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HomeMy WebLinkAboutMiscellaneous - 15 SARGENT STREET 4/30/2018 / 15 SARGENT STREET r 21oro1s.aoosa0000.o N° 2 51 0 Date ... . .............. NORTI� °f�"`°;•'"° TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING b,sSACMUSEt { This certifies that 0- .......................-' I has permission to perform ..........................:- .A -. ?` �� wiring in the building of................'' .......................................... at../i.... ....�-� "! ............................. .NPrth Andover,Mass. Fee.. Lic.NoA.�ZZ�.....:.... .......................... ............ /` ELECTRICAL INSPECTOR Check # /CqC/f r 6/' WHITE: Applicant CANARY: Building Dept. PINK:Treasurer IM(,UJUMU1VWP-4L1 H UP M11," ULNEJ J' urnce use omy DEPART 'IOFPUBLICS1FMitem - Permit No. BOARD OFF7EPREVENI ONREGUL477ONS5270 812:1X1 12.T Occupancy&Fees Checked UV FOR PERAff TO PERFORM ELECT WCAL 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 L L 7 n U Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) S4-, Owner or Tenant cmc^. N fVl e�Juk- - J 2 L( � �s Owner's Address ��hrc.-4 S4 Is this permit in conjunction with a building permit: Yes No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service (UCS Amps I& /NO NO Overhead ED Underground ® No.of Meters New Service ? Amps 1W/?10 Volts Overhead Underground ® No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 45C ra<ce � a (s^� No.of Lighting Outlets Q No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground El ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals f No.of Heat Total Total No.of Detection and / Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices / No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local ® Municipal ® Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER- P h�rat�ceCQ.aage.Rasua�Y6�theragtritana>Ls �C�alLaws I haw aamertLnbtkhwm=Policy mdt6ngCo ComaWor9s stk4ytd e4ndlag YES NO IhmeahnmedvaMproofafsatmtothe0ffioe YES ® Ifycuhive duJ(edYES,pkme hdr&thetMxofw=aWby&cdcrgthe lNsuRANCE BOND OUTER ® (PlemeSpe*) E4imFkdvahtecfE6c i A Wctk$ Work to Start �� ` OU h pectirnD*Rat�ted Ra#t t. r(( E q(( �® Feral V, Sigrw u ndAc etralties ofpajtay. �- (( a t_ FIRM NAME t �d• �Ca`Cr�cc C�r(� Lica&Na 1 5� 3 7 7-4 Lica= t-> c Signs IjXrSeNo 3 017 BtSiressTdNa 9 )ys Ai Tel.Na r S OWPIER'S1NSLRANCEWAIVER;I.amawarethattheLio=dbmnut to oo arAss l ast byM G L ar3d�my stern this p�holt this rt�quau3tta>t. (Please check one) Owner Agent Telephone No. PERMIT FEE$ !�® Location No. f Date _v HORT#j TOWN OF NORTH ANDOVER f � + Certificate of Occupancy $ 91/ 9 Buildin /Frame Permit Fee $ s�cHusf. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / Check # S 13 0 / Building Inspector f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING II&Section for Official Use Onl BUILDING PERMIT NUMBER: DATE ISSUED X J/f SIGNATURE: ✓i%( Building Commissioner/I for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0119. 0 00 ,30 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private ❑ zone Outside Flood Zone ❑ Municipal *A On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) Address for Service cA....— � Si n ure Telephone 2.2 ner of Record: O Name Print Address for Service: z M Signature Telephone QQ SECTION 3-CONSTRUCTION SERVICES 3.1 Licc*nsed Construction Supervisor: Not Applicable ❑ �Z 44e Licens*d Construction Supervisor: Nn � 1V1 License Number ..r,' a O 8� I� �zog3 3' Addre ic 'Lkej 7 Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable 0 Q Company Name '4zo IF- D e M (—>\ � , ^ t `►n Registration Number r Addre`s Q ( �` Oo0 Expiration Date `�• tinenawre Telephone a SECTION 4-WORKERS COMPENSATION I'll(M G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be co11 mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building rmit. -- Signed atiidavit Attached Yes....... No.......0 SECTION 5 Descri tion of Proposed Work check all a licable ons( New Construction ❑ Existing Building 0 Repair(s) ❑ Alteratis) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: C1, SECTION 6-ESTIMATED CONSTRUCTION COSTS OFFICIAL USE ONLY Item Estimated Cost(Dollar)to be Completed by permit applicant 1. Building (a), Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee(s)X(b) c 4 Mechanical(IiVAC 5 Fire Protection 3 O Check Number 6 Total (1+2+3+4+5 �,,��� SECTION 7a ENT OR CONTRACTOR APPLIES FOR BUILD BE COMPLEED WHEN OWNERS AG EN"' PERMIT as Owner/Authorized Agent of subject property to act ort Hereby authorize G NIS eha .in all matt rs relat'v work authorized by this building kern it application._` Date Si natu of owner SECT' 7b OWNERIAUTHOFtIZED AGENT DECLARATION (been Coy? S TC1 c„n ,as Owner/Authorized Agent of subject 1, property Hereby declare that the statements and information on the'foregoing application are true and accurate,to the best of MY knowledge and belief V, Print Na Si nature of Owner/A .ent Date SI7_E NO.OF STORIES 13ASEN1INT OR SLAB 1 2 3 SU.l:OF FLOOR TUvWERS SPAN l)IMIENSIONS OF SILLS DIMENSIONS OF POSTS DIML'NSIONS OF GIRDERS 11[ICKNESS l llil(il l'I'OI I OUNDA'I'ION X S!ZE OF FOOTING MATERIAL OF CI-llMMNEy IS BUILDING ON SOLI])OR FILLED LAND IS I1(JII.DING Co NECTED TO NA'IIJRAL GAS LIME The Commonwealth of Massachusetts iizb Department of Industrial Accidents oficeo//nuestieJAMS 600 Washington Street G, IVE "� Boston Mass. 02111 Workers' Compensation Insurance Affidavit lfcant 1n outrlafion j 9 Asx , v , .,lease>. R am lo-cation:Ct AA di, da,,�_,I-1 U� hone# Q F] I am a homeowner performing all work myself I am a sole proprietor and haveRRno one working in any capacity � I am an employer providing workers' compensation for my employees working on thts�ob. company name. address: city: shone# insurance co. ' pohcy# d. � I am a sole proprietor, general contractor, or homeowner(circle one) and have hired thefcontractors listed below who have the following workers' compensation polices: tom any name. a dress. X. phone# insurance co-. oltc #` 7777;77 c m an name. address. ci phone msurnce ca pohcy# X. A f1cf tfdttrional h .f'e�css ry z � � tic �� " ✓ �". Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of IVA a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify and a ins a d penalties of perjury that the information provided above is true and correct. Signature 5—/6 -00 Daten Print name o JG'r-f I�eG�'/'1..... .. .. .....: . .. . .. Za / Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# -Building Department OLicensinkBoard ——" ❑ ------------ check if immediate response is required pSelectmen's Office pliealth Department contact person: phone#; -Other (revised 3/95 P1A) ....._,..., .� '•;. L Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association;corporation or other legal entity, or any two or more of 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compiiance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. o7- /�/ s i �� VWR Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address.and phone numbers as.all affidavits may be submitted to the Department of 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. -' .� ye " f:r✓ p y�%c( 6jMr. rz° ss+ dam." City or Towns 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 penniUlicense number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. # ...*o x's The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 •a BOARD p6 `�� License: OIVSTRUC O REGU�A:TIt�IV µ : Num N SUPERVISOR ber• Bl 076691 da�,i08/t6%196 8 8�1`6/2.OU3 It Tpp0' ,' Tr,no: 76691 ROBERTA KEENS ,`rY 57 SECOND ST NORTH ANDOVER, MA 01 845 ! I Administrator 1 o w � �� 1 I ��� � M` �o i �3�(�'� i i � i � /� z� r- �- - 3,Z �_�.__._ � _.�. .,.� `f_ z � � �2, � NORTH µ Town of Andover No. ai,1 = x - �L A o dover, Mass., O a COCHICHEWICK ORATED P?a��� S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 0,400] BUILDING INSPECTOR THIS CERTIFIES THAT...�W..tri./.1w..... ... ........ .��.�.. .�. r�a...S........ """"" Foundation has permission to erect.../<.....0"..0.10'04.... buildings on ......1. ...s ..r. "�� ............... Rough ................................. to be occupied as...... ./1. ............................................................................................................................. Chimney �C.....rti .. .. .. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. rye A 340 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. w Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR Rough ... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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.