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HomeMy WebLinkAboutMiscellaneous - 16 ANDREW CIRCLE 4/30/2018 16 ANDREW CIRCLE 210/047.0-0117-0000.0 1 I r i 4 I I North Andover B�,-xd ofpA ssessors Public Access ., Page 1 of 1 µORTM North Andover Board of Assessors 7ZIroperty Record Card Click Seal To Retum Parcel ID :210/047.0-0117-0000.0 FY:2013 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels - Search for Sales ,..1 Summary Residence Detached Structure Condo aeuroPEwaRcLE Commercial Location: 16 ANDREW CIRCLE Owner Name: CHOWHAN,CHIRAG,&PUROHIT,NEPA Owner Address: 16 ANDREW CIRCLE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 0.29 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1152 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 212,400 215,400 Building Value: 77,400 76,800 Land Value: 135,000 138,600 Market Land Value: 135,000 Chapter Land Value: LATEST SALE Sale Price: 280,900 Sale Date: 06/22/2005 ArmKUTSMAN,s Length Sale Code: Y-YES-VALID Grantor: VLADIMIR Cert Doc: Book: 9585 Page: 101 http://csc-ma.us/PROPAPP/display.do?linkld=2253444&town=NandoverPubAcc 3/26/2013 Residential Property Record Card PARCEL ID:210/047.0-0117-0000.0 MAP:047.0 BLOCK:0117 LOT:0000.0 PARCEL ADDRESS:16 ANDREW CIRCLE FY:2013 PARCEL INFORMATION Use-Code: 101 Sale Price: 280,900 Book: 9585 Road Type: T Inspect Date: 08/19/2006 Tax Class: T Sale Date: 06/22/05 Page: 101 Rd Condition_: P Meas Date: 08/19/2006 Owner: CHOWHAN,CHIRAG,&PUROHIT, NIPA Tot Fin Area: � 1152 ' Sale Type: P Cert/Doc: Traffic: s M Entrance: � X Address: Tot Land Area: 0.29 Sale Valid: Y Water: Collect Id: RB 16 ANDREW CIRCLE Grantor: KUTSMAN,VLADIMIR Sewer: Inspect Reas: S NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: RE Tot Rooms: 5 Main Fn Area: 576 Attic: N NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4 Story Height: 2.00 Bedrooms: 2 Up Fn Area: 576 Bsmt Area: 576 Seg Type Code Method Sq-'Ft Acres - Influ-Y/N Value Class Roof: G Full Baths: 1 Add Fn Area: Fn Bsmt Area: 372 1 P 101 S 3000 0.070 133,346 Ext Wall: BV Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 0.220 1,672 ` Masonry Trim: Ext Bath-Fix:_ 0 'TotFin Area. 1152 4 VALUATION INFORMATION Foundation: CN Bath Qua]: T RCNLD: 96800 Current Total: 212,400 Bldg: 77,400 Land: 135,000 MktLnd: 135,000 Heat Type: HW Ext Kitch: Year 'Built: T Prior Total: 215,400 Bldg: 76,800 Land: 138,600 MktLnd: 138,600 ch: ' r'Built: �Built: 1978 Mkt 1978 Sound Value:dj: 0.800 Fuel Type: G Grade: A Cost Bldg: 77,400 Fireplace: 0 Bsmt Gar Cap: Condition: A Att Str Val 1: Central AC: N Bsmt'Gar SF: Pct Complete: Att Str Val2: Att Gar SF: %Good P/F/E/R: /100/100/78 Porch Type Porch Area Porch Grade Factor W 64 SKETCH PHOTO '�'�"�`„- W - s 64 Sq Pt r � FUJFMf6 576 Sq.Ft 'Tt"» 32 32 �. r� a t 1 ” • 16 ANDREW CIRCLE IS Parcel ID:210/047.0-0117-0000.0 as of 3/26/13 Page 1 of 1 Datel..U2'1 .. ............... OF NORTF�,� TOWN OF NORTH ANDOVER s PERMIT FOR WIRING sS�CHU5f� This certifies that�l .................... .. ................................................................ has permission to perform ..�JCL�QQ Gn. .............................................................. w,.iring in the building of........�..f!..9W '....................................................................... ! ` ?t ................... ....................P^�� ................RC�-.........., orthAndover,Mass. Fee... .2�..`.........Lic.N0.737�.. ELECTRICAL IN CTOR Check 4 �U 4 9 Commonwealth of Massachusetts 0 inial Ilse Only 31 Department of Fire Services Permit No. Occupancy and Fee Checked aM BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),5 CMR 12a0 (PLEASE PRINT IN WK OR TYPE ALL INFORMATION) Date: t _ 1 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice;4sh mte�ntion pAerfo a elec igal work dgscribed below. Location(Street&Number) I b J , , ` Owner or Tenant e,\I\ ['V-(A- v�—C v\QW 0(-/J0(-/JTelephone No. Owner's Address S Is this permit in conjunction with ffa building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building .lam F l 1 Utility Authorization No. - Existing 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: V-rr p w (;C- o V-ty C-S Completion of Ned by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fan' No.of Luminaire Outlets No.of Hot Tubs ' No.of Luminaires `Z Swimming Pool Above rnd. ❑ I / No.of Receptacle Outlets No.of Oil Burners No.of Switches No.of Gas Burners Tot; C� •� No.of Ranges No.of Air Cond. TO; No. of Waste Disposers Heat Pump 'Number"Tons Totals: No.of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances No. of Water KW No.of No.o Heaters Signs Balla No.Hydromassage Bathtubs No.of Motors Tota' FOTHER- Estimated 0o ` 00 Attach additional detail if desired, or as required by the Inspector of Wires. Value of Electrical Work: (When required by municipal policy.) i` 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 licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The 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 pains andpenalties ofperjur�y�hat the information on this application is true and complet FIRM NAME: _ )b S F(P u '�-' `� LIC.NO.: ? 2 fo Licensee: —T - VS V u ci,1 Signature LIC.NO.: Q (If applicable,e t ,exempt"z44WWiense6uqbpa_ line.) Bus.' No.• Address: b �t N l( 5`� ��w/.���g c.�y Y,X?t Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department 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 PERMIT FEE. $ 5 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 o e 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 M 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: G7 Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: r t Inspectors Signature: Date: FINAL INSPECTION: PassVN IN Failed Re-Inspection Required($.) ❑ Inspectors Com ts: Inspectors Signature: V Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 4 Commonwealth of Massachusetts o ficial se Only a Department of Fire Services Permit No. z�51 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cote C),52.7MR 12 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice oXfii, Pointention o erfo a 1�yaI�rk d�scr�ibed below. Location(Street&Number) or 1 r Owner or Tenant v,� ��� OW OwJ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building k A.>E (I ( t0 -) Utility Authorization No. Existing 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: ✓'e p 1 V- x- Cis -k- Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ In- E3o.o mergency Lighting g 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 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers HeatPump 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 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: 00 .. ©0 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: 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 coy age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties ofperjury hat the information on this application is true and complet FIRM NAME: . 'ted S F(P u LIC.NO.: r3 2 Licensee: C^\ Signature LIC.NO.: e-)p C 0 (If applicable,e t exempt"in ense umber line.) Bus.Tel.No.• " Address: b �t N l( c5'� �E�;►/.S S'�p c-ty y lYt Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department 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 EP—PRMIT FEE: $ Signature Telephone No. I ❑ 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 1 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 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IM Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ] PARTIAL ROUGH INSPECTION: P Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Com ts: d -Z Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ,fh i y X The Commonwealth ofMassachusetts - Department of Industrial Accidents Office offnvestigations 600 Washington.Street .Foston,MA 02111 www mass gov/clia Workexs' Compensation Insurance Affidavit:Builders/Cont°actorsXlectr cians/Pliimbers Applicant Information Please Prim LeAh Name(Business/Organizationftdividual): Address: City/Stale/Zip: ' \ eW-0b Lt J c MOM= Are you an employer?Check the appropriate box: Type of project(required): 1.[� I am a employer with 4• ❑I am a general contractor and I 6. New constriction f mployees(fall and/or pari-time)* have hire dthe sub-contractors 2.M 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 forme is any capacity. workers'comp.insurance. 9. El Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.[PElectxicalrepairs or additions required.] officers have exercised.their 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.Q Roofrepairs insurancerequired.] employees.[No workers' 13.[]other 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 indicatingthey tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am are employer that is providing workers'compensation insurance for my employees Below is the policy and job site infoimation. � (� n C A- L `f d� � ' Insurance Company Name:. J� y ` J n n Policy#or Self ins.Lie.#: Expiration Date: ` L O ` Job Site Address: W C VC City%State/Zip: N ` Attach a copy of the workers'compensation-poRcy declaration page(showing the policy number and expiration date). Failme to secure coverage as requ1 dunder 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 STOR WORK ORDER and a fine ofup 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 DTA.for insurance coverage verification. f do hereby eerti un or the pains and ti Y• at the information provided above is true/and erorr�.,eft. - Si afore• Date: ` O 2 t l Phone# Oficial use oily. Do not write in tlifs area,to be completed by city or town offzcial. City or Town: PermMicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CiWT- own Clerk 4.Electrical Inspector S.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 ernployee 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 fore goiug engaged in a j oint 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 ofthe 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.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-contractors)name(s),addresses)andphone numbers)along withtheir certificates)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,apolicyis required. Be advisedthatthisaftidavitmaybesubmittedtotheDepartm.entof 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' compensationpolicy,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,por it/11cense 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 PONY information(if necessary)and under"Iob Site Address"the applicant should write"all locations is (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 Hermits 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 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 Co on�oaTt�o�l�assarhusP�ts - Deparieat offi dustxial Accidents Office ofZuVe8tigatjons- 600 Wasbingtoa Street Basion,MA 02111 T01#RM-21.7-4900 end 406 or-1-87V,:M-S9AFg Revised 5-26-05 FaY,0 617-727-7749 v�vt�'.xllass,g4v�cb°a - d 1 J j C0MMo MgSSq�Hv, pP `SETT /SSU f fCfC9RD T AS A: Rf a�f FQ R OW ANS OS f_P RNf .Y N� H A BRAG Mgy �rC fCTR 1�6 PR f SAN, ��` /y�CC Rf;: � � T .. fWKSBURY. T ��1 •," 0 1 876 �= '?4�9 {`� Date...... r►ONTH, o . do TOWN OF NORTH ANDOVER 410 p PERMIT FOR PLUMBING ,g3'�CHUg�t This certifies that..�:Q97�..... . ................................................................ has permission to perform..........P,,.v-.-C..................................................................... plumbing 'n the buildin s of............................................................................................. at./ .... ................................. o Andover, Mass. Feec?.P.'00 ..Lic. No. 4.�.f ......1.::q...�. ....................................................... PLUMBIN INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK R ' CITY MA DATE PERMIT#- JOBSITE ADDRESS �� OWNER'S NAME L/j/Lj©/� tw'n�rt ►1 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES Of NO 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 1 �( __ i _._ _ _T w► I _�_ _f —( _ ( �( �( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1= _,___I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ _ i ___TM __—._! _... . ..__.__. J ..r_.._ KITCHEN SINK LAVATORY ROOF DRAIN i __. J __—f .1 _ _.E ( . E ._ _ _._.._ i ....-._._i __ _J _(= SHOWER STALL31 SERVICE/MOP SINK i TOILET URINAL WANING MACHINE CONNECTION _i WATER HEATER ALL TYPES WATER PIPINGE3E' OTHER _ S 1 I --- I —I i -----} - i .. - -I 1 - -E INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND Q 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 Q AGENT 10 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 ofAy kno ledge and that all plumbing work and installations performed under the permit issued for this applicati e m c nce with all Pertinent p io ne Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � PLUMBER'S NAME ° . . I LICENSE# 1 I SIGNAT RE MVIP 0 JP IJP" CORPORATIONJ# j PARTNERSHIP Q# LLC COMPANY NAME vADDRESS CITY lGSTATE /� _ ZIP TEL FAX CELL ���EMAIL I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY / FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth o,fHassachusetts - Depart hent of Intlacstrial Aceldents Office oflnves9gations 600 Washington Street Boston,MA 02111 www.mass.gov1d1a Workers'Compensation Insurance Affidavit:Bu ders/Cont°actor/ElectriclansTlrimberq A liteant Xnformation Please PrintLe 'bl 'Name(Businessiorganizationffndividual): h( OVI rl Address: 0 k ?S City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ X am a e mployer with 4. ❑ X am a general contractor and 1 6. ❑New construction f — e�loyees(full and/or part time)* have hired the sub-contractors 2.EK am a sole proprietor or partner listed on the attached sheet.t 7- ❑Remodeling ship and`havenaemployees These sub-contractors have 8. ElDemolition working forme in any capacity. workers'comp.insurance. 9. El Building addition (No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised.their 10.❑El repairs or additions 11. lumbin repairs or additions 3. X am a homeowner loin all work right of exemption par MGL ���g P ❑ . g and a have no ,, c.152,§14), , w v 12, Roofxe airs myself [No worke s comp. ( (� p insurancerequixed.) employees.to . o workersi p Y ' 13.❑Other comp.insurance required.] i p 'Any applicantthat checks box#1 must also fill outthe section bel6w showingtheir workers'compensa$onpolicyinformition. T-Homeowners who submit Phis affidavit indicatingthey Aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I afn an employer that is providing workers'compensation insurance fog•my employees Below is the policy and joh site information. Insurance Company Name% Policy#or Self ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensationpolley declaration page(showing the policy number and expiration date). Failure to secure coverage.as regniredunder Section 25A ofMGL o.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 ibsurance coverage verification. X doxeb under the pains and na es ofperjury that he information provided above is true and correct. - Date: Phone#• �� ��-�5-�9 Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permif/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, Pursuant to this statute,an eYnployee is defined as"...every person in the service of another under any contract ofh1ro,- express orimplied,oral or written." An employW is defined as"an individual,partnership,association,corporation ox other legal entity,or any two or more of the f6reg6ing engaged in a j oiut enterprise,and including the legal representatives of a:deceasedemployer,.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 apartmentsand 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 eroployer,.' MGL chapter 152,§25C(6)also states that"every state or local lie-ening 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 ofpublie woytlk until - cceptable evidence of compliance with the insurance requirements of this chapter have b con 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),addresses)andphonenumb er(s)along with their certificates)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. ff an LLC or LLP does have employees,a policy is required. De 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 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 Incense number on the appropriate lino. 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(ifnecessary)and under"Job Site Address"the applicant shouldwxite"all location in (city or town)."A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit-is ou file for future permits or licenses. Anew 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 orpermit to burn leaves eta.)said person is NOTrequired to complete this affidavit. The Office bf investigations would Me 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 fay,number: `the Coxr_ oawealtlt of )asa..chusett - Depat`meut ofZudwirial Arc donia Of oe offAvestiga-uDna 60(1 WaMa&n Slte,�t Boston,, 02111 TQL#617-727-4.900 oxt 406 or 1-877- Revised 5-26-05 Fax#617-727-7749 v,�wvc�.xaa�s,g¢vfd.;ia. . Date.......CJ: .�I/.. ............. poarh c?� •' °°9 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4• . V This certifies that LaU ........................................................... has permission for gas installation . ! .................................................. inthe buildings of.................................................................................................................. at.l!.. c ............................ ....... No ' Andover, Mass. Fee.�.VQ....:w Lic. NoA�, ..... ..... .... . . .... ................................ G INSPECT R Check# . � u MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /�!® - p�,�,rL _ _ MA DATE PERMIT# �► h�� (� JOBSITE ADDRESS OWNER'S NAME r�(// tJ , OWNER ADDRESS _ TEL�� _r FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:[], REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BOILER. _ _ _ _ . ! . r j L-1== = S BOOSTER - -. I+_- ---l - --— -- - - ._ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _- .. OVEN N POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER t I_ L, - - --��► - - - _ � - ---_-___. __-- _-- � -_ -•�_ — INSURANCE COVERAGE _ _. -_-- =-_ _-- _ -- kP hav*a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO [� IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW A LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY ( 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 E] 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 ' nce with all Pe . nt on of the Massachusetts State Plumbing Code and Chapter 142of the General Laws. PLUMBER-GASFITTER NAME ='�'t --- LICENSE# ( SIGN URE MP 0 MGFI JP U2'--JGF 0 LPGI[711 CORPORATION E]# PARTNERSHIP®#=LLC E]#= COMPANY NAME: ADDRESS CITY _lt/�� -�y - STATE VJ(J]ZIP ,1J TEL FA) �,,6�,tI CELL MAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 The Commonwealth o,f 1V1assachusetts . - Depart'nento,flndifstriglAceidle is Office oflnvestigations 600 Washington Street .Boston,NIA.02111 vww.mass gov/clra Workers'Compensation Insurance Affidavit:Bufftiers/Cony°actors/Electri.cians/Plumbers A licant Information Please Print Le U Name(Business/Oxgani'zation/Xndividual): 1 d Address: Pzo, &6 r Zl S City/State/Zip: til'1� Phone Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ I am. ployer with 4. ❑ I am:a general contractor and I 6. ❑Now construction f e oyees(full and/or part-time).* have hired the sub-contractors 2, am a sole proprietor or partner listed on the attached sheet.t 7• El Remodeling ship and'have nonemployees These sub-contractors have 8. E]Demolition working forme in any capacity. workers'comp.insurance, 9. F1 Building addition (No workers'comp.Insurance 5. ❑ We ate a corporation and its 10.E]Electrical repairs or additions xequired.] officers have exercised.their 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.❑Roofrepairs insurancerequixe4.1► employees.[No workers' ME]Other comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. i Homeowners who submit this affidavit indicatingtho go dging allwork and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. X am an employer that isproviding workers'compensation insurance for my employees Below is the policy andjoh site information. Insurance Company Name' Policy#or Self-ins.r ic.#: Expiration Date: Job Site Address: City%State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requI dander 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 tine 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. X do lid r udder the pains an enal'es o erjury that the information provided above is true and correct. - Si gwre• Date: �S 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#: • t Information and Instructions . Massachusetts General Laws chapter 1S2 requires all employers to provide workers'compensation for their employees. x Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• express or implied,oral or written.." An employer is defined as"an individual,partnership,association,corporation or other legal entity,ox any two ox more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a:deceased employer,or the receiver ox trustee of an individual,partnership,association or other legal entity,employing employees. Owever the owner of a dwelling house having notmore 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 Iicensing 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of chapter ebee q p v n presented to the contracting authority." Applicants Please fill out the workers'compens aiZon affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name,(s),addresses)andPhone numb ers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners,arenotrequkedto carry workers'compensation insurance. If an LLC orLLP doeshave employees,a policy is required. Be 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 Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a*oxkere 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 thatinust submitmultiple pannit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"fob Site Address"the applicant should write"all locations in (city or tov )."A-copy of the affidavit that has b can officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit-ii on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit 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 cooperation and shpuld you have any questions, please do not hesitate to give us a call. The Department's address,telephone aiidfax number: `Shea Coxnax 0RWQ-aTtbL Of a-,(,-is Department oflhdwWal AAcc denta Office ofJAVestigationa 69 V1 as1 o-a Street Boston,MA 02111 TOL#617.7.217,499Q ext 406 or-1`877-MASS"p, _ Revised 5-26-05 FaX 0 617"727'7749 tiORTy BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION /� +f,/ori •�..,..� `� •K Permit NO:—77 Date Received "DaA{�D•�"' cy �SSACNUSE� Date Issued: IMPORTANT:Applicant must complete all items on this page ..:...:. .. -... ,' �: -. -. . .., ... :,..::•' ).cit.:' - WN : ar. tea`+' •.a.'r; l J._ r t - - { NG 'f: `fit. ,.�is��rac'L•Dis'ar : ::,. �` .. ..?l.' r„...,.�. ..i;+.::,:,.:.i-..., ...-..n.. ..:,:,.�..,..•.:�:.... `;fe,'.'t,`fcf'. k' M� - •J;r t' p//-<' TYPE OF IMPROVEMENT PROPOSED U E Residential Non- Residential New Building One family- Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other d -- - -.4maers _ . fe _ Ie�aras ;,•;:..:. �;.>:.-. F.'.,•;._ a..•..a1: t�.,�!-.;r_ 5-Ff't'.j.» - =`L,r'P,• -.�tr:.s•::.... �.�g'.:.tx.,...:� _ a e.. - i _W � r�•�e. _ _ DESCRIPTION OF WORK TO BE PREFORMED: //V 6'-%J-Lc 94 epi t- 41,, s- Identification Please Type'nr Print Clearly) OWNER: Name: ' 61,-" 4- '1A�ctU. Ci�GCK Phone: G/7 Address:-9 ANDJ44EW G•L& !• A--P 4eJlN1A,S5 t tt. xi. . ,-.:. a ,.�.> ., ._.>4 .....�....,...•.� .... -. .. _. ...E. ... .........: ..."r.tee_..:.:� �,xr. - - ,-e;.�:...'r.":ij.�::'.>_�.. _ / t Off' �'�'`� _ - :i ..to i< ..-...., A' :mess"`� .:. .•; - >�3 b+ :apt. ..Z<•: - ... ., .. t' t . .. .�.-,. .. .::......'-..,.}.�.;:'-�...: __. ....: a.,, .,, .;Y?,• '=fit - y. :r+r 4iH : : . . 4- �4 ;4' - ti^r ARCHITECT/ENGINEER Phone: t Address: Reg, No. FEE SCHEDULE:SULDING PERMIT:/$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. Total Project Cost: $ 7 / _ —FEE: $�r � Check No.: l3 Receip." _ NOTE: Persons contracti with unregistered contractors dors r1,fn12d Slgnature.Qf �gent/ wrier.' �' �• `�1