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HomeMy WebLinkAboutMiscellaneous - 166 SALEM STREET 4/30/2018 (3) 166 SALEM STREET 210/037.D-0021-0000.0 u B U I LDHUlf` FILE Date.. ` . . ... . pORTIy 'k Of 19.0 - 3j TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CH - This certifies that . . . . .�. .. .�1 .. . . �`. .. . `. has permission for gas . . . . . . . . in the buildings of .� . .-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Feev . `~. . . Lic. No./��, . . !. . .. t1 . . . . . . . . . . GAS IN PECTOR Cheek 4�— 6366 MASSACHUSETTS UNN ORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Ifs NORTH ANDOVER, MASSACHUSETTS Date Building Locations �J Lei t,,O�k(A( I Permit# Owner's Name -- Amount$� . s o k Lu 1 4 A-, J New❑ Renovation Replacement ❑ Plans Submitted ❑ Ed y0 o ` w .o u m H x oZ C � GLQ oG C7 U w x Z I" C p a > w LQ F Z Q x W W F W f- x x Z Q w d a E~ F O > LT. F U w > w z o x o x 3 0 o a° > a H 0 SUB-IJ ENT BASE ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FL,O0.R R (Print or type) Name Check one: Certificate Installing Company 0. r? ha n I �' ❑ Corp. Address r ❑ Partner. Business 1 a ep one ❑ Finn/Co. Name of Licensed Plumber'or Gas Fitter 1,j A.. j�<C INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes o❑ If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: IAm 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 ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permifl�ssued for this application will be in f compliance with all pertinent provisions of the Massach tt State Gas Code and apter 42 of the General Laws. iBy: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber WS• c� City/Towm Gas Fitter IN ' 1❑ (cense umber ❑ Master _ APPROVED(OFFICE USE ONLY) ❑ Journeyman � A' Date . . '. . . r: I ' ".O RT:��a TOWN OF NORTH ANDOVER o � PERMIT FOR PLUMBING 1�A ,SSACNUSE� This certifies that . .{:'.�=?'.l' . . . . . .✓ ..... " . . . . . . . . . has permission to perform . -, . . . . . . . . . . . . . . . . . .plumbing in in the buildings ofd. . . . . . . . . . ... . . . . . . . . . ` ,., North 'Andover, Mass. - Fee%�� .. . . .Lic. No.. �. 1 .t_�_- `'c- '? .. . . . . . . . . . . . . . PUUUM/dING INSPECTOR Check .N C 7680 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ( � Date Building Location ` S� Owners Name Permit# Amount— Type of Occupancy New Renovation Replacement Plans Submitted Yes No FIXTURES C O O FA w o O a BA99VENr ]S�FIDCIt � Il1II I+IAOI2 �INIACR MMaR M FUM .� 6TH FLaR 7IHRJXR gm ffiom (Print or type) - Check one: Certificate Installing Company Name Corp. Address ,/ Ald 11 -m ,❑ Partner. Q/ Business Telephone Firm/Co. � Name of Licensed Plumber: Insurance Covera e• Indicate the type of-insurance coverage by checkin-g-'theme appropriate box: Liability insurance policy � Other type of indemnity ❑ Bond 4 F Insurance Waiver: I, th undersigned,have been made aware that the licensee of this application does not have any one of the above nsura er lgnature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma chusetts to Plumb �d6lndChapter 142 of.the General Laws. BY 1 �i ign r o i ense u m Title Type of Plumbin License City/Town se umr APPROVED(OFFICE USE ONLY Master Journeyman ❑ t. 14 V el Date.... �.. .....s . NORTH , °�<��`°;^_�"o TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING `. ,SSACMUSE� r. This certifies that ......... ....... . ................... , _ has permission to perform �7 /............•• �� l . Z4©... v ............. wiring in the building of....^...... .............JQ A5.................................... 1(,,�„... •.••..�� ,North Andover,Mass. G .� i' .�.� ��i Fee...................... Lic.No. ....... �1�. k ELECTRICAL INSPECTOR Check,#�6 DERL 111t WOFPf1BIMA>`NT a Permit Na BQ4Id)OFFMPREVFN1MRBOULA7I1gM16S iadnDin 10mopwity&Fm Chedmd �•� APPUCATTONFOR PERMIT 70 PERFOR194 FJZcnuCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WfrH THE MASSACHUSSrS EIICrM C&CODE,527 CMR 12:00 (PLEASE PRINT 1N INK OR TYPE ALL 1N1s0RMA1I0N) 7�6 S Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perfomt the electrical work described below. Location(Street R Number) 6 Owner or Tenant r Owner's Address is this permit in conjunction with a building permit: Yesc] No (Check Appropriate Bos) Purpose of Building Utility Authorization NoggA�? Existing Service /45D— Amps,Volts Overhead Undergratnd a No.of Meters New Stxvice Amp.4a. XVolts tverhead Ud C3 No.of Metes Number of Feeders and Ampacity Dation and Nature of Proposed Electrical Work Na of U&M Oaths Na of Hat Tobe _ Na Of Tmuftrma TOW Na Of Liahtiry @gams Swhmdng Pod AboveBelow KVA �� KVA BMW Na of Raoapta*00" Na doll Bumn Na of EmWpOo Liandrta Ba"Uaiu Na of Switch Outim Na of 0a own= Nm of Rama Na of Ali Cad. Totd FIRE ALARMS No.of Toros Taal No Of DUP01* Na of Haat Totd Na If Ds andPoI111111 TOW KW --. No.of Diahwuhma Spate Arae Kw leadfS Device of Sawdsq Dtsrtca No.of SW Cuoubw No.of Dryan Hadty Devi= Kwt� �� thw No.of Water Horan KW Na d No.Of Cotmecdons 0 slag Ballads Na Hydro Mauap TOW Na Of Moon Told HP ,moo. �r�bp i t1 S e� �,a_ Z,'tyyi lo( !fin t a4 hUff=CbYWV PMMID6110ofMrsci>mlC3trmlLaws IhateaaamtL+ Y Y� arbsk*dWgs}'Ain YM NO Ihaves+itirni>edvaidpoddssmzbttet�Yl;s r�wferededordYBg, h�1104rd, Comrby M(AaNd B= am nitedVaisrafHectdorlq+�s WakeStit lor �Daf E9 110-P -1 0fP11* ERtMNAM LiodaNa tme t), �y►� r ra . �r t Sig+ioiae c &*nTem (50 75757 CIWMR'SII4URANCEWAN3k-Ie iixiie ltatdleiicai� ALTMNa se a►dilffirr�ysi�tanontlisp�applceiQtrtsitslitegsimet �'�0 °s10�10idbYsmc�riilLaas (Pleacheck one) t)vmer Q Ago Telephone No. pgRw Fa I 4.���.k ...-.+r+.J�.,.,�..�..-. -�.--..... ,.,..».-�- ..r-r^,mss ..o-.T. ....,.-....r..-.�-•�'.,.d...�,.+-.-.-,-..r:,-...ter-.+...r..+7--�--. r Location Date No. NORM TOWN OF NORTH ANDOVER F ?i ` Certificate of Occupancy $ �' b'•°•'�� Building/Frame Permit Fee $ ,SSACMUSE Foundation Permit Fee $ Other Permit Fee $ %s ,t TOTAL $ / 14/2 Check # 17301 f Building InspCct r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING -i�� BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of BuiMings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 16� • �'�.i-ewt S�: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 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 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ "SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record _ r Name(Print) Address for Service q��l- 68S-Z16 7 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: -Signature Telephone 4 SECTION 3-CONSTRUCTION SERVICES 00 3.1 Licensed Construction Supervis r: r Not Applicable ❑ „ S � �l Cir.n.So✓l Y-`�1�r4 �i'(�Lt�w�' Licensed_Construction Supervisor: 45- License Number Addre /� / / Gl 6/a 6 Expiration Date Sigiladire Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ I�eGI� Gm1i-tis p_ Company Name Y MA- Registration Number 5 I-1�� � �-<9 • -t-�,�-e,-t��tr at��z Address !! O Expiration Date A Si ture I Telephone �i/ t 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 buildigg permit. Signed affidavit Attached Yes....... No.......❑ SECTION 5 Description of Proposed Work check au applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify A Brief Description of Proposed Work: " t Vl�nt4c-e SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to bebFFICIAL USE ONLY ." Completed by permit applicant � 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection o 6 Total 1+2+3+4+5 3 ao Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. -Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1 SGv- > U✓SC ��ll� („//�a�w } ,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 �--- Si ature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMERS 1 2 3RD SPAN DRVIENSIONS OF SILLS DRvIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE UZ) W- O O o V p to In g � W D E ce y Z zz V00 o o CD o Z U) o 0 0 �1 ! r�1 ei iri p ' +.;i' Board ol� Building Reg lahons illlCl StilllC�ilICIS d ; CLN Y g� One Ashburton I'Iocc - IZoonl 1 .301 z m a owe Ijc►st()n- IVlassachtisetts 02 108 0 z �Q I longe Ing �rovenlcnt Contractor Registration ^: w zm w m w IZc4listralion: 1241774 (nn 1 ype: D13A Expiration: 11/2/2005 r PELLA WINDOWS AND DOOIRS [RAYMOND ADAMS 45 FONDI RD. HAVERHILL, MA 01832 Upda1c :address;uld return card. Mal-h reason Ibr ch:ml t. Address Rcncllal I':uydocull'tll Los(Card • Ilnal d;;I Iluillling Itrl!nlalinn� and tilanil:n d. I IC('1111' nt'"11'l,ltil l�allllll 1:11111 1111-II11111111111 list-mil% I '' ,I• HOME IMPROVFMFNf CONLRACtOR Irt'Imc IIIc c111italion dale. If-luood rclm'n to: Ilnard nl Iluildinl; Rcl,ulalinns and tiland:u ds t Rcllistration: E'9771 - lJnc A'dibinlon I'Iacc Rill 11111 Exphaliow I 1 ype: I II IA i PFLLA MNP(AVS AM)1)(x IR`: PAYIO )t1I) AI)AI-Y; d5 I-0rjPI 121). M I IAVEIRI TILL, MA 0 183 2 \,Ilnini,.IfA n Not \Aid 11 ilIInnt sil,naltn c xAORTH TONM ti' 6Andover ® -lidkms. :.'.r'�....y.... T No. .. �` 4'ro dove t, Mass., Y O LAKE 1• COC MIC ME WICK � ADRATED `S U BOARD OF HEALTH Food/Kitchen ERM T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ....... ........................................................... ...................................... ...................... Foundation • ......................... has permission to erect........:........0..................... buildings on .. .....�..... Rough to be occupied as 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 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 Final PERMIT EXPIRES IN 6MONS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION .S� Rough 45441,W- Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough 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 SI®E Smoke Det. L/ PXe HIC Registration#129774 Federal ID#04-3277886 Pella Windows& Doors Pella Windows & Doors of Boston 45 Fondi Road Haverhill, MA 1832 "Viewed to be the Best" PH (800) 866-0 9886 Service: Ext. 124 Fax: (978) 373-7274 WINDOW CONTRACT Sales: (866) Pella06 Sold To: c Date: Address: Phone (Home) 27 City: State: Zip: Phone (Work) �D!SY 22tZ-77 Job site Address If different): Phone (Cell) A rox. Start Date: G A rox. Completion Date: WA PP PP P Pella Boston Will Furnish and Install: YDS NO PLEASE READ CAREFULLY:ONLY THE ITEMS CHECKED YES ARE INCLUDED — — — — 1. L�( Remove Windows from the opening where they now exist on: il _ Lily ❑Taffy ❑Bone ❑Celadon ❑Mocha ❑Golden Oak #of Units Location of Units 20. ❑ Interior of Units to be Unfinished(Ready to Paint or Stain) Painted ( ❑Pella White or .9!�Lihen White) ❑ Primed Only ❑Stained ❑Natural ❑Provincial ❑Cherry ❑Early American ❑Clear Polyurethane ❑Golden Pecan ❑Golden Oak 21. ❑ Roof on Bay/Bow to be: []None(Within 18"of Soffit) ❑Asphalt ❑Cedar 422. ❑ Clean up and vacuum nightly and remove all debris at completion of job site 23. ❑ Remove and Dispose of existing Windows and/or Storm Doors 24. ❑ All workman's compensation and liability insurance maintained 25. ❑ Warranty mailed to customer u�mpletion�hgn full payment is received 126. ❑ Total Project Amount$ 7 C / // 27. ❑ Financed If Yes:Amoun inanced$ (Reference# ) 28. ❑ Deposit Received$ 29. -]—Z—Balance on Substantial Completion$ (Payme s payable to installer at completion of job) 30. ❑ Additional Comments: ( �w4cd PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE PLEASE REMOVE ALL SHADES,VERTICALS,BLINDS,CURTAINS,DRAPES ANY REPRESENTATIONS OTHERTHAN CONTAINED INTHIS AGREEMENT OR WINDOW MOUNTED AIR CONDITIONERS,PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR OFYOUR NEW WINDOWS.INSTALLERS ARE NOT RESPONSIBLE FORTHE RELIED UPON BY "OWNER".YOU ARE ENTITLED TO A COMPLETELY REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. FILLED IN DUPLICATE OFTHIS AGREEMENT. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION WARRANTY PROBLEM. DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract is a legal document.Your Pella products will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS OR CANCELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRACT HAS BEEN SIGNED AND DEPOSIT PAID BY SIGNING BELOW.YEAR ARE ACKNOWLEDGING THAT THE ABOVE SPECIFICATIONS FOR THE PELLA PRODUCTS YOU ARE ORDERING ARE CORRECT Pella Rep.Signature: 4 zDate: — C' Customer Signature: `/� Date: hG" y_ White- riginal Yellow-Customer Pink-Store Date . 4/—/7 •�b�M'J7"iib7� ,. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies . . . . . . . . . . . . . . has permission to perform . . . . QG��2'-cmc, �.'. . .2� wiring in the building of . . . . . . . . . . . . . . . . . . . at . 774450. . .yl. . . Ste . . . . . . . . . North Andover, Mass. Fee .!.Z572�Lic. No. .q �. . . . . . i ELECT 1CAL INS CTO Check# c��l` 01��\1� f _ � f f f f l f ......... e 4/1 vvlj_ LI-Ii f , f f f f f , f f f f LIA Y"e I . Ck eta {� (�,� ioLoll)� Lo � f �IZ ocw��- t " Commonwealth of Massachusetts Official Use Only Departmentore ervces Permit No. f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 C4R 12.00 A (PLESE PRINT IN INK OR TYPE AMALL INFORTION) Date: `2 10Z K [Z— 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) I\Q� ti-A S Owner or Tenant -tatu L tftlk,I Telephone No. Owner's Address S tf�/V1 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: y Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting rnd. grnd. BatterV 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 Rang.' s No.of Air Cond. Total No.of Alerting Devices Tons No.of Was�e Disposers Heat Pump Number Tons J.KW........... of Self-Contained Totals: Detection/Alerting Devices No.of Dis washers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of _ No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Mres. Estimated ValueM)U'W lec ical 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 liabili 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 ❑ pecify:) Xcertify,under the gins and pe�of erjury �Itat the info .tt�tion on this application is true and compl te.� FIRM NAME: . LTi LIC.NO. Licensee: T!1'" ,M 6—t6b Signature LIC. 0 . (Ifapplicable,enter "exempt"in the license number line) Bus.Tel. o. Address: Alt.Tel. *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.N . rA I / OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance cov rage normally 1 required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. � S ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection - Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: ' r' Inspectors Signature: Date: SERVICE INSPECTION: d Pass❑' Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: I Inspectors Signature: Date: FINAL,INSPECTION: Pass F?1 Failed M Re-Inspection Required($.)❑. Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legib Name (Business/Organization/Individual): Address: 3_1 �� City/State/Zip: S � �C Phone#: "I \ Are,Tou an employer?Check the appropriate box: Type of project(required): 1.® 1 am a employer with (� 4. ❑ I am a general contractor and I 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ? EJ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition ` • working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El 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' comp.insurance required.] 1311 Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Dontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site zformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: :)b Site Address: City/State/Zip: Atach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do her ertify under th as s a penalti perjury that the information provided above is tri and correct. i nature: Date: 2 2� � none#: 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#: i 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 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�ihis 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 d necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 evised 5-26-OS ,xnviv rnaec an-,r/rl;n 7 Date . ./Z- ` lr TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . 1.��!l . .T�l/�,�,�P .Z L�a . . . . . . . . . . . . . . has permission to perform . . . .. . . . . . . . . . wiring in the building of .l,�Gc/. �, /.4 C. . . . . . . . . . . . . . . . at . . . . �b . .� �?�l. . . .�?'. . . . . . ,North Andover, Mass. Fee Li c. Not}.94� �"f. . . . . . ELECTRICAL INSPECTOR Cllteck# 1 .1290 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.forin.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 actlir ity,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 periy beginning ont 15,2008 and extending"through August 15,2012. Rule ii—Permit/Date Closed: ` ***Note:Reapply for new permit ❑Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.iml eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATIOA9 Date: L 11) )2, 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) ` sx)l fim Owner or Tenant `TSG�L �6 t Telephone No. Owner's Address S rh"t� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: 1� d ( DOM QvY 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 Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons _ Heat Pump Number Tons KW No.of Self-Contained � No.of Waste Disposers ................................................... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No..of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of W2res. Estimated Value o Electrical Work: (When required by municipal policy.) Work to Start: )Z I 1 t It IZ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless w ived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili nsurance 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 E BOND ❑ OTHER ❑ (Specify:) I certify,under t1 ains and penalties ofperjury,that the information on this application is true and comple FIRM NAME: IYyyr9'S Oyvl '�� LIC.NO.. j 4V Licensee: ,WVM i'i'i OWl� r A-T UO Signature LIC.NO.. (If applicable,enter "exempt"in the license number line) Bus.Tel.N IC� ILA �1 Address: _ ZZ )�Su lel c �n S VMN W0 W, H 3 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:$ Signature Telephone No. .r ❑ 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 [J 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[N Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ I! Inspectors Comments: f Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Co ents: Inspectors Signature. Date: FINAL,INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com t 4� • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ib vl Name (Business/Organization/Individual): '�as, {yo Ic Address:_ N6vAW8c City/State/Zip: S WN�i N Phone#: 17 AVI on an employer?Check the appropriate box: Type of project(required): 1. am a employer with 0 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ? El Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.E]Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 131-1 Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site zformatiln. isurancetompany Name: olicy#of Self-ins.Lic.#: Expiration Date: :)b Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do here rtify under the ` 'n an penalt perjury that the information provided ab ve is trace and correct. i nature: Date: l 2 2A_1 Z zone#: 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...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 produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance +, requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. s City or Town Officials A Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727•-4900 ext 406 or 1-877-MASSA-FE evised 5-26-OS Fax#617-727-7749 it www.mass.aov/dia LAWRENCE R.OGDEN,P.E. 198 EAST MAIN ST S'E'T GEORGETOWN,TWA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 Scptcanb&26,201'2 Mr. lack Cahill 166 Salem.Street North Andover, RE: Cahill Addition 166 Salem Street. Noah Andover,Ma. 01845 As you requested I visited the site 9/14/12 to review the installation of the r Engineered Materials consisting of LV'Ls utilized in the framing of the above project. These are shown on plans A-1 to A-3 prepared by G.J. Bruno Associates dated 8-13-11 with the framing sheets certified by me 8/17/11. Based on the above site visit and based on what I could visibly see. I can certify that to the best of may knowledge the LVLs members utilized in the framing as shown on the ftik Ings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts S tate Building ng Code for 1&2 Family Residences. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules,blocking,connections and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, R Lawrence H. Ogden P.E. Structural 27765 '<�'2745 27 �. FS T E �. S Oh NG �1L E LAWRENCE H.OGDEN91',M. 198 EAST MATT S'T'REET GEORGETOWN,i1IA 01833 978-352-83 IS fax 978–352-2858 cell: 978-502-5921 Scptemb;r 26,2012 Mr. Jack Cahill 166 Salem Street North Andover,Ma 01845 U.- 0ahl11 Addi ioh 166 Salem Street.,Notill Andover,Ma. 01845 Bear - .C.a `Il As you requested I visited the site 9/14/12 to review the installation of the Engineered P Materials consisfing of LV Is utilized in the framing of the above project. These are shown on plans A-1 to A-3 prepared by G.J.Bruno Associates dated 8-13-11 with the framing sheets certified by me 8/17/11. Based on the above site visit and based on what I could visibly see. I can certify that1ifn f4hte lt!!aVanJt vt.�py hJ"-a VLedg0„Ovo L SYOI nJ members nbers utilizedin the framing as SI'LoF:-'Tl on the diawit:gs are installed properly and meet the loading conditions of the 8th Edition of the Massac-busetts State Building Code for 1&:2 Family Residences. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules,blocking, connections and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. — _ – Yours truiy, Lawrence H. Ogden P.E. Structural 27765 o oma` = _ _..:•.� �: v OGD* s