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Miscellaneous - 171 APPLETON STREET 4/30/2018 (2)
171APPLETON STREET 210/037.B-0057-0000.0 1 -7 Date...... ... ..!...... ........ 40RTH TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING CHU This certifies that ��.'� cJ!!�2% Ahas permission to perform .......:... ............. ......................... ................. ....................... wiring in the building of....... �., j... at ....... ........ .. .... .............No 4 ndover,Mass. Fee.... 07.............Lic.No. ......1..... - ELECTRICAL INSPL;C w Check# f Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked 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 Code(MEC),527 CMR 12.00 (PLEASE PRINTIN-WK ORTYPEALLNFORWTION) Date: -1-UtiE /7/ 9d46" 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) Z 7 n g Owner or Tenant _John Telephone No. Owner's Address tti vl ��� Is this permit in conjunction with ja building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building ]J f�t,/ell/dM 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: Zo �y, 94& 1-f� Completion of the following 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- TV-Elo.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g 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 t No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as regadred by the Inspector of Wires. Estimated Value of Electrical Work: 4160.0 00 (When required by municipal policy.) Work to Start:.-TV /2� `�OLS�pections 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 suchc�over is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA-NCE Ltd BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: OR 11-lh+ LIC.NO.: � Licensee: A 5'he",A :i.S&/& Signature LTC.NO.:5,0 / (If applicable, nter "exempt"in the li ense number line.) �} Bus.Tel.No.: f�&1a Address: 4- /</rc� Alt.Tel.No.: *Per M.G.L c. 1'47,s.57-61,security work requires Dep ent 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. 6� Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accoidance 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 if 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 0 Re-Inspection Required($.)❑ r Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: r ROUGH IN ECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: 0.0, Date: FINAL INSP CTION: Pass 0 Failed 0 Re-Inspection Required ❑ Inspectors Comments: Inspectors Signature: Date: 11-If DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 4 The Commonwealth of Massachusetts Department oflndustrialAccidents y 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): �'^L a-VI Address: �& r� City/State/Zip: Phone#: Are you an employer?Check the ap iopriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.®'1 aim a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. • 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.F1 We are a corporation and its officers,have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit#his 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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.Lie.#: 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 required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certif nder the pains and penaltie erj hat the information provided above is true and correct Si ature•. 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/I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �t `t 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. 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia COMMONWEALTH OF MASSA'CHUSE S 0 0 0 0 0 BOA�tD Vii^ t ELE CTR*I C I ANS ISSUES: THE FOLLOWING C1 CENSE 4> E AS A REQ` JOURNEYMA..N €LEG-TRI SHAWN'M SMITH �f ' 28 WOODLAND AVE a, 13'€V€RLY IAA 01915 2926 I t -5_0618 07/31 16' 75616 ORYP1 O� qac➢eS�fJ' , NORTH ANDOVER BUILDING DEPARTMENT ➢RATE➢F �5 .1600 Osgood Street . . North Andover Tel: 978-698-9545 Fax: 978-688-9542 .BUSINESS FORMFOR TOWN CLERK Sdh�c� NV ADDRESS. r j ZONING DISTRTO T: $ I TYPE O BUSINESS: �c� �,�C rr— /101177(`— :BU[LDINr`LAYOUT PROVIDER: YES RTO AYA1LAf C-RP t`IVG'8PACPS: ZONING BY LAW TTSAGE: YES NO BLTI LDIWG INSPECTOR SIGNATURE BUSINESS FORM FOR TOWN CLERK 2.40 Home Occupation(1989132) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal . address, which is clearly secondary*to the use.-of the building.for living piuposes. Home occupations shall 'includebut not'limited to the following uses; personal services such as fuuvshed by an artist or instructor, but not occupation involved with motor vehicle repairs, beaA,parlors, animal kennels, or the conduct of retail business,or the manufacturing of goods,which impacts the residential nature of the neighborhood, 4. For use of a dwelling in any residential district or multi-family district for a home occupation,the following conditions shall apply: a. Not more than a total of three(3) people may be employed in the home occupation, one of whore shall bethe owner ofthd home Occupation and residing in said divelling; b. The use is carried on strictly within the principal building; c. 'Acre shall be no ex-terior alterations, accessory buildings, or display which are not customary with residential buildings, - d. Not more than.twenty-five(25) percent of the existing gross floor area of:the dwelling unit. so used, not to exceed one thousand (1000) square feet, is devoted to'such use. In connection with such use,there is to be kept no stock in trade,commodities or products which occupy space beyond these limits; C. There will be no display of goods or wares visible from the street; £ The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of desiga not cust6mary in buildings for residential use. Signature Date Date.... 10243 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that..........w................J�, ................................................................ has permission to perform.......... .................................... plumbing in the b ildings of.....AUk iA 'tY 2......................*"*........*........... at..................................... North Andover, Mass. Fee... Lic.No. ...................................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 9 J J c6 t,h { MA DATE „� PERMIT# l D JOBSITE ADDRESS / f , OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: Q, RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES Q NOQ FIXTURES 7 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 GASf01L1SAND SYSTEM —J,--j -_-.J ( � DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _rI _. _._{ DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) - -! i _.-. KITCHEN SINK ___-- LAVATORY ROOF DRAIN _ 1 __. I _—F _--( 1 SHOWER STALL SERVICE/MOP SINK _-_..1 l . { __-! ---_-I (I __l HE TOILET I I R I J { � URINAL WASHING MACHINE CONNECTION -J -__.1 ._:_._1 __..__J WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY� OTHER TYPE OF INDEMNITY Q BOND Q _ �I 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. 1� CHECK ONE ONLY: OWNER Q AGENT IQ 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 of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pe -n t provision of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L 7 FF q JILICENSE# d0 f SIGNATURE MPD JP CORPORATION 0#PARTNERSHIP Q# f LLC D� _I COMPANY NAME �� �� ,J p �¢ ; ADDRESS ,U S� j CITY ,�„��s f� ]STATE N6'` 9 ZIP 0 4YT^� TEL - 3a FAX [149 i CELL 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 i ' The Commonwealth of Massachusefts Department of IndustriqlAccWhis 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 Legibly Name(Business/Organization/Individual): f�,7 /l,� 1917_J P,r°!� Address: City/State/Zip: Phone#: 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 —�oyees(full and/or part-time).* have hired the sub-contractors 6' El New construction 2.LArl am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. ❑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' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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. 1 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: 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 requiredunder 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert! the pal, penalties of perjury that the information provided above is true and correct Si afore 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.PIumbing Inspector 6.Other - - - Contact Person: Phone#: l Infor� ation 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-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 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 Departwc,jat ofl adustrial Accidents Offaee of Iuvestigaiions 600 Washington Stxeet Boston,MA.02111. TeX.#617-7274900 at.406 or 1-877,MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia PLUMBERS ANSFITTERS LICENSED ASA JOUFc.�1EYMAN PLUMBER (( 18SUEGTA A90V�UGENSE TO! THOMAS ,S ;F'ARHADIAN, , 415 MAIN ST HAMPSTEAD, ---,NH U3b41=2073 -�'� + �' 19420 05/01/14 163615 Date-WtVzi...... 10274 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Hu � / This certifies that....... ............................................... ......... ........... ........ ................ .... has permission to perform.........-.5.....; .................. plumbing in the b 1nZs of....A..�K4...... ......................................... at........ Xr....... 1 .......5............ k..., North Andover, Mass. Fee3�.....Lic. No:,&ffl/.- h*................................................................ PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY d MA DATE ,r l DPERMIT# )OLId — JOBSITE ADDRESS 11 _- A��� a� � OWNER'S NAME��v\ r `v U,n aS POWNER ADDRESS 9 I TEL 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ®! EDUCATIONAL ® RESIDENTIAL Lk- PRINT -CLEARLY NEW: 0 RENOVATION:Ell REPLACEMENT:Q' PLANS SUBMITTED: YESE111 NOQ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 .BATHTUB _► ^l I ___._ l ___. I ___J I _. __.l' ( _l CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM =11= ( ._--___i __. { I _i _ T_, .1 .__._._( ______! __.-J f I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I DISHWASHER DRINKING FOUNTAIN —.1 ---___.1 .---._! I _-_I ( ._...__._j FOOD DISPOSER FLOOR/AREA DRAIN .JA_J .__( INTERCEPTOR(INTERIOR) �l __J_J _ I _I ..._.__i _ i j ._._._ _.._ ( ( ( -_..__.i KITCHEN SINK i ,, _j �� -- ---- _- -_-_..I -- LAVATORY ROOF DRAIN _l J ___J �I __l__-_._1 _____- ._.. .J _-.-___! _._.___( _.�l.____.I _.__._� _ ► -_-_! SHOWER STALL SERVICE/MOP SINK ____l TOILET URINAL ( ......._( �_._ _---► __J _.__.___G ......___ ___.._ E __.._. ___.._ _._J -___.._I ....._. ,` ._.____! WASHING MACHINE CONNECTION I I __._l .__..._._+ _.. i _ 1 .. _ -f _--_-J==== � WATER HEATER ALL TYPES WATER PIPING ( j OTHER ---- ( -- ...- I -._.._J I. n i INSURANCE COVERAGE: I,have 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 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. J b CHECK ONE ONLY: OWNER Q AGENT �] / 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 an aceuratOt , e ba of my knowledge 7 and that all plumbing work and installations performed under the permit issued for this application will bm c mpli nce ith a( ttinent prove 'on of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. T PLUMBER'S NAME-LKfir` , LICENSE# vSIGNATURE MP d JP 0 CORPORATION 0#PARTNERSHIP 0# LLC COMPANY NAME iADDRESS (, l CITY o����1�•� j STATE ZIP TEL FAX � CELL -'?�7f 5-83H EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Sig FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(susiness/Organization/lndividual): Address: m AA o P L k, city/stat Lo 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 construction employees(full and/or part-time).* have hired the sub-contractors 2. am a le proprietor or partner- listed on the attached sheet.1 7• E]Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance, g, ❑Building addition [No workers'comp.insurance 5. ❑ 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 1 L❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i 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 Homeowners who submit this affidavit indicating they are 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. lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name:. S Policy#or Self-ins.Lie.#: 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 requiredunder 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 may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby c c rider the pains and pe of perjury that information provided above is true and correct Si ature: ZDate: 0 t3 Phone#: J 2� �'� 8� 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#: 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 requjred" 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 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 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 Commonwoaltb of Massachusetts Department of Industrial,Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877 MASSAFE Revised 5-26-05 Fax ir#617-727-7749 www-mass,govfdia Date.... V►OiR7M ° '••��� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that,..................... T'� .�..�ti........... ........................:.................................... has permission to perform .......`'-...(...MA-k-;!/...................................................... wiring in the building of..........:� I).m'.V......<1. ! .1 ........................ at ....t...7 :...�`f � �.?`...................... .North Andover,Mass. . .................................. ... Fee. ".....Lic.No.JJ`.ZA N................� !f ECTRICAL INSPECTOR Chel# 1 �� 1 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ,:, -� Occupancy and Fee Checked !' .• 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 Code(MC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date:ZZ•—/ /—? 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) /-7/ 5± 44✓e- &Azv,,- 01"-5, Owner or Tenant Z)j hpl I VA-fJiat has Telephone No. Owner's Address r/ A(4gs e ��, 12-etnk lAduxet, Is this permit in conjunction with a building permit? Yes ®"' No ❑ (Check Appropriate Box) Purpose of Building .�✓e/l/�� 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: 62cu hw C/d'(it h l k rt�� C rao)CP5-� dlGS on /,,, �(jlJ S _ i lc'e� /r 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 LiInE] IN o.o Emergency Lighting y rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons_ KW No.of Self-Contained p Totals: � .....".... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances ger SecN.o Devi es 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 MHER: Attach additional detail if desired or as required by the Inspector of Wires. E i imated Value of Electrical Work:f&� -Q0 (When required by municipal policy.) Work to Start: // �/3 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofpetjuiy,that the information on this application is true and complete. FIRM NAME, LIC.NO.: Licensee: .rr` Inl Signatur LTC.NO.:624?!Y�E (Ifapplicable,enter"exempt"in the license number line) Address: /_5 Alt.Tel.No.: *Per M.G.L c.'147,s.57-61,security wor requires D partment 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. W my signatgre kelow,I hereby waive this requirement. I am thecheck one)NR El owner's agent. Owner/Agent coS ��a�7IPERMIT 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 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 .V 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($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass N Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ T Inspectors Comments: Inspectors Signature: Date: FINAL INSPE TION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comm t : 9 L�^ Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 'Y— }e' 4 J i _ The Connnonlvealill of Aliassachusetis Department oflndralifirlAccidents Office ofhvestigiWons 600 Washington Street Boston,MA 02111 rvonvnrassgov/din � Workers'Compensation insurance A.Sdavit:BuilderslContractors/Electrieians/ bers tLp Amlmcant Information Please Prinnt Legibly Namo(nuamwomanimtion/Individual):5l I&to/1A 'SAIrfk Address:�Q AD jt -Ia►til� cl t APT � City1Statc17,ip:YPW1V Ma, O�lPhone#: _ [2. royou an employer?Check the appropriate boa: Type of project(required): El am a employerwith 4.Q I am a general contractor and I 6. []New construction ,employees(full and/or part-time).* have hired the sub conhactors �(/ lam a sole proprietor or partner- listed on the attached sheet.t I (])temadehng drip and have no employees These sub-contractors have S. Q Demolition 'workin for me in an ca act workers'comp.insurance. d Y P ty 9. ❑Building addition [Ido workers'comp.insurance 5. Q We are a corporation and its 10.�Bieotrical repay or additions required.] officers have exercised their 3.[IIamahomeowaerdoing all work right of exemption perMGL 11:QPhmrbkgrepairs oradditions myself.[No worms'comp c.152,§1(4),and we have no 12-El Roof repairs insurancerequired.]t employees.[No workers' comp.insurance required.] 13.Q Other *Any eppiieaat that Checks boz#i mustaiso fill outthe section below ChowingtbeirwodCehs'compeasationpOUey h&nadon . tHamtpwnasNvhoanbmitthisaffidayitindicatingtheyatedotngaIlrmhiiandthenhaeoutsideCAAftot amnStaubmltanCwaffdavah7dicaHngSa0I1 tcanuactors Mat chak this box must anadied an addiffandsHatshowing thename ofttm sub-contractors andtheirwod=e comp.policyhrfotmation. lam an employerilrat isprovldbig workers'compensation insarmrceforn{v employees.Below is thepolfcy and jab site ' in,formation InsnranceCompanyNtune:. k Policy#or Self-ins.Lie,M BxpirationDate: lobSbAddress• rcity/State ft: Attach a copy of the workers'compensation policy declaration page(showing the policy number andeapiration date). Far7m to secure coverage asrequiredander Section 25A of MQ,o.152 oan lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year hnpdsonment;as well as civil penalties in the form of a SMP.W01 RK ORASR and a fine of trp to$150.00 a day against the violator. Be advised that atopy of this statement maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. Ido hereby cert' under ihepahis and pens ofp '`that the bormation`provrded above fs true and correa .� _ Siena4re: one#: Official use only,Do not write fn this area,to be compiled by city or town offkW City or Town: t i Permit(License# Issuing Authority(circle one): 1.Board of Health 2.BuildingDepartment 3. ' 6.Other _ CityTown Clerk 4.ElectrIeai Inspector S.PIumbing Inspector Contact Person: { PhoneM Generated by CamScanner from intsig.com Location /7/ I�v- No. Date �d / . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �^ Foundation Permit Fee $ P �' Other Permit Fee $ VS- TOTAL'°`.�r►,sa,t TOTAL $ I Check# f '1 27060 Building Inspector i TOWN OF NORTH ANDOVER 1 APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received Date Issued: IPORTANT:Applicant must complete all items on this page - LOCATION- re OCATION r p PROPERTY OWNER. 1 Print 100 Year Old Structure yes no' MAP NO: _ _ PARCEL: ZONING DISTRICT: _ .Historic Districtyes no Machine Shop Village yes go TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial D Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well El Floodplain D Wetland's ❑ 1Nafershed District p Water/Sewer . _ nn DESCRIPTION OF WORK TO BE PERFORMED:1 ]�-e 4,� � lX�°r,coo�S �• C��4C�.t C�11 9C+�;� cJ T 1 _!�✓1�U��. newC�.IN^ 1l �5 new /' , r�i p`o;,� fG9S W �s a .. Identification Please Type or Print Clearly) OWNER: Name: — �� ti�©� Phone: ��� )L--) Address: CONTRACTOR Name: Address: Supervisor'sConstruction Licenser _. _ _ __ -- Exp. Date: Home Improvement,License:. - _ _ . 'Exp., Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Wo (� T Check No.: 1 Receipt No.: 0 (2 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signaturefof Agent/Owner - Sig iafure.,of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The fol,owing is--a list of the too ui red forms to be filled out for the appropriate permit to.be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire-Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all caws if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apm-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bp subm.tted with the building application Doc: Doc.Building Permit Revised 2012 I Plans Submitted-E] Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ ..TYPE OF SEWERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools 0 Well ❑ Tobacco.Sales ❑ Foo_dPackaging/Sales ❑ Private(septic tank,etc.. ❑- - Permanent Dumpster on Site ❑ THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE.APPROVED PLANNING& DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on _ Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes . I Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DAIW ToNvo Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTME-NT. -`Terijp Dump'ster on site yes no Located at 124{MainStreet -Fire Departmerf•`signature/date�� '' a; • ` ' _'� .._ • d COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. .Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector _ Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter-166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— For department use Notified for pickup - Date Doc.Building Permit Revised 2010 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 159000.00 m $ - $ 180.00 Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 171 Appleton Street 399-14 on 11/4/13 Rehab Windows, Kitchen, Roof, Heating System t►ORTFf Town of t E 1, Andover p - No. _ - ' h , ver, Mass, lad A-O COC.NIC(WICK y1. 79 AERATE S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR a�► a•� ! N has permission to erect buildings on ..... 0T) sr .. Foundation Rough to be occupied as ...JqAkJ...W.1Ad(JVA..*...... ..... a4.0 rr�........ Chimney provided that the person accepting this permit shall in Ivery respect conform to the terms of the application Final on file in 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOVTA T Rough Service ...................V. ... .................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE Permit Listing Report Date Range:Issued between 01/01/2073 And 10/37/2013 by Permit Type Printed On:Thu Oct 31,2013 SQL Statement:Street No.like"171"AND(Street like"APPLETON STREET"OR Work Location like"*APPLETON STREET*")and([Type of Permit]='Building') Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 171 APPLETON STREET AVAGIANOS,JOHN Residential Alteration $10,000.00 037.B/0057/ 015-14 OPEN Jul-02-2013 AVAGIANOS,JOHN Replace Siding on Back and Rear Roof Only $120.00 502 Permit Type(BUILDING)TOTALS: ESTIMATED COST: $10,000.00 NUMBER OF PERMITS: 1 FEES INVOICED: $120.00 FEES PAID: $120.00 BALANCE: $.00 GRAND TOTALS: ESTIMATED COST: $10,000.00 NUMBER OF PERMITS: 1 FEES INVOICED: $120.00 FEES PAID: $120.00 BALANCE: $.00 GeoTMSO 2013 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 Location /7i zqal-,� Z!S of Sal- No. /Z Date �aRTh TOWN OF NORTH ANDOVER y 3?0�,,`•o I•�'M�OL ..Yi ` Certificate of Occupancy $ s�CNUS� Building/Frame Permit Fee $ Z:2 " i' Foundation Permit Fee $ %j si Other Permit Fee $ TOTAL $ Check # �1 247 Building Inspector 61s { TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: /— 2 Date Received Date Issued: zo I ORTANT:Anplicant must complete all items on this page LOCATION PROPERTY OWNER Print Print MAP NO: D37 Umt# PARCEL: 0,5_7 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ErUne family ❑Addition ❑Two or more family 11A ration ❑ Industrial No. of units: ❑Commercial epair, replacement ❑Assessory Bldg ❑Demolition ❑ Other ❑ Others: vsgphc t0 tWell E (�Flo.odplan 1'tWetlads �04Water/Sewer a istncf DESC TION OF WORK TO BE PERFORMED: f ou PC / o%P 1 Aa f 0 (Identification Please Type or Print Clearly) OWNER: Name: Q ---,�. Phone Address: CONTRACTOR Name: Address: C - 43 1 Supervisor's Construction License: o� I D� Exp. Date: Home Improvement License: D Exp. Date: ` 2 ARCHITECT/ENGINEER Phone: Address: Reg. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S F. Total Project Coat: $ , I / FEE: $ 367.00 Check No.: 0 7 C/ NOTE-I Persons o tracting with unre istered contra Receipt No.: A e1 7 4 7 g s to ara ty f nd not ve cces Si nature`of�A'eri- caner t gu e Sidafure o cow"r`act J ■ Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 1,w Building Permit Application '10 Workers Comp Affidavit — L�,��;L; Photo Copy of H.I.C. And/Or C.S.L. Licenses '1 Copy of Contract ❑ Floor Plan Or_Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require,sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses • Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned)to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL ❑ Swimming Pools ❑ Public Sewer Tanning/Massage/Body Art ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Signature Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS ■ L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: . I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$10o-$1000 fine 1 i (VOTES and DATA— For department use 4 i I f i 1 ❑ Notified for pickup - Date I Doc:.Building Pernut Revised 2011 June/mi FORTH Town of And o o dover, Mass., LAKE COCHICHEWICK ADRATED PPS` �� qS E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT............/...`` %..... Foundation G.. — .c.,��l o 7. has permission to erect........................................ buildings on..../.7 ...1,9?f..f0Y.....5r................................ Rough to be occupied as..................A�.�......S^ ?u C r"E�;_l . 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 6 MONTHS . ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS - Rough Z. ................................................ 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 T No Lathing or Dry Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. i ,ems ✓die Tanmirrroaurrva.�,�i a�✓!/faG�zu6el�G �,,, urvo,- (Sflice of Consumer Affairs&Business Regulation lw 2m u'r sreg%sltrafid i'alid fot hidividull i� y HOME ItYIPROVEMENT CONTRACTOR it mthe expiration dat& Tf-i60kid return,to:Registration ,_149298rce-of Consumer Affairs and�Business I�egu:ation � Expiration 12120/2011 . . Tr!# 292179 4t�i�tk Plaza-Suite 5170 Type Public Cbr#}oration �» Mt'h02316'> , BEST CHOICE Ap6iw NT-'DEMOLITION INC t ., MANUEL JOAQU1N 43 JACKSON ST LAWRENCE f�iA•01840 - Undersecretary i ;:x, NY pi3� tua' I - Niassachusert �tils�icrneitiifPuiiiic Sa#etr; - 9 Soars#of ku"l Jin'Zi-Rc ul 1"6) S rind Stand.rcls Construction Supervisor license License: CS 102179 Restricted to. 00 MANUEL JOAQUIN PO.BOX 2162, METHUEN,-MA 01844 .- t � - Expiration2/25/2013 f ,ssi ills loner Tr#: 102179 The Commonwealth of Massachusetts U Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass.02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �F- ST C),1D 1 G.t ��� 4� 'Q! /j4 10 AV Address: !2_3 _T'rq C� k_SDN _177 -ee77 City/State/Zip: til Ye A,1 C to, 2V,669Phone#: J -W— �8l Vi2 Z6— Are you an employer?Check the appropriate box: Type of project(required): 1.14 1 am an employer with 5 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ required] 5.F1 We are a corporation and its 10. ❑Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11. ❑Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12. ❑Roof repairs employees.[no workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name:�Q yq , J'j—r .4 7!� T.e / ., YA1 J['e_,0 V" eXoy V Policy#or Self-ins.Lic.#: tAzC �D 0 _ g,5 - 2 1 h Expiration Date: Job Site Address: /?f �� )%A2 ,ST City/State/Zip: A.�. AA) vu_Pk 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. Ido herby certiVuera pai and penalties of perjury that the information rovided above is true and correct. t Si natur : Date: Print Name: Phone#: — fl 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: Z'77- (Location of Facility) 4 SignaturePe t Applicant Date D) ert 1 ms ���� 4 (-,ee WORK ORDER Work Order# Date Issued KODY &COMPANY,INC. 171 APPLETON ST 9/29/11 LINDA KODY NORTH ANDOVER MA 01845 60 ASHLAND ST,MA 01845 978-686.1954 This Work Order is issued under the provisions of a CUSTOMER contract. The services authorized are within the scope of services set forth in the Purpose of the contract and the original Work Order. All rights and obligations of the parties shall be subject to and governed by the terms of the contract and original Work Order including any subsequent modifications,which are hereby incorporated by reference. Purpose;REPAIR APROXIMATE 100 SF OF SIDING.IN THE LEFT SIDE OF THE HOVE. PLACE STAINED CEILING TILES IN THE BASEMENT Statement of Work Start Date End Date Budget Description/Task Quantity Unit Unit Cost Total Hrs. 1. SIDING REPAIR 1 $ $1200 2. REPLACE STAINED CEILING TILES,AND $ $975 PATCH/REPAIR SMALL HOLES IN THE BASEMENT Original Dollar Amount $ Business Objective Supported:Repairs AGENCY shall pay an amount not to exceed $2175 (Revised Work Order total dollar amount) Both the Agency and the Contractor are res)7ai—i�ible for'-,ensuring work.performedlis within fhe scope of the original 1 Work Order and this Amendment. The Agency must monitor:.proper compliance with the terms sof the,original,:Work Order, this Amendment. Any and all further changes or amendments to the original Wark Order must be,iii writing and acknowledged by the GA Coordinator.. IN WITNESS WHEREOF the parties have executed this Work Order Amendment. Contractor AGENCY Approval i I 9/29/11 A%�'j i.—/�-�/ 92911 (Si nature) ontr for Authorized Re Representative (Date) (Signature) AGENC uthorized Representative (Date) W/O Manager B.C.A.D.Inc,Manuel Joaquin W/0 Manager LINDA KODY Telephone No. 978-688-4045 Telephone No. 978-6861954 Email: Pro'ects@bestchoiceabatement.com Email: LKODY@CONCAST.NET NAUTILUS INSURANCE GROUP® Nautilus Insurance Company Great Divide Insurance Company IMPORTANT NOTICE-PLEASE READ 8/30/2011 BEST CHOICE ABATEMENT DEMOLITION INC ATTENTION: INSURED 43 JACKSON STREET LAWRENCE MA 01840 Re: Nautilus Insurance Company Policy Number:NN 159628 Policy Term: 08/28/2011 to 08/28/2012 Dear Insured: Thank you for placing your insurance with Nautilus Insurance Company. We calculated your initial policy premium based on the estimate you provided us for your sales,payroll, admissions or other cost basis.Since your actual premium basis could differ from your estimate,we may have an auditing firm contact you to review your actual figures,either during the policy term,or shortly after the policy expires. If we determine that your premium basis sales,payroll,admissions,etc. is higher than originally estimated,we will bill you for any additional premium due. Please refer to endorsement L601 or S001 AK(Alaska)-Amendment of Premium Conditions,attached to your policy for a more detailed explanation of these premium audit and policy provisions. Please contact your local agent to discuss if you feel that your current future operations are not clearly defined. If you have questions on the audit provisions in your policy or other concerns about your insurance,please contact your insurance representative. For specific questions relating to any scheduled or completed audit,you may also call-our Premium Audit Department at 800-842-8972. Sincerely, Nautilus Insurance Company Premium Audit Department 7233 East Butherus Drive Scottsdale,Arizona 85260 Phone 800.842.8972 480.951.0905 Fax 480.951.9730 A#ri rAR K&EY CfJMA sK Y- NAUTILUS INSURANCE GROUP® Nautilus Insurance Company Great Divide Insurance Company AVISO IMPORTANTE POR FAVOR LEA 8/30/2011 BEST CHOICE ABATEMENT DEMOLITION INC ATTENTION:INSURED 43 JACKSON STREET LAWRENCE MA 01840 Nautilus Insurance Company Numero de Poliza:NN 159628 Fecha de Vigencia de Poliza:08/28/2011 to 08/28/2012 Estimado Cliente: Gracias por colocar su seguro con el Grupo Nautilus de Seguros. Nosotros calutaled su premio initial de poliza basado en la estimacion usted nos proporciono para sus ventas,nomina,admisiones u otra base de coste.Ya que su base actual prima podria diferenciarse de su estimacion,podemos hater que una firma de revision se ponga en contacto con usted para examinar sus figural actuales,durante el termino de poliza,o poco despues de que la poliza expira.Si determinamos que su base prima(ventas,nomina,adminsiones,etc.)es mas alta que al principio estimado,le facturaremos para cualquier deuda adicional prima. Refiera por favor al endoso S001 or L601-enmienda de conditions superiores y del S006/L240- limitacion de la clasificacion,unida su politica para una explication mas detallada de estos a provisiones superiores de la intervention y de la politica. El S006/1,240 es una forma exclusionary y una limitation de la clasificacion,que indica que cobertura, puede no solicitar las operations no clasificadas o no demostradas en su politica.Entre en contacto con por favor su agente local para discutir si usted se siente que usted las operaciones futuras actuates no debe claramente defmir. Si usted tiene cualquier pregunta sobre las provisiones de auditoria en su poliza,u otras preocupaciones por su seguro,por favor pongase en contacto con su representante de seguros. Para preguntas especificas relting a cualquier revision de cuentas prevista o completada,usted puede llamar tambien a nuestro Departamento Primo de Auditoria en(800)842-8972. Sinceramente, Grupo de'Seguro de Nautilus 7233 East Butherus Drive Scottsdale,Arizona 85260 Phone 800.842.8972 480.951.0905 Fax 480.951.9730 u FOR REGISTRY USE ONLY NOTE SEE N.D.E.R.D . NORTH ANDOVER REALTY TRUST v co PLAN. No. 7621 o N 42° 33'05 E 386.65 ' R oo � o mJu N O V d- ' M V EXISTING M o 3 LOT 2 DWELLING—' 10CO �1v ( HSE# 171) .78'+ 67, 622 S.F. W �- kv0�� ' LO q �SWIMMING �° cn m QO POOL 6411 ,0 N v. - I HEREBY CERTIFY THAT THIS � M 455. 74' PLAN CONFORMS TO THE RULES !� N 42023 '56 "E AND REGULATIONS OF THE o O REGISTERS OF DEEDS OF �- MASSACHUSETTS. N / F RITA EMMERT o J a Q REGISTERED LAND SURVEYOR NORTH ANDOVER ZONING NORTH ANDOVER PLANNING BOARD PLAN of LAND BOARD OF APPEALS I� THIS PLAN DOES NOT REQUIRE THE NORTH ANDOVER , MASS . APPROVAL OF THE NORTH ANDOVER DATE OF APPLICATION PLANNING BOARD. OWNER - STEPHEN a DANNI CALLAHAN SCALE I 1 "=50 ' DATE ; JUNE 24, 1981 DATE OF HEARING `JH OF Mgssgc DATE OF APPROVALWILLIAM DATE alndove r o S. consultants THE ABOVE ENDORSEMENT, IS NOT A 213 Broadway �Inc' �'�ocsu vE+ CHAIRMAN DATE �P — DETERMINATION AS TO CONFORMANCE Methuen , Mass. WITH ZONING REGULATIONS . 0 50 100 150 200 Ft. u D � D n 0D M11H M411Ie BEenr`dl1'0�12 " 0 20 100 120 500 EI' VyaLe- CH'dikSW`dV1 DVIE DE.LEBWIVI'd110V1 V2 IOD ,POVILOVVYVACE W6}I�n Goa MaT 1HE t1B0AE EVIDOB2EVQEM-L 12 001 d S12 B q IUC �ag121E D D n c 2' ouanl jau. a DVIE OE `dbbbOAVF DVIE : 0 0 augOA6l o �~ i o y,� Mirnrw �a� DVIE OE HE' BI We 0 a 2CdrE I 1 11=201 DVJLE : '1nWE 54' laBl DVIE Ob VbbrlCV110VI brVI414100 BOb13D' D o OMV1E13 21EbHEV1 Y Db'VIVII Cdrr`dHbVl Vbbi&OAbr OE 1HE 1400�1H V14DOAEV BOVBD Ob dbbEVF2 1H12 bFVM DOE2 1401,, 014EonwE 1HE VOH.I.H ViADOAEB ' NV22 MOBIH ` MDOAEB SOWIVIe MOBIH VMDOAEB br—oVO IIMe BOVHD bFvv 01 FVWD a 0 0 a a { L6Ee121EHED rVWD 2nHAEAOV N D 4 A \ E WIV EWWEVI °a a 4 frl a ) O Wb22VCHn2El12' Sty ° a° S BEe121EB2 OE DEED2 OE �F` VI ct5 o 53 2 m V14D BEenrb'11on OE 1HE 5 422 14, Q) W bFVW COHLOI32 10 1HE HnrE2 r• �aS 0 t: I HEHEBA CEBJ.IEA 1HVJ- 1H12 4 0 CO ,D 4 60 s boor, .,,; - . _ e,4,� c a 2Mlww�i�� � `�-o es' C'ss 2"E ° m - rol S H 2 E# 1�1') �8'+ co 7 DMErrlge)-., coo w EXIUIW� 0 0 w w i� 0 4-' CO N O �y A"' � D a�5 �0 D p t2se ee , N A 45. 32,02„ E c brvm- wo* Sesl ° o to 0 2 EE V1 D E l3 D MOBIH VADOAEH BEdr1QAD iBn21 co VIOIE : ao m R LOO BEClaiu k n2E OWFA 4 + n 'f t Date Jul 13 1961 `eti-,'Jun No.. 8.1. 8.1. . . . . . . . . x of Ca i ! i J 171 at . . . a. .sw.i..i mi ng. .poo.l . to. extend. 12...6 . feet . f.rom. .the . ,=r:,,ii:. . . . . i .i.i. ? � .� :i.J.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;vun on the !iLu "e do thi 7 r t E � i3O . .Q'- 4 qtr , SOW 31i11i ;m J . Sullivan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Auusi inCKei'Son . . . . . . . . . . . . . . AI ter F. Soule Murice S . r. :1yt July 23 , 1981 Stephen and Danni Calla:'lan 171 Appleton Street F:aticion No . 2.3 - ' 81 '.r . Daniel Long , Toth C1 : rk T•.:•,n 0ti'i .:,e 3,jiIdi .iy or f:{1 ',i ✓'er , ss a „r . i.,)ng : The , yard of Appeals held a publ i c neari ng on !Monday ;�veni ng , July 13 , 1181 upon the application of Stephen and Danni Callahan . The hearing was duly advertised in the North Andover Ci ti zon on Junin 13 and 25 , 1031. and , 11 abutters were notified by regular ,ai11 Tile following ,romb..rs were present and voting : Frank 5crio , Jr. , ChairAn ; .!illiam J . Sullivan ; Augustine Nick,, rson ; i, a I L a r SQiUin , . Id �, � Wi1A nu41ds . nn C 1C ` 1r . no C, it 0e evvisio is of Oction 4 7 ) { t 1 w i , .r 1 l 11 Vo oxknd dProxinaLdly O Vat Kon iko 1, 'iiding Iinn, in the pi'. jisus Iocated at 171 pp? noUnn t . he Z&tiL . _ or W KK C, 1 & the cun1r. 1' r" . ill �d "'ol r l � .'lo:ld L�I�' P, nit l) 'l 1'� -,1���_' � 11i1g �,o i� lUid ? •/ ll.er' j1"M . ,a a the , a OF 16;ie u `operty . no further testified that after a Stop-Work Order was issu2d by . �c Assistant Building Inspector , the pool was c01QArd Pun ho Ys FaiIuce to inform the contractor of the oiler. in a Yo`_i in rude by Mr . Soul e and s, c&)nt.ed by Nir . li ck;• He !card voted unanimously to deny the variance as recuesled . Petition No . 1 � � ! , Stephen and P .i Faye 2 Fhe Board finds that the require nen cs o P Section 10 .4 iave not been satisfied . In particular , the pool could be located in accordance with the Zoning By-Law and that the size and shape of the lot permit a proper location of the pool . Sincerely , 30ARD OF APPEALS Frank Serio , Jr . , Chai rman AEF/A Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS C14US This certifies that .......... ..L."... ,fir............ . 5"has permission to perform !. .............................. 5 wiring in the building off & ..... ...................... .................................................. at..... 7.—a.V........ North And M . . ...... ov r, ass. Fee.........."".... Lic.No.IN ........... ............ ......... ELECTRICAL INSPECTOR 0, 6'5-1 cl? 14J 1 96?-7 Check # 10411 Commonwealth of Massachusetts Otv fjfcial Use Only Department of Fire Services Permit No. / L1,/r Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORIVIATIOA) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of.hislor her intention AN ollpterform a electrical work described below. Location(Street&Dumber) JK Nop Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 4 Existing Service I Amps /24Q-Volts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and.Ampacity 3ubig WOW5 Location and Nature of Proposed Electrical Work: •�- - �' Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVO' Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool nd. Elrnd. 11Batter Units --. No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of • No.of Switches No.of Gas Burners No.InDetection and ][nitiatin Devices No.of Ranges No.of Air Cond. Totnal No,of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained P Totals: ... ............................ ........-............ Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal Other P g Connection No.of Dryers Heating Appliances KW No. Systems:* 1'y 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 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 h bili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force,and has exhibited proof of same to the pen-nit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Sp cify:) I ceHify,under thepains andpenalties ofperjury,that the inform 'on on=thl* tion is true and complete. FIRM NAME: LIC.NO.: Licensee: 1/ Signature LIC.NO.: 10230-6 grapplicabl erste em t"i the hcen num ailing" Bus.Tel.No.: Address: Alt.Tel.No.: W5: *Per M.G.L c.147,s.57-61,security work requires Department oPkIblicKafety"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 _-_l!7_ PF,RMTT FEE:S �1I T_l_.L The Commonwealth of Massachusetts �= I Department of Industrial Accidents Office of,investigations °`•'� 600 Washington Street ilit;f Boston, MA 02111 www.rgzassgov/dia . Workers'Compensation I itrance Affidavit. Builders/Contrafctors/EIeatricians/Plumbers Applicant Information . 1. , ., +, Please Print Legibly Name(Business/organization/Individaal): �t rt -• .E, r'c c Address: City/:State/Zip: Phone#:. F mployer?Check-the appropriate box: ployer with 4, ❑ 1 am a general contractor and IDad f prgject(required):es(full and/or part-time),* have hind the sub-eoritraciors ;^. ew coristructianle proprietor.or.partner. n listedvr>the attached sheet.# ` emodelmg s3iip and.have no employ8es t rA •'r$66 sub-contractors have emolition working for me in any capacity, workers' comp.insurance. [No workers'camp.insurance 5. ❑ We are a corporation and its Building addition required.] officers have exercised their lectrical repairs or additions3.❑ I din a homeowner doing all work right of exemption per MGL lumbing repairs or additionsmyself[No workers'comp• c. I.52, §I(4);and we have no oof repairsinsurance required.)t employees,[No workers'comp. insurancerequired.] ther *Any applicant that checks hoz#I must also fill out the section below showing their workers'bompensafion policy information, t Homeowners who submit this affidavit indicating they am doing all work and then hire outsidecontractors must submit a new affidavit indicating such. #Contractors that check this box mustattaebed an additional shv t showing the•name of the subcontractors end their tvorke.:'camp,palicJ:nfor;a6oa, ' l aan employer Mal esprmvidiF-jg:wor herr'compenseadon insurance for my employees below is Mepolicy rand job site lraforrraatinra Insurance Company Name: ' Policy#or Self-ins.Lic.#: 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under thepains and Penalties ofpedury that the information provided above is true and correct Signature: Date: Phone#: t Offlciat use only. Do not wrie th dkis area,to be completed by city or town officiaC r r Ci>ypr,Town: Permit/License9 - Iss i3th' Atafhority(circle one): I.B`oaM df Health 2.Building Dept irteri't 3 Ci Jimwu Clerk 4 Efeetri al lits 6.Other - • pector"i5.d'litinbiitg'fas Or Contact Person; Phone#: i The Commonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations, 600 Washington Street Boston,M4 021X1 �V Workers' Compensation Insurance Affidavit: t guilders/Contracors/Electricians/Plu A licant Information tubers Please Print Legibly ame(Business/organization/Individual): i Address: City/State/Zip: f jj Phone#: Are you an employer?Check the appropriate box: 1•❑I am a employer with 4. ❑I am a general contractor and I Type of project(required): ployees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2• am a sole proprietor or partner- listed on the attached shget.1 7. ❑Remodeling ship and have no employees These sub-contractors have working for mein any capacity. workers'comp,insurance. 8. El Demolition [No workers'comp.insurance 5. E] We aie a corporation and its 9' El Building addition 3.Elrequired.] officers have exercised their 10rElectrical repairs or additions am a homeowner doing all work right of exemption per MGL 10r Plumber Myself.[No workers'comp. c.152,§1(4),and we have no g repairs or additions insurance required.]f employees.[No workers' 12-El Roofrepairs COMP,insurance required.] 13.❑Other !Any applicant that checks box 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-confractors and their workers'comp.policy information. ltzfn an employer that is providing orkers'compensation insuran information. ce for my employees. Below is tlae policy andjob site Ingi ance Company Name: Policy#or Self-ins. C.#: Expiration Date: Job Site Address: A City/State/Zip: .N 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 nuof mber 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 n es to tion. day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigation.4- the DIA for insurance coverage verification. Ido Izere ins and penalties ofperjury that the information provided above is true and correct. Si nature: Date: 'hone#: Offzci 1 use o rein this area,to be completed by city or town official City or n; N. Permit[License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspect' 6.Other p or Contact Person: Phone#: • f 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 orrepair 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"everystate 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 k 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 e 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)and phone numbers)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. r City or Town Officials t r' 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. i Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an`applicaut that must submit multiple pernut(licensa 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 homeowner or citizen is obtaining a license or permit not related tor 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. The Department's address,telephone and fax number: , xhAe GGA onwealtl o.i.tvfassacl�asetis _ ( ' Deparb ,ent of Industrial Accidents i Office of Investigatio>sns 600 Washington Street B oston;M-A 02111. Tol.##617-727-4900 ext 406 ox 1.-877-M- ASS,AFE Revised 5-26-05 Fax#617,727-7749 www.mass.govaa Y J rDate...... ......`...................d� t Hp pTH 3?�•`;r��•:-�°!s•pp` TOWN OF NORTH ANDOVER p PERMIT FOR WIRING .5 ,S-SA CNUSfc� .3 This certifies that ..... .....C�� 11....... lc'U ................. has permission to perform ......;A Q ....5kx://.:!4 ............................ wiring in the building of..ZFL)....... ...................................... A �......: y" ,North Andover,Mass. K at...... ...... ........... ......... 'p f D 7zsl� Fee_................. Lic.No.............. .................. .. . ..... .......... 9LECTRICALINSPECTOR Check # Sib 0 7065 e F Commonwealth of Massachusetts Official Use only I r Permit No. 7D e��— Department of Fire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11-21—e� City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her i tention to perform the electrical work described below. Location(Street&Number) 4 Owner or Tenant Telephone No. Owner's Address /91 pv ,U �— Is this permit in conjunctio with a b Iding erm, ? Yes ElNo [9� (Check Appropriate Box)2 Cj/ G� �� Utility Authorization No. f��9Q Purpose of Building �4; Existing Service /00 Amps /20 ZyQVolts Overhead � Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Locati n d Nature of Proposed Electrical Work: A/ eC p ODM 2 e / 10 1-- Zv*nq 0a.4J / ZO 2 `/o v,0,44o� t(trC J Completion of the following 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 n- o.o Emergency ,g ,ng 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 g No.of Waste Disposers eat Pum Number Tons KW No.o Self-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal Connection [I Other No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.o No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP elecommun,cat,ons ,ring: No.of Devices or E uivalent OTHER: Attach additional detail if desired or as required by the Inspector of 44'ires. 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the ins r enaltie f per"ry,that tl in rmadon on this application is true and complete. FIRM NAME: -�G- I Ce- �` �J`C-e- LIC.NO.: 167; �lj-6 Licensee: Z, Signatur. LIC. NO.: j (if applicable, er "exem n the license number line.) / Bus.Tel.No.: /4 Address: � �� 2u ��� �fy_1``j��A--1-15AS;S ®�[ �y(� Alt.Tel. No.: *Security System Contractor License required for this work;if applicable,enter the license number here: 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, l hereby waive this requirement. 1 am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No.