH ANDOVER SUPERINTENDENT OF OPERATIONS
MUST BE NOTIFIED OF THE GRADE AND SETBACK FROM
STREET. CALL THE SUPERINTENDENT'S OFFICE BEFORE
FINISH GRADING AND SURFACING FOR.APPROVAL OF
SUCH ENTRY.
FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT.
V `
x
1934
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass.Application by by the undersigned is hereby made to connect with the town sewer main in L i Street,
subject to the rules and regulations of the Division of Public Works.
4.
The premises are known as No. Z
ea Street
or subdivision IoLgo.
Al z
Owner V Address
Contractor Address
Applicant's Signature
PERMIT TO CONNECT WITH `SEW R MAIN f I
The Division of Public Works hereby grants permission to 3 ` Gv
4
to make a connection with the sewer main at L l a� AIeC—:1 Street
subject to the rules and regulations of the Division of Public Works..
Divisi n of Public Works
By
Inspected by
Date
See back for rules and regulations
A/ ��2
1284
APPLICATION ;FOR WATER SERVICE-CONNECTION
North Andover,Mass.'
Application by the undersigned is hereby made to connect with the town water main in Z-L&at 1-41d 167 Street,
subject to the rules and regulations of the Division of Public Works.
The premises are
known as No.
( J - di Po Street
or subdivision lot no.
Ow er Address l
t
Contractor Address -- '
A A
pplicant's Signature
I vCj
PERMIT TO CONNECT WITH WATER MAIN
The Board of Public Works hereby grants permission to /
to make a connection with the water main at_ z�sgh Street
subject to the rules and regulations of the Division of Public Works.
Board of Public Works
Byz ��//
Inspected by
Date
See back for rules and regulations
TOWN OF NORTH ANDOVER
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845-2909
J. WILLIAM HMURCIAK, DIRECTOR, P.E.
Timothy J. Willett NORTy q Telephone (978) 685-0950
Water Superintendent Fax(978) 688-9573
o - �
t
�9SSACHUS�S��
AUTOMATIC LAWN IRRIGATION SYSTEM PERMIT
DATE RECEIPT NO. f f Z
HOMEOWNER l4 T"f—PHONE
LOCATION
INSTALLER PHONE
Note: The Installer shall verify that there is sufficient water pressure for the new irrigation
system prior to the start of any work.
.,,General Requirements—
Bypass Meter Set-up -
A plumber shall set up a horizontal space for the bypass meter. The bypass meter shall be
located before the house meter. Deduct meters are not allowed except for those homes
with water booster pumps. Ball valves should be installed on both sides of the meter.
II. Rain Sensor—
A Rain Sensor shall be installed on all new irrigation systems.
III. Backflow Preventor—
The proper backflow preventor shall be installed and tested annually.
IV. Sprinkler Head Location— .
All sprinkler heads and piping must be installed entirely on the homeowner's property.
Sprinkler heads will not be allowed in the Town's Right-of-Way (R.O.W.), which is
typically ten to fourteen feet back from the edge of roadway pavement.
V. Bypass Meter Installation and Town Inspection
After all work has been completed, call the DPW for bypass meter installation. The meter
installer will use this Permit to inspect for proper meter set-up, rain sensor, backflow
preventor, and sprinkler head location. This Permit must be present at the location for
the bypass meter when the Town's meter installer arrives at the property.
Bypass Meter Rain Sensor Backflow Preventor Sprinkler Heads Date
SEP-02-2003 . 11:25 NATIONAL SALEM P.02i05
. I I
MASCh'F:Ck COMPLIANCE REPORT I {
Massachusetts Energy Code { Permit # j
MAScheck`software version 2.01 I I
,I
I I
! j Checked by/Date
CITY: No th Andover
STATS: Massachusetts
HDD.- 632,2
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING,,T,YSTEM TYPE: Other (Non-glectric Resiatauce)
DATE; 9+,2'-2003
�ht..
DATE OF111P S: 8-18-03
,..
TITLE: Birchwood
PROJECTI7rNFORMATION:
t
Lot 2
tl�iq,�7:
Lisa �U
North over
COMPANY;II
INFORMATION:
Cyrus Conatructon Co.
COMPLIANCE= PASSES
Required',YUA = 712
!n
Your Home, = 691
1:11.I1'1'' Area or Cavity Cont. Glazing/Door
Idf i.
� Perimeter R-ValuC R-Value U-value UA
-------�r----------------------------------------------------------------------
lh
CSILINGSI 2450 30.0 0.0 86
WALLS. iWoad Frame, 1611 O.C. 3213 13.0 0.0 264
GLAZING,. or Doors 430 0.350 151
GLAZINa:�'windows or Doors 128 0.350 45
GWINGP Windows or Doors 33 0.320 11
GLUING,',Windows or Doors 42 0.330 14
DOORS ' 44 0.280 12
FLOORStfOver Unconditioned Space 2277 19.0 0.0 108
HVAC EQUIPMENT: Furnace, 85.0 AFUE
--------
, - -�
------------------------------------------------------------------- --
COMPLIANCE STATEMENT: The proposed building design described here is
consistent with the building plans, specifications, and other calculations
submitted with the permit application. The proposed building has been
designed to meet the requirements of the Massachusetts Energy Code.
The heating load for this building, and the cooling load if appropriate,
has been determined using the applicable Standard Design conditions found
in the'!code. The HVAC equipment selected to heat or cool the building
shall lie no greater than 12$% of the design load as specified in
Sections 780CMR 1310 and J4.4.
Builder/Designer Date
O '
Ia� 'I
I�Y,SII:
I
I�
SEP-02-2003 11:25 NATIONAL SALEM P:03i05
MAScheck'.INSPECTION CHECKLIST
Massachnsett:s Energy Code
WcheCk Software Version 2.01
Birchwood
DATE: 9=2-2003 -
Bldg,
Use
SILINGS:
Or
R-30
I conments/Location
'4 l•',
LS! �
Wood Frame, 15° O.0 R-13 j
Comments/Location
WNDOWS ANP GLASS DOORS:
( ]
1, U-value: 0.35
it describe features:
Por windows without labeled U-values, u
f:
I # pangs Prame 'type_ Thcrmal Break?• ( I Yes. [ I No
Comments/Location
[ ] I U-value: 0.35 '
li( For windows without labeled U-values,.describe features:
# panes Frame Type_ The
Break? I.) Yes [ ],No t '
Comments/Location a
( ] �i;3. U-value: 0.32 '
'a!f
For windows without labeled U-values, describe.features:
II # Panes Frame Type Thermal Break? ( ) Yes I ] Na Y
comments/Location
4- U-value: 0.33 f;
For windows without labeled U-values, describe features:
r.
Oil,
# panes Frame Type- Thermal Break? ( I Yes
I'l CommeAts/L'ocation
xf '
III hl.
U-value: 0.28
Comments/Location
( '.FLOORS: Y
1. Over Unconditioned Space, R-19 �
r �.; Comments/Location
c �j""HVAC Eg.UIPHRM!
d
11 p. 1. Furnace, 85.0 AFUE or higher
Make and Model Number
(,.AIR LEAKAGE: (
joints, penetrations, and all other such openings in the building
, Iji,envelope that are sources of air leakage must be sealed. When
f� installed in the building envelope, recessed lighting fixtures
` shall meet one of the following requirements:
1. Type YC rated, manufactured with no penetrations between the „
,SII inside of the recessed fixture and ceiling cavity and sealed or
gasketed to prevent air leakage into the unconditioned space.
,
. . SEP,,-02-2003 11:25 NATIONAL SALEM P.03i05
w
:.'.MAScheck-''INSPECTION CHECKLIST
Massachueet;-Is Energy Code
MAecheck Software version 2.01
Birchwood
DATE: g-'2'-2003
Bldg.
Dept. ,I{'''
Use l ;1'
ILINGS:
R-30
Comments/Location
�! LS: i
Wood Framer 16° O.0-, R-13
a
V� V � Comments/Location
NDOWS AND GLASS DOORS:
U-value: 0.35
IIIh�,i For windows without labeled U-values, daecribe :features: Ati
# Pancs Frame Type Thrm
cal Breaks [. I Yes. [ ] No t
Comments/Location i
[ 1
U-value: 0.35
I 'll"
!
Ali #
i 'll" For windows without labeled U-values, describe features: �
# Panes Frame Type Thermal.9reak? C.:] Yes
11�'+ ' Comments/Location t
IU-Value: 0.32
SII{ For windows without labeled U-values, describe'fe.atures:
# Panes Frame Type Thermal Break? I ] Yes I I No
I Cowents/Location
a_ U-value. 0.33
f��el`II� For windows without labeled U-values, describe features:
# Panes Frame Type_ Thermal Break? •[ ] Yes [ ] No
Convents/Location
'DOORS:
1. U-value: 0.29
comments/Location
T ;FLOORS:
jI' ,' [ ] ��•, 1• over Unconditioned Space, R-19
Coaemente/Location
t HVAC EQUIPMENT:
1. Furnace, 35.0 AFUE Or higher ,
Make and Model Number
111I,AIR LEAKAGE:
penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. When v
�lV installed in the building envelope, recessed lighting fixtures
shall meet one of the following requirements: _
1. Type ICrated, manufactured with no penetrations between the
inside of the recessed fixture and ceiling cavity and sealed or
•° �(�I,i Basketed to prevent air leakage into the unconditioned space. ,
I j •�,, y
SEP,02-2003 11:25 NATIONAL SALEM P.05i05
COOLING SYSTEMS:
Ch4lled water or 40-55 0.5 0.5 0.75 1.0
refrigerant below 40 1.0 1.0 1.5 1.5
[ } CIRCULATING HOT WATER SYSTEMS:
Insulate circulating hot water pipes to the following levels (in.) :
PIPE suss (in-)
Til
NOCIRCULATING ` CIRCULATING MAINS 4 RUNOUTS
HEAPED WATER TEMP (F) : RUNOUTS 0-1" 0-1.25" 1.5-2.0" 2.0+"
ii���i?o-1so 0.5 1.0 1.5 2.0
140-160 0.5
o.s 1.0 1.5
,100-130 0.5 0.5 0.5 1.0
pfd(i�
h----NOTES;!.TO FIELD (Building Department Use Only))-----------------------
L]
------------- ----------o
c
I,
F
i
r'
I �
���;I TOTAL P.05
� ORT►y
Town o . Andover
No. Al _ 70
-�- LAKE -yob ndover, Mass.,
If, COCMICKEWICK
ADRATED P?Y`, �
SSAC HUSH
IT
FOR
EXCAVATION
AND FOUNDATION
THIS CERTIFIES THAT .. �� TO N S oN V .......2.-P.Hy �rA � St.......... .................................................... ... ..............................................
hes permission to excavate and pour foundation at 407-107.. .� .... ,� ,t7....4040
.............
fODN�
...........
for the purpose of.. � Q� 5���� �� • //V I� �l�J//a
The person accepting this permit must return to the office of the P Building Inspector a Xcertified P lot lan show
of building thereon before Foundation will be inspected. 0 p/ /�S
VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS
The holder of this f=oundation Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS
assurance that a permit for entire building structure will be granted.
BLDG. PERMIT F l� .4
—
e
LESS FDA FE E•+o - am
............. .. .
..............................
DUE FRAME PERMIT$ BUILDING INSPECTOR
XAORTH
own of ►: 6Andover
No. -
C, dover, Mass., 62m // -a Oct/
COC NIC ME WICK ���
�d
ORATED p`? Cl
U BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
THIS CERTIFIES THAT 3.8.3...1o.4*4 e4.....b , �, I'�Y 77rkU *% BUILDING INSPECTOR
Foundation
has permission to erect...... .....`.............. ......... buildings on1d A....�... s...... ....I 6.i4.....,�,,/4 N1 Rough
D Roo�►+n a A a o t) .R� � S N 1� w�
tobe occupied as ..........................e........... ... ...........!........ ............. ..............�.....#....................... ........D...........II Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the spection, Alteration and Construction of
Buildings in the Town of North Andover.
q 8 A 1 PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMU ENDS IN 6 MONTH Final
E ELECTRICAL INSPECTOR
; S SIRTJ � 1 1 z T aTS ww Rough
.............................$A.`.. ........................................... Service
BUILDING INSPECTOR
Final
Occupancy Pema Required to Oaxipy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved .by the Building Inspector. Burner.
Street No.
SEE REVERSE SIDE Smoke Det.
Location
No. Date -�
NORTIy TOWN OF NORTH ANDOVER
10- 9
Certificate of Occupancy $
HusEBuilding/Frame Permit Fee $
G Foundation Permit Fee $
Other Permit Fee $
TOTAL $ J
Check # 1
I
1737 ) 111� ���
- Building Inspector
v
Professional Land Surveyors & Civil Engineers
ESSEX SURVEY SERVICE 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
3 PIAT PLAN OF LAND
G
LOCATED IN o �
APR
L�
2s 226
4"?I
L
5- LisPtLANA
�lll�
I hereby certify to the
115,4 L _ Building Inspector that I have
examined the premises and the
SCALE: �Q buildings are located on the
DATE: MAIN,r2(, z6fj 1� ground as shown, and buildings
shown conformed to the dimensional
zoning laws of Ii012,71 /iwl���/�'' ,t MA
REFERENCE: BK PG when constructed. oF
H
This Plan has been prepared for Building
t purposes only for the above �a CHRISTOPHER
permitting purpo y party,
and is not to be used for boundary measurements, o MELLO
land conveyancing or mortgage loan inspections or " No.31317 O
plot plans. UMtopher R. Mello PIS 3133 ST�F`yc��
104 LOWELL STREET
PEABODY,MASS.01960
(978)531-8121
1-0% C"
TOWN OF NORT.H.ANDOVEIR v%0RTh
"...
Officeof the .Building Deparbijent
coninumitV Developl.nellit apal sell-icef
27
Nf�rth
1), R,?bzrf NTcclta, Telephone 97 8)f-M-954-5
FAX(`7 ��'
April 15, 2004
383 Johnson Street Realty Trust
Joseph Pelich Trustee
44 Michell Road
Ipswich, MA 01938
RE: Budding permit#479 issued 2/11/04
For 15 Lisa Lane formerly known as 383 Johnson Street
North Andover, MA
Dear Mr. Pelich:
Please be advised that upon an inspection at the above referenced site, it appears that the grading
and foundation has been placed at a higher elevation than what was proposed and or the natural
topography of the site. If this is in fact true then steps will need to be taken to prevent runoff from
inundating the neighboring property with washout from rain and or snowstorms etc.
This letter is being sent to you in advance so that adequate steps may be taken to prevent
problems of this nature.
Please contact me so that we may resolve this issue in a timely manner, I may be reached at 978-
688-9545 between the hours of 8:30— 10:00 AM Monday through Friday.
Respectfully,
Michael McGuire
Local Building Inspector
Cc file
4 _
g
µ'10177y -
q ,t.aw
�4SSaC14
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number /V c/ Date 93
THIS CERTIFIES THAT
THE BUILDING LOCATED ON ,Co 7e /S— /S A LA /U �—
MAY BE OCCUPIED AS
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING.
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TOc�8 ,% N S U N I /R • T-
Building Inspector
LIZ tkOH
RT
Town of 6Andover
No. 479 -
�` C% dover, Mass. %2
T O LAK 1
COCKICHEWICK V
7�AoRATE0 P'P�,c��
S U BOARD OF HEALTH
Food/Kitchen
PERMIT T D
Septic System
3 8� �0� 0 S d 64• 1 !, ' 7rit.94
BUILDING INSPECTOR
THISCERTIFIES THAT............................................................................... ................x.... .... ................... . Foundation IV (C41--1
has permission to erect.............k............. .......... buildings on ..�►R? A. *..IS .�6.A.....4A.N Rough 1 > l 1D
to be occupied as Q R y!!�.�.a.' � •� 4#t �!.. N 1! �wll'� Chid /°
P � �
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in FinalG,
this office, and to the provisions of the Codes and By-Laws relating to the spection, Alteration and Construction of `' "��` /
Buildings in the Town of North Andover. at � ) S d PLUMBING INSPECTOR
I
VIOLATION of the Zoning or Building Regulations Voids this Permit. in
PERMT EXPMES IN 5 MONTHS
EL CAL INSPECTOR
UNLESS O S -UJ 1 ani TARTS � Rough
.. ......................... .fes..:.'...... ....... .............. Service
. . .. ..
BUILDING INSPECTOR
1�n 7'
Oxupancy I)ermit Required to Occupy Building GAS INSPECTOR ��
gh 7-7 -- O
Display in a Conspicuous Place on the Premises — Do Not Remove In a �-
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det. `vf,
TOWN OF NORTH AND0TV'FR
Office of the .Buflid-Ring Department
r 0
commiginiti, Developinlent "Andl. sel-,,ices i I
1114f
41 1. ot
27 11-harles Stred
North An(Wn ei%-Wassachuseas 01 R�t5
SS'ACHUS
D. Robert Nicclta, Telephionc(978)088-9;545
Builffif�g Commissioner YVI*_- 1)7 8 6S 8-9 4 2
April 15, 2004
383 Johnson Street Realty Trust
Joseph Pelich Trustee
44 Michell Road
Ipswich, MA 01938
RE: Building,
"''permit #479i*sued2/11/04-
:Ayq",,j�
or n1lisa Lane f6nnerly known as 383 Johnson Street
114� dove'r-,""Z'L
Dear Mr. Pelich:
Please be advised that upon an inspection at the above referenced site, it appears that the grading
and foundation has been placed at a higher elevation than what was proposed and or the natural
topography of the site. If this is in fact true then steps will need to be taken to prevent runoff from
inundating the neighboring property with washout from rain and or snowstorms etc.
This letter is being sent to you in advance so that adequate steps may be taken to prevent
problems of this nature.
Please contact me so that we may resolve this issue in a timely manner, I may be reached at 978-
688-9545 between the hours of 8:30- 10:00 AM Monday through Friday.
Respectfully,
Michael McGuire
Local Building Inspector
Cc file
Date....41;171
0 TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SA US
This certifies that ......tp- ............... ................................-P . C.
has permission to perform ......./ j
......A6!-1.41.......A ...........................
Mcq,oadlw
wiririg in the building of......... ........................................ .,................
at....... .....
ca. o /6 . V
.... orhAndover,yas.
7
Fee...k17..... .Lic.No.
Check # -7 INSPECTOR ELECTRICAL
5r 5 )
THE COAMOATHEALTHOFMASSACHUSETTS Office Use o 1 p�
DEPARTMENTOFPUBLICSAFETY Permit No. D�l l
BOARDOFFIIIEPP-'-' TIONREGUTATIONS527CMI1I2.*01 I
Occupancy&Fees Checked
x `t
APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICjCL CODE,527 CMR 12:00 f
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date b '?. o`1
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described belo
Location(Street&Number) l , N 09.
Owner or Tenant q-v-S O C.
Owner's Address v XJ �.
Is this permit in conjunction with a building permit: Yes[E NPdl ' (Check Appropriate Box)
Purpose of Building Utility Authorization No. �
Existing Service Amps / Voltsverhead Underground = No. of Meters
New Service — Amps( 6/`�}��Volts Overhead Underground E. No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total
KVA
No.of LightineiFixtures Swimming Pool Above Below Generators KVA
round round
No.of Recep�ile Outlets No.of Oil Burners No.of Emergency Lighting Battery Units
No.of Switch 6utlets
No.of Gas Burners
No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones
Tons
No.of Disposals No.of Heat Total Total No.of Detection and
Pumps Tons KW Initiating Devices
No.of Dishwashers Space Area Heating KW Nq.,of Sounding Devices
N4]bfself Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal Other
w Connecti.y
No.of Water Het#ters KW No.of No.of //
Signs Bailasis
No.Hydro Massy.ge Tubs No.of Motors Total HP
OTHER'
InstnaticeCov Rustle>ttotheteq�r�of�GenaalLaws
[have aoxmiiabllityhwxmwPbhcyiwkxhngarnplefp,Opff=wCovatageorAssubsuitblequiAut YES NO
[hawabmiMdvandpicofofsametotheO>iim YES � Ifyocl�
ubaNededYES,pkmmdcat3detypeofcD�
A)e�ig the box j
NSURANCE ty
BOND r7 OTHER F-1 fleas,-Specify). 4, -�za (� 7
ExpilationDaM
ESttm>ed Vak1eofElectrical Wodc$
✓NDIktoSlatt 6 Inspec6M' DateRegtles1ed Rough Final
>ignedund��ie iesof
7RMNAME LicmseNo.
icen,ee Gl?4-, Signahace Ii..
BusulessTelNo.
kAi pcc AIL TUNo.
)WNER'SINSURANCEWAIVER IamawatethatdrLitmsedoesnothavedr-mSs mio--covetageoritsabsU tialegamientastequnudbyMassa fiuscttsG nedLam
-id that my signahueon this pemt application waives this Iegtmt r ica
?lease check one Owner ® Agent
Telephone No. PERiIMIT FEE$
lana ure ot Owner or 7gent
CDate. .
,Ott Try
Of a o 1 H
o� TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
h
�7S SAC HUSEfA
This certifies that . .W. .L t SV A" . . .
has permission for gas installation . . 'e.Lt-'. 1'tD.`' .'r. .
in the buildings of . .C.!I!r.v. S . -t".~
i
at . . . . North,Andover, Mass.
Fee. .f�57. . Lic. No.Q GM. . . T DW?i?4 ����
GASINSPEC OR
Check# [ 0t�
4769
THE COADIONWEALTHOFMASSACHUSETTS Office Use o I p�
DEPARTA1EW0FPUX1CS4FL7Y Permit No. l
BOARDOFFIREPREVEWONREGULWONS527CMRI2 00
Occupancy&Fees Checked
x.
1
APPLICATIONFOR PERMIT TO PERFORMELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 /
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described belo
Location (Street&Number) 6
Owner or Tenant S d C.
Owner's Address u�.
Is this permit in conjunction with a building permit: Yes[Eg--No r--J . (Check Appropriate Box)Purpose of Building Utility Authorization No. 2-437
Existing Service Amps / Voltsverhead = Underground No. of Meters
New Service ;;L00— Amps( olts Overhead r-7 Underground �- No. of Meters
Number oi'Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No.of Lighting,Outlets No.of Hot Tubs No.of Transformers Total
KVA
No.of LightinjOixtures Swimming Pool Above Below Generators KVA
,) round ground
No.of Recep�:e Outlets No.of Oil Burners No.of Emergency Lighting Battery Units
No.of Switch 6utlets
No.of Gas Burners
No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones
Tons
No.of Disposals No.of Heat Total Total No.of Detection and
Pumps Tons KW Initiating Devices
No.of Dishwashers Space Area Heating KW N9.of Sounding Devices
Na o£Self Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW LocalMunicipal Other
d Connecti-Y
No.of Water HeAers KW No.of No.of
Signs Bailasis
No.Hydro Masa ge Tubs No.of Motors Total HP
OTHER. �' C
ft%M=Cov2rage.Ptns m ttothewWmrrttsofNb%whise8G=IalLaws
[have aamentLiab>ltyfinlnancePblicyinchxhngCompl Coverageoritssubsuitialegrmlent YES NO
[haw subn 2dvandproofofsametothe0ffice.YES IfyvubavedleclodYES,pk=h)diratethetypeofoovetage y
lleclmmgthebox �� Q
NSURANCE BOND a OTHER M ��Specify).
EgmationDate
Estff a Value ofl7ect<ical Wolk$
votktostart InspectionDateRequested Rough Fugal
>ignedundert e esof
7RMNAME Lie�eNo.
jc mTe C/i/q��? {,f' i�/l�� Sio-lature LicenseNo � 7
—�� BumessTe1NO. SG 3g,
�ck}tesc Al Tel.No.
)WNER'S INSURANCE WAIVER;I am aware that the License does notbave the inatrancecov�-eorits sural equivalent as wquaed by MassaLbusen Ctlieral Laws
xl that my signature on this permit application waives this wgrmnmemlt
?lease check one) Owner ® Agent
Telephone No. PERMIT FEE$
71—nature ot Uwner or Agent
W The Commonwealth of Massachusetts
d Department of Industrial Accidents
Office of Investigations
Boston; Mass. 02111
Workers'Compensation insurance Affrdavif
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
aI am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone#:
i
Insurance.Co. Policv#
Company name:
i
Address
City: Phone#:
Insurance Co. Policy#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 k
and/or one years'imprisonment-as well_as_civil..penaltiesinlhefnrmnf_a_STOP WORK_ORDPR..and_a.fine_of_(.$]DO.00J_a dayagainst.me.. I
understand that a copy of this statement may be forwarded to the Office of In: of the DIA for coverage verification.
I do hereby certify under the pains and penalties of penury that the information provided above is true and correct.
Signature Date
Print name Phone.#
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing _
E:] Building Dept
F-1 Check if immediate response is required M Licensing Board
F-1 Selectman's Office
Contact person: i Phone A- _ E] Health Department
F� Other
MASSACHUSETTS UNIFORMAPPUCATONFOR PIItMIT TO DO GAS MTNG
(Type or print) Date N e 1.1(r (A
NORTH ANDOVER,MASSACHUSETTS
Building Locations Z07- �^ / Permit#
J l Amount$
Owner's Name// 0— �U S ' tiSTr(JCT1.wj
New Renovation ❑ Replacement F1 Plans Submitted ❑
� a
U � �
W p 0 F x x
z O W F G'+ O U O z H
a
W p
WWx xww G z w 1 A Ch, a UW w WCC o W O A F
OO a
SUB -BA SEM ENT
BASEMENT
1ST. FLOOR
2ND . FLOOR
f{j-TjCKE— 3RD . FLOOR
4TH . FLOOR
5 T H . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or ty Check one: Certificate Installing Company
Name �- �� ` ❑ Corp.
Address ((0 '1 1 La Ke -SlU=,-F IPartner.
a 't rAA_ y'> � 0
.BllSrneSSTelep one Fi /C
Name of Licensed Plumber or Gas Fitter J Jct ll l A l(..S C)Y\
a
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No[]
If you have checked Yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy M 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 p
I hereby certify that all of the details and information I have submitt d(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installa ' ns pe nn under Permit Iss!pd for this application will be in
compliance with all pertinent provisions of the Massachuse s State G s de and Chapt r of the General Laws.
Signature of Licensed Plumber Or Gas Fitter
By:ittle ® Plumber
,T
City/Town ❑ Gas Fitter License Num5er
❑ Master
APPROVED(OFFICE USE ONLY) 0 Journeyman
d' Date. '0/e/a(
b
NOR7M TOWN OF NORTH ANDOVER
'• O
3j ��•_�`• ,• OL
° p PERMIT FOR PLUMBING
�,SSACNUSE�
This certifies that . W 159 f4-
d has permission to perform . .N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of Qt-r rte � . . . . . . . . . . . . . .
ti at . . . . A. . .t.4A-).\.Q. . . . . . . . ., North Andover, Mass.
Fee. .C�I�v. .Lic. No.. Iq.-'3c3
JOSI
(� PLUMBING INSPECTOR
Check #
660
J
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIlV
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
Date ��u V\6 149 doc4
Building Location Lore G�s�� � � Owners Name yRLIS 0QnST(-UC*i 0MPermit#
Amount
c
Type of Occupancy��ES(1�� T7
it
New Renovation 0 Replacement El Plans Submitted Yes No ❑
J
FIXTURES
F
A
ST.1gR4V1!)C
WS1H1 EW
]S1C)FIDCgt
2m MOOR
MHDM
4M YLOCR
5M)NI M
6M HMR
'7II3 FLOOR
9M FI"
(Print or type) Check one:
Installing Company Name /G Q ltla rp.
Co Certificate
Address o
Partner.
Ila 41&—A
Business Telephone !4W =6 —p/ / � Firm/Co.
e
Name of Licensed Plumber: ��(j l8 t C so n
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
lnsur - ver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
thr u a ce
ignature Owner Agent
(w I hereby certify that all of the details and information I have su fitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and in latio s p rmed under Perim' 's-sued for this application will be in
compliance with all pertinent provisions of the Mass usetts to lumbi d hapter 142 of the General Laws.
7
By: igna re o icense um er
Type of Plumbing License
Title 3
City/Town tcense Numner Master Journeyman
APPROVED(OFFICE USE ONLY
Date.. . . .!G./L . ... ....
NORTry
p TOWN OF NORTH ANDOVER
• =PERMIT FOR GAS INSTALLATION
h
SACMUSE�t
o . � 6"1 {
This certifies that . . . . . . . . . � . . . . . . .11. . . . . . . . . . .
eool-- 57X41,0
has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . .
in the buildings of . . . . . . /COU/U
at . . . . . �i�SS'„ G� / ' N rth Afird er, Miss.
Fee. . oU Lic. No.. �Z S'/E�" /./.!G vc�. . ..'.`? . . . . . .7
GAS INSPECTOR
Check#
8041
c
r '
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY C A „. do� MA DATE C�-d`�a0/( kERMIT#
JOBSITE ADDRESS[ S,q LANC OWNER'S NAME C C l- 6
GOWNER ADDRESS _ TEL AX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALF] RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:t7.1 REPLACEMENT: PLANS SUBMITTED: YES E] NO
APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER I _
CONVERSION BURNER
I --
COOK STOVE -
..
DIRECT VENT HEATER -
DRYER
FIREPLACE - - - - --
d
FRYOLATOR ---
FURNACE
GENERATOR _
GRILLE -� Al
INFRARED HEATER - - - - -
LABORATORY COCKS _ -
MAKEUP AIR UNIT
OVEN -
POOL HEATER - - - — - ---
i
ROOM/SPACE HEATER
ROOF TOP UNIT - -- -
TEST --
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER �.
OTHER I
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ANO [
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY r- R OTHER TYPE INDEMNITY r I 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 [..-j AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and acc rate to the best of my kn wledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia MA all Pertinent provision 01he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTEP.NAME LICENSE# / SIG
N TURE
MP)<MGF [ -1 JP -_j JGF[ ,I LPGI[ --1 CORPORATIONEW ��PARTNERSHIP E.,,"#[�y__ _ j LLC 1._* �y
COMPANY NAME:I_ (S _ )! -ADDRESS[
CITY ��.. a. ��( _ STATE ]ZIP :.D I ���. STEL ��
FAX[_ _::. �CELL� _._'sEN1A1L . �(9'Ut/`����..< ag�n _t9 a
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONL1 � FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
v
d
T1w Commonwealth of mm1whrmelft
DeparinuWofIttr mA afAecixlfetzit
o;Q�»oflnrstigrt[fo�rs
6010 WaslibigfouRred
Boston,MA 02111
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Add :, #
'SWCO4)z-1!bO--r kt- 1�O6�(% (Phom
hire yore ou eur Ctrl C(teeh the appropriate box: Tymof project.(retlu wd):
1:0 I atn,a ennprbyerartil, �r.El f anti a gelteral aluttmecor awt k.
err ees(fnit ancllorpat cn�se h ve hired fire s arottircactors " ® ��eoirsfsiiction.
2.f am a,sore propriexorer part'aer_ listed,on tiro altar~ited sheet.= 7. Remode nig
Ship tttd 1latreno cmproyces These S16-contradors.fim, & Dmuotil otn
working r'ornre m mlycapaeity. cworx`ere comp:.iustnam 4� Q`Btu' tit adtiit'"rom
[Noworkerecomp.jITSIMM 5:El We are it corpocatiotr and its
r.equireE efficersM ewchedthek MDMctriicafteomorad'dibons;
3.E1 f am>,tr homem.wrdoutg all work rfglit ofcremptiott per MGLP.hnub itg,npabs er addt'tiions
mysem.ICo,twmtew",cryontp: c.M f[QQj And%veh.mw, 0 Itoofcepaii
iatsnrance regoired-It enfproyem(Irau:orl�-ems°
comp.insumucaregF rred:] 13,[]Other ` 4
�1[tiryr{�plirAiCfliaC,C11"CKs box all mklarso fig outthesection h,toirsll�ning.Uktic�tnrKers'eoievpcivatron policyi damalion E
t tbmn intt<rs�rho StAnitI its eflizCticie irrdicnGng,Ihey sit Bohm all work cad thea Ria ouiside cartrscic�ts nnlst stet?ntd a Kew sta(mviik ardieatin suck
ifl tcxiris.:t7r3tcRrtkt#citracttnrsE',aryrcf.Cj an lditiea�tslee�K'.sttsnery,iSeuarrle cCtitrsnRcuu Ki4arsnmffUiz�rr rkixe'aYerr GrpnrtGnna>ii�sr 1
IrwH(in eag)[vy,ardor'fspmrwimn�nrlie�"cUm�rens�li�ai�csrrrmirejor,na�enrpfrn+ees B�vn�Lclils�pollefand�lislt� u
ln,�vsurnf�vn. � f
lnstuanccCompaiWl trei
k
Pa1f its or Sdf-fit Li+t.ft.-
Job
:Job Sale tOdchcss iCl
Altthatta eo'i 01 theao Gcrsti'co�nitensittiou policy decfatnttFotr1 :�stto Itrgtl iroirty>ilrrilbet:titd esyirinrimr.t.etc
Sallum to,seum covmgensrequired widersection 2m Of MGL c.E52 can Lead to,Meiniti s#tion;o€criiitaitlrpowAi sofa;
rme tip,tb)5r.$ t: '�Q,and/or.one-y ear imprisoument,,as weir as civil penalties ln:trio fonu of a;STt,1R WORK OrtDML and m far( 3
afn} f�S2S.fldr0ada�^aotitist[3icvrorttor: Beadvised1hata.copyor'irassta3enicnf.uia}be fimarded,(o,dw Offim of j
lIves litptions.of,theDIA,Eorinsltmncecoverage°reri&adson
I fltrlrer�}�ccr[if rrrrdet-llie:pertrtss artrfrsr{rfFlcFs ogerrr{tr I/irtt[!tela,verrlCprrauftl¢;!'alidtrnls!fire rel zee .
SieunwreT title
WOW 0114r.Do ffvt trxff.e uzOds area,fo he a mpdsyedtYCO orrown Offtdaf: I
City.or'Tbuwu L'erndttLP rse '
Isslii>jg�.ttiTrotif},geltscfit:oue�;
t.[ioant of ffe:titti:2.Iln r'dritg IIepartutent 3.Cify.f "owl Crerrc 4 Ckdsiaetl'ruspector S.I'iirn:bfug D"Vetor
&Other
Contact PersoM pitotteff:
i
i
Information
and Instrn'
14 assn++setts General U%vs,chapter 152 requires all employ=,to PMVdde;w wkers'
uarit.to tlhfs;statute'an etirloyee.is ckrft ed as-;-e-i - Bi oto for theme ernpP°yees
e>r person iir fake ser iw.of annflier ianalersaiy+coiitract of Tii
"Press or implied;oral or writttm,"
I
As enrpfr ye is defined as"an individual,par%w shkp assucWon;c o ation or Otho
of tileforegoing engage4 in a,Ioint erste � � 'p on any hvos or mote -
rP t and rrt:Iiirh'ng the representatives of a&ceas ed employer,or the
receKN,erortrnstecof'arn fnd v bal„pallmsfnipaasseciat'ionorodl rkgalentit3„eAVloyingernplayew, Howevert'he
owner of a.ftelling,house having not more Man three aparnmi}ts;and Who;resides therek or thel accupant ofthe
dwe1144910116e of another who employs;penons,to do mavuenene,const awden,or repair urorkl-on such dwelling,house
ar .the,gzounds or IhaiIdnrg,appurtenant tPtereto 6.hal!,rota becariser of'sticlh,eiraplorynterat be;dbeinedt to bean employer-
MUL ”
claagter 152;§25C(6)a aPso stag that"every state or locait Ifeensing,agency slhalr wrtihhol"tI the ssuanee or
renewal of it license oar permit to opMte a lziisixess or to,eonsfrnet buildings in the commonwealth for any
alrplucan"t tYlur has.not produced awepfable evIMeme Qf'com rlraneewith9 tlteihistt.i iarade Qovt age.regrt red's
1tETdi oirall „MGL cliaptcr 1'S2;1t25E 7)states"i�Peit1wr
the coiiinrcanwealtli nor any of its polifirart'subdivisions sbailI
enter into:any contract for the performance ofpublic:work iurtr'T;lacaeptable evidence of(ImPliandae With the insuranc e
requirements oftbis chapter have been:presented to the con
trading,antlharii
AptpRemifs
Please fill out the Workere catnpensation affidavit,coats lel b.checking 1y: 3
� ng fhe boxes that apply tOyoairsituatirin and,if
necessaTY„supply sub-contractors}name(s),address(es)and,gtij�oe number(s)along with their wxtifrcate(s)of
irrsurance:. Limited.Liability Companies.(LLQ orLimftedLiab"iAXPattnexshipsaJP)Wtlh.noeanployeesother than the
members.orpadners,are not:required to carry workers'compensation insurance: Yarn LLC or LLP`does havaa
emplayMp a policy is requited, Be advised that this uff dac�ff may be srrbriiitted'to lite oartment of'Industrial
Accideaafs fvr confirnaaffon:of insurance coverage: Aho be slff tarsigAt and date the:affidavit. The affidavit should
be returned to tlhe city or town that the application for the,p miit or license is being requested,'tot the Department of
lndustrW Accidents. Should you have any questions regardu1g.t to lai{T er if yorr arm
required to ohtaiir a worker,'
compensation policy,,please call the Department at the number hilted'below. Self-insured co hies should enter their
aePE aisi ante
license member on the ,opi ate”Brie..
CFtg or Tonn offieiars
Pimse be sure thatt the affidavit is complete.andd printed legibly, ' to ll-att—nt.has provided a.space at the bottom
of'the,affidavitfor you to fillout in the event,the Office of fnvestigstmirs has fo contact ,ou r
Pleasebe Satre to fill ins the � � applicant..
permit/license'lumber winch grill'be ukd as a reference nrnnber In addition,,an applicant
that must sarbmft mnitiple Permit/license applications irn.any,g .i,year,need,only submit one afBlavft indicating current
PO,hr-Y in brmation(if necessary)and under"Job Site Address"the app:Picant should write"all vocations,is (cite or $
Nva)L7,copy,ofthe.agwavit thathas been officfal'ly stanxped ormarked lip the city ortown may be provided to;the
applicant as proof drat a valid affidavit is one f le for future perinif or licenses. Anew affidavit:must.be Palled out.each,
year..there:a home caner or citizen is obtaining a license:orrpert ft:not related fo any bus iiess or commercial venture {
Garr a dog license or permit to burn:leaves etc)said person is-'Np�required to compl?em this affidavit:
Ofwe ofinvestigations%vould like to thank your in advance ft your caoperatiot and shwId yatrhave any.questions,,
please,do not:liesitate to give us a call.
TiC`k>aparrtinent's address,telephone and fax mmnber;
The nsonceMitt,OfM'as 3useft
Department o�`IU&StrjaT Accidents i
office ofInvesst gaftd ns
600 Washington Street
Boston,MA Oil I I
I
Tel.#617-727-49001 ext 406 11:-6 7-MASSA E
Revised 5-26-05 Pax#6.1,7-72.7-7`I49 I
wV1'4 amss.got',1a