HomeMy WebLinkAboutMiscellaneous - 150 BRENTWOOD CIRCLE 4/30/2018 (2) 15 BBRENTWOOD CIRCLE
210!064.0-0056-0000.0 -
Date.....q......7
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ....... ......................... ...... ........
has permission to perform ................ .......... ......................
wiring in the building of................ ..........................................................
at ...
41
..................................... 1 ...... ............ North Andover,Mass.
Lic.No. ............. . .
LEC INSPE YOR
Che'C'k# 6 L13o
11777
Commonwealth of Massachusetts Official Use Only
77 7
\� a Department of Fire Services Permit No.
�\ BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy
v. /1 07]y and Fee Checked
M, tr ( ve blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMR 12.00
(PLEASEPRINTWINKORTYPEALL.INFORMATION) Date:
O ` 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) 4_S22 AZ,, ,,1&ppZ9 C1. C Ie
(�
Owner or Tenant r d'1 s �a✓'��� Telephone No.4'7,5 _�O
\� Owner's Address
\ Is this permit in conjunction with building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building R p g- ;A&PS�� `-� Utility Authorization No.
' Existing Service Amps / Volts Overhead[_1Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 4.0
Completion of the followin table maybe waived by the Ins ectorof Wires.
No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Ge erators KVA
No.of Luminaires Swimming Pool Above ❑ In- o.of Emergency Lighting
rnd. grnd. .Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.o�Zones
Teo.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: """""""""' Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KyV 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 E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 9_6'f 3 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
IKSURANCE 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 covert e is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,tinder thegains andpenaI'es ofperjury,that the information on this application is true and complete.
FIRM NAME: . L G LIC.NO.: /..? ,Tib
Licensee: —Signature LIC.NO.:/3,0
(If applicable ter "ere t"in the license natmber line.) Bus.Tel.No.•
Per M.G.L c. 147,s.57-61,security work requires Department of Public Safe 'S"License: Lic.No.
OWNER'S INSURANCE WAIVER: Tam 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:$
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the �t
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed Cj
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 M n, Failed Re-Inspection Required($.)❑
Inspectors Co
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 1� Failed Re-Inspection Required($.)❑
Inspectors Comments:
6
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass F71 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
R
The Commonwealth of Massachusetts
Department of Industriql Accidents
Office of Investigations
kvi 600 Washington Street
Boston,3M 02111
www massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):�
Address: 18�� y,
City/State/Ziphone
Are you an employer?Check the appropriate box: Type of project(required):
1.Mama employer with4. El am a general contractor and I
employees(full and/or p -time).* have hired the sub-contractors 6. ❑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. [1 Demolition
working for me in any capacity. workers'comp.insurance. 9. E]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 I L❑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' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Hombowners 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.
Insurance Company Name:.
Policy#or Self-ins.Lic.#: Expiration Date:: q
Job Site Address: � p�/�ir�cvp���,���_City/State/Zip: tel/ w�we./ Nl
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains ndpenalties ofperjur ai the information provided above is true and correct. -
Signature: Date:
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#'
v
E
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 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 producedacceptable 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-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
i
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 permithicense number which will be used as a reference number. In addition,an applicant
that mustsubmit 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. r
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of ZndusWal Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel,#617-727-4900 ext 406 or 1-877rMASSAFB
Revised 5-26-05 Fax##617-727-7749
www.mass.gov/dia
Location
No. Date !
NORTq �-- TOWN OF NORTH ANDOVER
p Certificate of Occupancy $ �Y
Building/Frame Permit Fee $
..
Foundation Permit Fee $
cMusE 4�`LLgP
ermit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
wilding Inspector
/�T l� 66
.QTc
8047 Div. Public Works
PERMIT NO. wAPPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
'EMAP lqO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK iPAGE -
ZONE SUB DIV. LOT NO.
LOCATION Ire) PURPOSExOF�6171LIJ7#1G
✓OWNER'S NAME NO. OF STORIES SIZE
✓OWNER'S ADDRESS `rte OY_' BASEMENT OR SLAB
ARCHITECT'S NAME y3 LJ 4:i1s} SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAMESPAN
,C
DISTANCE TO NEAREST BUILDING- DIMENSIONS OF SILLS
DISTANCE FROM STREET '" '" POSTS
DISTANCE FROM LOT LINES—SIDES REAR "" '" GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
.�S BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
�W,ILL BUILDING CONFORM TOREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
✓BOARD OF APPEALS ACTION. IF ANYIS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST +• 00'C�
PAGE 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED�G{ARfttS MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MISY'BE FILED AND APPROVED BY BUILDING INSPECTOR
I,--,
DATE FILED J ,
� nuum Na INiPBCTOR
�./SIGNATURk OF OWNER OR AUTHORIZED AGENT
F E E 6,t--2-7 /OWNERTEL.# 66e
PERMIT GRANTED /CONTR.TEL#
19 / CONTR.LIC.# ®/
H.I.C.#
00 4-7
I
S
8
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY ST I?IES 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 —I 8 INTERIOR FINISH
CONCRETEd I 2 13
CONCRETE 151.K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL
UNFIN
3 BASEMENT 11
AREA FULL FIN. B M AREA _
71 1/2 3/4 FW ATTIC AREA _
NO B M T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH
ASPHALT SIDING HARD"J D
ASBESTOS SIDING _ COMMON
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 I-1 POOR
ADEQUATE l NONE
5 ROOF 10 PLUMBING —i
GABLE I HIP BATH 13 FIX.) _
GAMBRELMANSARD TOILET RM. 12 FIX.I _
FLAT I 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 2,d _ ELECTRIC
1st 13rd NO HEATING
COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY
OF UNE ASHBORTON PLACE
MASSACHUSETTS BOSTON,MA 02108 Vi a
Y 4
LICENSE
EXPIRATION DATE CONSTR. SUPERVISOR
09/12/1995
RESTRICTIONS EFFECTIVE DATE LIC-N0.
NONE C9/3.0/'1993 049019 ,r
oCR�4IG J HANCOCK
97 LAKE SHORE RD
SS 030-52-1553 EW B�OXFORD MA 01885
m
PHOTO(BLASTING OPR ONLY) �EF'.00 •' �
0U NOT VALID UNTIL SIGNED BY LICENSEE ANDOFFICIALLY
HEIGHT: STAMPED-OR-SIGNATURE OF THE COM ISSIONER
DOB:
9/12/19:5$
THIS DOCUMENT MUST B
CARRIED ONiHEPERSONO" % SIGNATURE OF LICENSEE'S
`..ti..v
THE HOLDER WHEN EN
OTHERS-RIGHT THUMB PRINT GAGED IN THIS OCCUPATIONK, ""'� - - ' y
'iQ. F'y Y�1�`.;.•�� 'MI S$0NEFI 1fi
.GT.Ee� seulsalG4,�✓1��'watr./ruae�r`r:;��� !
•.uu� -. ::�'Y�1i-�11. v'11ItiAv.V!`�
_ 1 •1
/Mfi •Il/�1�J1DUhL • >.3
I, CN�V�W a• 1.vJvis Jf7C Vl.�y '- fill(((( ('
ADMINISTRATOR A. N.,.;vi Uha'+`
i
`r' ' — . 1 Nonn A[IUUVci.
APPEALS NORTH ANDOVER Massachuseas o 1845
(6 1 7)68547 7S . ;
CONSERVATION DIVISION 01'
H –\NNI-1
PL�i\\I,IG PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P.NELSON,DIRECTOR
In ac :rdance with the provisions of MCL c 40, S 54, a condition of Building Permi;
Number is that the dcbris resultina from this work shall be
disnosed of in a prepe.ty liccnsed soiid waste disposal facility as det7ned by MGL c 11:, S
1�OA.
The det'ris will be disvosed of in:
(Location of city)
I
Sicnatu.e of ?c,—,nit Appii int
LA; ;moi
Date
;0 Jz_oi_c oer-"-_ f� W _t e -o,,m, of Vorrh -Andover -must be aotc:-__
..rr:u - `e Of=_ce or the 3u,Idi:g Inspect :.
00�cao
ovm Andover
No
l t.
' , 19'
o �A= Nott i;� , dover, Mass.,
d100,
BOARD OF HEALTH
Food/Kitchen
Septic System
P E � IT TBUILDING INSPECTOR
THIS CERTIFIES THAT.. .. ... . ..... ......... ...,0q.. .... . .. .....
Foundation
.•� Rough
has permission to•e�i. .. .'f�:.IC....... buildings on ..�
��
Chimney t
o.. ....
t0 be OCCUPIBd as........ .... C imne
'provided that the perso accept g this permit shall in ever espect confo to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Fina
UNLESS CONSTON ARTS ELECTRICAL INSPECTOR
Rough
Service
.... ... ..................................
n
BUILDING INSPECT
Final
Occupancy Pen-nit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Finalh
No Lathing or Dry Wall To Be Done
FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
PLANNING FINAL CONSERVATION FINAL Street No.
Smoke Det.
SEWER/WATER FINAL eo q q, DRIVEWAY ENTRY PERMIT