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HomeMy WebLinkAboutMiscellaneous - 177 ROSEMONT DRIVE 4/30/2018N O cCDW V O Co cn 0 m CCA o z O 0 oM-- < O m or, Date ...�:... �%:.,1 U........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that /( has permission to perform . . /Q! wiring in the building of ......... A... ....................................................... at .......... 1.22.)e.9S /ylvx771 ..... , North Andover, Mass. P � Fee ..._ r ........ Lic. No. ,k6. Z ®4 ......... ti ........... �.. �/ `) ELECTRICAL INSPECT RV Check ll .Z____� 9,195 -t\- Commonwealth of Massachusetts 0.1 Department of Fire Services 1w, BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. / Occupancy and Fee Checked [Rev. 9/05] (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 WINK OR TYPE ALL INFORMATION) Date: 1 -11 - City -11-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) 1717 Rosernon l df Owner or Tenant 5 u m p n pq } e l Telephone No. 9 7F :39 7 _) L b Owner's Address 5 Q m e Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building D Ul P l l i n Q 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: K; I C h en + d i n n i »a r o a m Ce M o of e) . s� r 1 l ComDletion ofthe follotivinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle).Fans of Transans Total Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires (a Ca iAe} .� Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pum Totals Number _ ._ Tons __ ___ KW No. of Self -Contained Detection/Alertin Devices No. of Dishwashers S ace/Area Heating KW P g 3 2 �� local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, Security No. f Devices or Equivalent No. of Water KW Heaters o. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: f No. of Devices or Equivalent ! OTHER: Attach additional detail if desired, or as required by the Inspector of YVires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ) - ) I - ) 0 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 JN BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Undaren Electrir_LIC. NO.: 2042LIA Licensee: S h ayn i. I n da f e r) Signature LIC. NO.: (Ifapplicable�erS rQ"exempt'; in th icense num�gr l,[7:) M Bus. Tel. No.:% O:- �3S-Q7® Address: ti % 0;n 51 170i��1), ��tA ME -20 Alt. Tel. No. -X09 - 72 9 - Q TA *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, I hereby waive this requirement_ I am the (check one) ❑ owner .❑ owner's agent. Owner/Agent PERMIT FEE. $ 570, 00 Signature Telephone No. ' The Commonwealth of Massachusetts ^; Department of Industrial Accidents -A t r . Office of Investigations listed on the attached sheet t 600 Washington Street These sub -contractors have Boston, MA 02111 www.mass.govldia . Workers' Compensation Insurance Affidavit: )builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): L i n d g r e n E l ee f r i g Address:-- _6'79 A a t'n S{. v City/State/zip: Holden r AA 01596 Phone #: 501-735 _q7o� Are you an employer? Check the appropriate box: 1. (S i am a employer with 2 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. E3 I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [] Remodeling 8. Q Demolition 9. ❑Building addition 10. LnL Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks hoz # l 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: FQ(M FGm*l y Policy 9 or Self -ins. Lic. #: 90114 W Gl, Expiration Date: 11114110 Job Site Address: 177 Ro3tm on D(. City/State/Zip: NAndoyef /MA 01845 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 Iead 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 certify under thepains and penalties of perjury that the information provided above is true and correct 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 #: a _ '7—//) Date... �- .......... Of a40PTH 1ti TOWN OF NORTH ANDOVER -.z PERMIT FOR GAS INSTALLATION this certifies that .. .. .. ............. .... . has permission for gas installation in the buildings of ... .............................. at .. � . -/ 2.... Ttt' 7 ��, North Andover, Mass. Feer.'. 7. Lic. No. /Ga °.. .......................... GAS INSPECTOR Check 4 Ti 44 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date q h o / U NORTH ANDOVER, MASSACHUSETTS Building Locations fosP i'YI /civ i Permit # 1 � Amount $ ?e,� � U " A N P4 % C' L Owner's Name New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or. type)'' `` Check one: 'Certificate Installing Company Name_ A C LCj }tel f1 m al /U G uL # 4T lvc, ❑ Corp. Address 7 SC! -r non- 3-7- 5P6A)GEi.2 11 Partner. r?siness a ep one 9 5 � Firm/Co. X*e of Licensed Plumber or Gas Fitter % ROY A [ j,,U AJ J INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® NoO If you have checked y_es, please indicate the type coverage by checking the appropriate box. Liability insurance policy K" 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner E Agent 0 7 1-1.....e..a:A.sL—..71 -.1 - .—....aL V11 , l.avc ,uuiii,ucu kor enterea) 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 Massachusett to Gas Code and Chapter 142 of the General Laws. Title City/Town OVED (OFFICE USE ONLY) 5ignaturoe f Licensed Plumber Or Gas Fitter 0 Plumber 3/00 0 Gas Fitter License Number Master Journeyman �C � w � � a W w x C7 F a z H z x W H ° z W I a w '° a x c4 3 o z o Leix Ix. � 0 ° a° > v ° W o SUB-BASEM ENT BASEMENT. 1ST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR - - 8TH. FLOOR (Print or. type)'' `` Check one: 'Certificate Installing Company Name_ A C LCj }tel f1 m al /U G uL # 4T lvc, ❑ Corp. Address 7 SC! -r non- 3-7- 5P6A)GEi.2 11 Partner. r?siness a ep one 9 5 � Firm/Co. X*e of Licensed Plumber or Gas Fitter % ROY A [ j,,U AJ J INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® NoO If you have checked y_es, please indicate the type coverage by checking the appropriate box. Liability insurance policy K" 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner E Agent 0 7 1-1.....e..a:A.sL—..71 -.1 - .—....aL V11 , l.avc ,uuiii,ucu kor enterea) 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 Massachusett to Gas Code and Chapter 142 of the General Laws. Title City/Town OVED (OFFICE USE ONLY) 5ignaturoe f Licensed Plumber Or Gas Fitter 0 Plumber 3/00 0 Gas Fitter License Number Master Journeyman �C � �w The Commonwealth of Massachusetts Department of LndustriaiAccidents Office of Investigations 600 K ashington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nIr111P9T�' jn'inrm o4�... Name (Business/Organization/Individual):di18/N 9 g� / -4 %j/V Address: City/State/Zip: UL Phone #: c.SO S — S-0 V —,,, , -Q _5 - Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.4 I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet t ship and have no employees These sub=contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] 3. [:].1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' *. -nx, a±RiliP? t taut Ah Ln 1.,,.. 4!t ..._ comp. insurance required.] Type.of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11 AlPlumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ­_uVL u=!t`w snov! rc; v!orPc ,' compinformation. ensation policy infoation. t indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Homeowners who submit this affidavi iContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp policy information. Iam an employer that is providing workers' compensation insurance for my employees. Below is thepolicy andjob 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 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. I do hereby cerci he pains and penalties of perjury that the information provided above is true and correct S�) �r- s Official use only. Do not write in this area, to be completed by city or town offciaL o/ U 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 #: •A Information as d 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 apar axents 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 notbecause 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 co=mpliance 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 instance coverage. Also be sure to sign and date the affidavit. The affidavit should be meturned to the city or town that the application for the perrmit or license is being requested, not the- Depa=ent 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/licrose 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 Office, of Investigations would like to than 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 Dcpartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02 111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass-gov/dia -;) _ %J__� Date............. TOWN OF NORTH ANDOVI PERMIT FOR"PLUMBING ity. 'SSACNUSE` - r This certifies that ........ ..... .1.. ... ...L.... ... .... . has permission to perform . ...e ''�.. . plumbing in the buildings of .. ............................... at ....... ................. ,��` -'�. , North Andover, Mass. Fee.'!/. ..... Lic. Nov . . ' 1'` .......... PLUMBIN T R Check # 8526 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date. Building Location 17-7 R o 5 t 1"ClU T D12 Permit Owner U M P t J Amount �//• �� New ® Renovation ® Replacement. ® Plans Submitted Yes No FIXTI1RFc (Print or type) Check one: Certificate Installing Company Name _At (-EN t u irD/y1! 3- df -AT 0 Corp. Address S«yoo L- 6-r Sf AU6 C/L m12n Q a7 Partner. Business Telephone ® Firm/Co, Name of Licensed Plumber: �Ige y &C Al Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy R Other type of indemnity � Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner [3 Agent I hereby certify that all of the details and information I have submitted (of 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 Massachus lumb*=Chapter 142 of the General Laws. Signature or Llum= Title Type of Plumbing License City/Town Mcense 3 f j �) um er Master11Journeyman M APPROVED (OFFICE USE ONLY M. - The Commonwealth of Massachusetts Department of Tndustrial 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 Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. [:]I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. , workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] r ----• --•-• -•----.W ++.,,. r.. — a;sv ill! Uut CCC SecuoTT peint. si.CMA'm +j.e— Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E]Building addition 10. Electrical repairs or additions .11 - Plumbing repairs or additions 12.[]Roof repairs 13.❑ Other s t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and thew workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: 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. I do hereby certify under the pains and penalties of perjury that 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 offcciaL 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 #: 0 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 i xat the application ffor 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 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-MASSAFE Fax # 617-72.7.7749 Revised 5-26-05 www.mass..gov/dia 0 09891 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that iftyw. h aspermission to perform ... plumbing in the buildings at ..... k.1.1. ..... .. . North Ando/,er, Mass. ...... Fee...O'... Lic. No .......... ... ... . PLUMBING INSPECT R Check #? URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER.____ INSURANCE COVERAGE: I have a current liab_ ilifv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9—N0 �]1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L OTHER TYPE OF INDEMNITY [1I BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT Q hereby certify that all of the details and Information I have submitted or entered regarding this application are true and that all plumbing work and installations performed under the permit issued for this application will be in compli< Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —1-1001 PLUMBER'S NAME — I LICENSE # MP 0 JP ®/" accurate to the best of my knowl with all Pertirprovision of the SIGNATURE CORPORATIOND #PARTNERSHIP D.i! # LLC 'r COMPANY NAME _ a�A/ r ,� _ ADDRESS CITY �O�F�—....._..,_.J STATE f ZIP p / _ TEL FAX CELL l ! MAIL- --- M V) r"- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MFM— CITY MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME . P OWNER ADDRESS_I TEL �� �� FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT ,II CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES EQ NOD FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB======= ��•�r��®r�r� ter® i CROSS CONNECTION DEVICE F DEDICATED SPECIAL WASTE SYSTEM FOUNTAIN _I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER.____ INSURANCE COVERAGE: I have a current liab_ ilifv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9—N0 �]1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L OTHER TYPE OF INDEMNITY [1I BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT Q hereby certify that all of the details and Information I have submitted or entered regarding this application are true and that all plumbing work and installations performed under the permit issued for this application will be in compli< Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —1-1001 PLUMBER'S NAME — I LICENSE # MP 0 JP ®/" accurate to the best of my knowl with all Pertirprovision of the SIGNATURE CORPORATIOND #PARTNERSHIP D.i! # LLC 'r COMPANY NAME _ a�A/ r ,� _ ADDRESS CITY �O�F�—....._..,_.J STATE f ZIP p / _ TEL FAX CELL l ! MAIL- --- M V) r"- M—FM—FP--M M—FM—FM— MFM— SFW WF00-0WDISHWASHER - ,II . , .. • - ������� ��•�r��®r�r� ter® F FOUNTAIN FLOORDRINKING FW- FM- FM -FW- r®FM- F=- M F=- FM- FM -r® INTERCEPTOR �FF—F—F— F� AFM M—r FW—W FM M� M MN— FW— FMFM Mrd FM— WM WOMM—MM®I M SERVICE MOP SINK _ F�—F�-- ���IF�f�lF�—f�lF�—(�1—r�l[� URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER.____ INSURANCE COVERAGE: I have a current liab_ ilifv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9—N0 �]1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L OTHER TYPE OF INDEMNITY [1I BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT Q hereby certify that all of the details and Information I have submitted or entered regarding this application are true and that all plumbing work and installations performed under the permit issued for this application will be in compli< Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —1-1001 PLUMBER'S NAME — I LICENSE # MP 0 JP ®/" accurate to the best of my knowl with all Pertirprovision of the SIGNATURE CORPORATIOND #PARTNERSHIP D.i! # LLC 'r COMPANY NAME _ a�A/ r ,� _ ADDRESS CITY �O�F�—....._..,_.J STATE f ZIP p / _ TEL FAX CELL l ! MAIL- --- M V) r"- The Commonwealth of Massachusetts Department of IndustrialAccidints Office ofInvestigations kvtj 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/fndividual): n!r r t/ 00�/V" Address: 4/l6_ _ 224 , ij ! �' T City/State/Zip: i�j�vr�/0j )4e g, � ��t f G�Phoin #: e -c Are you an employer? Check the appropriate box: 1. ❑I am mployer with 4. ElI am a general contractor and I e loyees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. 1 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. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company 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 cert undg the pains andp_M'al ' s ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: I 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 bean 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 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 oflndustrial Accidents Office o£Investigationss 600 Washington Street Boston, MA: 02111 Tel. # 617-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 JFax # 617-727-7749 wv wanass,gov/dia s 0 I k f, ,j U1, '01 e. Ac zr- m >M m,) v) -n, cc n;u n CA > C- Lrl > ij� , Z po .0 7 o C: I'd t< > M Mcn Z <-n U) m 0,%zm IN 1 10 I( s 0 I k Date..) -7.v ." - /.... TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION 9 kr �9SSACMUSEtt This certifies that .. ��. � r:(. �?!? / �� ..... i.)/ 4 ........... . has permission for gas installation ,%' . l .................... in the buildings of ...�,.'€ 1. �.. ........................... . ats. 6.' .`.° ::....1 North Andover, Mass. Fee. �.�..'.... Lic. No. ,�,GASINSPECTOR Check # 3736 MASSACHUSETTS UNIFORM APPLICATION FOR PERMrr'rO DO GASFITTING T T 23 C Q UV Mass,n T) vAA C, Buldini; Lavation_ Name ` Type of Occupancy Gl New 0 Renovation 0 Replacement pians Submitted'. Yeso No 0 Instalffm Company I Pj (A' Check one: , Ceftcate Address_U -1-A 13 mv 6 &C I ' M r+ at -1 0 ftrtnership \ -2 15 0 FhWCO. --- M.MArj1k-P.,:mPh=,bff oroasFuer rAR. -SrEV67W --T- -7 A20iUe,6 1 INSURANCEOV "GE: I have a current7baftyinsurance pdW or Ks substuM eqt"ent which meets the requirements of MGL Ch. 142. Yes - No 0 if you have checked Yes. please Indicate the b" coverage by d)eckWg the apprqxlate book I I A lialATity ftumncc Policy 0 other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee gg" 091 have the insurance coverage required by Chapter 142 of the Mass. General Laws, and, 90 my signaUxe an this permit appffcaWn waives this requirement- - dte& one: OwnerO Agent 0 �Sqmw, of owner., re's Agmi I hereby certify that an of the detaft and information I have utmilfttl Or enteiadl in above application are.boa and accurate to the best of my bwwhdge wd tW an pkm*kd work ax! kWuAtUmpubmed *xW theparoAlsmW for Us AP" *ill be in with all Pedirmt PMVWWS of the hUssmhusem State Gas OP& wd Chapter 142 of the GmeW taws. gy T�aw of Lkauw liji�e� Lk&aRl Pkimber I 2: be Tft� 4; tc V; u+ ser W Z p 1 cc 4 10 9A 0 13'a W s t 0 U. us T cc 4, Ix �m 0 C: > G&L. 0 0, -Aqu L— '3S MT ; 7 H T ........... I-- iST FLOOR 2NDFLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Instalffm Company I Pj (A' Check one: , Ceftcate Address_U -1-A 13 mv 6 &C I ' M r+ at -1 0 ftrtnership \ -2 15 0 FhWCO. --- M.MArj1k-P.,:mPh=,bff oroasFuer rAR. -SrEV67W --T- -7 A20iUe,6 1 INSURANCEOV "GE: I have a current7baftyinsurance pdW or Ks substuM eqt"ent which meets the requirements of MGL Ch. 142. Yes - No 0 if you have checked Yes. please Indicate the b" coverage by d)eckWg the apprqxlate book I I A lialATity ftumncc Policy 0 other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee gg" 091 have the insurance coverage required by Chapter 142 of the Mass. General Laws, and, 90 my signaUxe an this permit appffcaWn waives this requirement- - dte& one: OwnerO Agent 0 �Sqmw, of owner., re's Agmi I hereby certify that an of the detaft and information I have utmilfttl Or enteiadl in above application are.boa and accurate to the best of my bwwhdge wd tW an pkm*kd work ax! kWuAtUmpubmed *xW theparoAlsmW for Us AP" *ill be in with all Pedirmt PMVWWS of the hUssmhusem State Gas OP& wd Chapter 142 of the GmeW taws. gy T�aw of Lkauw liji�e� Lk&aRl Pkimber I 2: be Tft� � .� �{•&2t� » g \ 2 � £ § ¥ i � © m - , . � ■ . :. » ¢ Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. 11.0YnAt ..... ..................... permission fo has pen r gas installation .............. in the buildings of. . ............................... at ..... , o/Andoverass . Fee .ZQLic. No..,!�4e..... .. .. GASINSPECTOR Check # 8657 y 2� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA MA DATE f PERMIT # JOBSITE ADDRESS —%— r _ { OWNER'S NAME GOWNER ADDRESSt� rr TE FAx TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL (I EDUCATIONAL RESIDENTIAL [ CLEARLY NEW: [j RENOVATION: REPLACEMENT: 4 PLANS SUBMITTED: YESF- NO Q APPLIANCES"I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE z _ GENERATOR GRILLE INFRARED HEATER -,_-- LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER I ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER µ I UNVENTED ROOM HEATER— WATER HEATER I_._ I OTHER � IL INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES B'NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE HECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [j BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER (] AGENT D.1 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be incompli a with all Pert' provision of the 1<. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMEpY� i LICENSE # �µ SIGNATURE 1 MP I MGF � JP GF C LPGI CORPORATION 0# �� � PARTNERSHIP[ (# LLC Ej#[Z �( COMPANY NAME: 4,1f�/`�,� ADDRESS[---- ----------- DDRESS _-.-.._-.CITY CITYSTATE,�ZIP TEL FAX CELL c EMAIL �u _ y 2� 0 z o U W a W a� o F] Z Z O N W F— W OF a Z U w �* 3 W X ~ � W 5 a WCO O uj > a W w W C wd o a a a U J a = w F- LL. W F O z z - �w rA -� I e TM r Ff1 i � ' .w The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.massgov/dia Workers' Compensation. Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: t/rS' ✓n 41 _r City/State/Zip: Ay,1 ,n of 1PV C/ �� Phone #: 6 �--? - 3—a � - 6�0 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 1 6. ❑ New construction `dloyees (full and/or part-time).* have hired the sub -contractors ❑Remodeling 2. amp 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. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E1 Electrical repairs or additions required.] officers have exercised their 3111 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' 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I 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 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. Idolierebycertrfjv,%Oerthepainso ddnalfles of perjury that the information provided abov . is true a d correct. Cio„afiira• �� Mata �// / C / / ..5 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 #: was 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 permittlicense 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 1-877,7MASSAFB Revised 5-26-05 Fax # 617-727-7749 vw.Mass,govfdla I 2 0! Z!, 1 M M U) 0E z ih U3 1 .0 m MIEJ cf) cn;u to ;;o > Ll t > Oz CDIc o z F- m > zcy m min c,q C)ft C) -M w2 `V� A 4t4 ,yam 71, 7 WV WV I 2 Location�i�� Flo. ID 20 Date Ut /-/:7- 9& O Q TOWN OF NORTH ANDOVER 4 Certificate of Occupancy $LD Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ t �hT Water Connection Fee $ _- TOTAL $ -� ©740 Building Inspector 9451 Div. Public Works Location EX11 Wt No. Date TOWN OF NORTH ANDOVER LpJ Certificate of Occupancy $ Building/Frame Permit Fee .$ Foundation Permit Fee $ Other --Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector t' /aRI5 11.45 150.00 PAID i+ 8g .9450 Div. Public Works R l77 /xj Location , � No:$�. Date- 4O TOWN OF NORTH oT ;, o . +' �! .ANDOVE& Certificate of Occupancy $ Permit Fee -� Building/Frame $ ~S24 Foundation Permit Fee $ L� -C Other Permit Fee $ / Nv Sewer Connection Fee $ �, Alm' 4443 Water Connection Fee $ 11 N_ TOTAL $ Buildi g In pector NTO8 / , 6v . uvic Works APPLICATION FOR PE�T� TOr112 = 4VTHtAZN9VER, MASS. I 7Y,'� n 2 C-6 z_._ PAGE 1 MAP KBO. I LOT NO. Cl 2 RECORD OF OWNERSHIP IDATE BOOK '.PAGE — ZONE SUB DIV. LOT NO. l �I LOCATION PURPOSE OF BUILDING !J U r 2 L7 OWNER'S NAMEy/L2`OLu /I'V'► ��a%� ��v�— NO. OF STORIES v SIZE f OWNER'S ADDRESS ��O C ASEM NT R SLA ARCHITECT'S NAME �/! SIZE OF FLOOR TIMBERS 1ST �,� 2ND D /YiL;-o 3RD Ovy_ `.+ BUILDER'S NAME rra5d 1�i2'� 177 Uw`-'/ SPAN l� DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS --_ DISTANCE FROM STREET ^) POSTS GLv DISTANCE FROM LOT LINES-fSIDES REAR O '� GIRDERS &'X G AREA OF LOT / FRONTAGE HEIGHT OF FOUNDATION O I, THICKNESS G b IS BUILDING NEW I/,.�c, SIZE OF FOOTING G.d X,?? IS BUILDING ADDITION w X91/ MATER:AL OF CHIMNEY IS BUILDING ALTERATION /IL IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Y ' /e-51 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER e IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST W SEE BOTH SIDES EST. BLDG. COST . PAGE 1 FILL OUT SECTIONS 1 - 3 PERMIT FOR FOUNDATION ONLY EST. BLDG. COST PER 6Q. PAGE 2 FILL OUT SECTIONS 1 - 12 REGULATED BY PARA. 114.8-S. B.C.EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE E REGl0�1�414A—1EE PAID nn /� A PLANS MUST BE FILED AND APPROVED BY UILDING INSPECTOR /� /I DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE L — 11 PERMIT FOR FRAME/BUILDING PERMIT GRANTED &--D NOV 3 0 I� 19 DATE: FEE PAI OWNER TEL.# x'682-2 JM CONTR. TEL. # 02:iaB2 -,i g!?� CONTR. LIC. # 0-5 6G C/ib. (G H.I.C. # v '� 1 OCCUPANCY SINGLE FAMILY S-ORIES MULTI. FAMILY OFFICES APARTMENTS a CONSTRUCTION BUILDING RECORD r 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES, AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC... SUPERIMPOSED. THIS REPLACES PLOT PLAN. 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ B I 2 13 CONCRETE BL K. ---III PINE BRICK OR STONE HARDw D PIERS PLASTER _ DRY WALL' UNFIN. 3 BASEMENT L AREA FULL FIN. B'M'T' AREA _ '/ 1/1 '/, FIN. ATTIC AREA NO B M'T FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I _ 9. FLOORS CLAPBOARDS B 2 3 DROP SIDING . CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING `HARD,.' D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK N MASONRY ATTIC STRS. 8 FLOOR I_ BRICK ON FRAME ' CONC. OR CINDER BLK. STONE ON MASONRY WIRING r STONE ON FRAME " L , ` 11 i :p SUPERIOR POOR _ ADEQUATE I NONE 5 SPOF 10 PLUMBING GABLE HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) - +~ FLAT SHED WATER CLOSET _ p .•' r ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO. PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING 11 HEATING All 1 i WOOD JOIST PIPELESS FURNACE }! L�� FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. 3 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING 31 RADIANT - 3 1 RADIANT H'T'G UNIT HEATERS 7 NO. OF ROO/JY S GAS I r-- OIL t d, g'M'T 2nd—.� _ .ELECTRIC 1st 13rd I NO EATING ill— ,a _ _ _SY ff4+srs cc d v y C o O � O O Ns C CD n Z y CD O '0 ar n C � ? C CL CO) 12 o v CD CD o O CL CDCD 0 CD mm C O N!� CD CZ O CO) co CD I B v CO) O 'o Z CD O CD O G CD O ca O C� c r H = d O m10 W »o o m n Co C9 CO)C2 ac = z - =-a H CD �= s CD o T CD a=m y -� m CD o 0 N?mom m 2 > > m m -a-t _ n co O .w ic O N !7 F 00 o m ,d^� N v r m a �.m �=-'� co � CACL m 3 O C N cc cr �VY 7 V N C VJ y CO) CAO3 CD m CD moi N CD � O • m m CD Mo- m N •-T �D d rrnn a � m K 74 CD bo CD o P7, z n w Cr- GO) n C r a_ C O c = �- c L o r O rj y O C. C O 9 y o. 0 c FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ��( ���� 5 Phone LOCATION: Assessor's Map Number Parcel Subdivision &(ZF(-c /4(IY6 zt14?2 ArjT4— z r— Lots) 121 1�y Street St. Number «� ************************Official Use only************************ ,RECOMMENDATIONS OF TOWN AGENTS: <��"Jw i�&, Az,� Date Approved Con ervation' Administrator Date Rejected Comments %:ice! i ITown Planner Comments Food Inspector -Health �J0ktc- Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections -x7-6J //--/&-9V - driveway permit :ML=) /<- 1141;- ?4 Fire Departmenth&,± Dom-' R cei ed by Building NOV 3 0 199" 1 FROM : LAND PLANNING BEL,LINGHAM 0 , 0 PHONE NO. 508 966 5054 i / l 386 ~� r J84 — J�l 1� 3,90 370_ ase � -- m 0 7i f 364 i ` 363-00 0AS`' {3620) O SLAD��'S5.2R INv p� r - j3J30L , P01 TOTAL FRON L. 130.22' 6413127'}' 142. 010 _ + �7.9R kC, r — 359 R, 125 _ V.- —�� ItJ 0 L f -_WA TCR r �_ BEIMCSN T DRI VF (50' WIDE APP. WAY) NOTE: ALL VTILITY LOCATION;i ARL IO DC nCLO VCRIFII-D BY T11C SITE CONTRACTOR. "CURNELL FEDERAL" SETBACKS: F-20' R-20' S-20' betw. bidgs. LAND PLANNING ENGINEERING & SURVEY 187 H"rkVHI) AVENVL 06: UNGHAM, MA 02011) (500) 068 4130 FAX (508) 808-GO54 GRAI)ING / SITE PLAN I.M=ATM AT IAT 29 NORTH ANDOVER ESTATES NORTH ANDOVER, MA rno rom mn 'POLL BROTHERS, INC. 1000 WEST PARK DRIVE WESTBORO, kA 01581 11-10-95 1 1"=40' 1 NAE 29 WA- _C= y C � O � O CO) C) 10 CD CID n Z y O O 'fl C r ClCD) C O � C Q = CO) O n O CD CD C O CD CD o CD ao vo � C CDCD y� CLO y O I CO CD v CO) O 1 Z O O O CD O G CD O —• N o N Cm W co m o n a c� o N m �. C 3 Z � � �-a N •"1 ado• m .► CD W , . CA CD oo .. P-4 i �my tT o a > > m m -� � o o y' In, a C* co ,�^ C N V " mCM CD � rt � � c �� c a 3 �o n y �i C y N e-+ . 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I C O - N Q N C4 =tmn m C") O ci a 0 m Z - =r '2 N _I O� .► = .- m N i7 G • d O O O O O C fA O 3m r O _ `D CD O N• C7 CO CL ca m o C? � m O N � 1 m CED O N x N CL =d -k F� C -- ��-j-�1J H , m t0 N VJ NCD Co -t N _ = O CO •') � Cf O O CD O 3� N m y W Om -< m a o a ,_ �c oo=.a .y Et :n u L i o J C W 0 c O w ^O' O a � W J C W 0 c _= setts Otfice Use Onl 5�•� =MCI The Commonwealth of Massachusetts Permit No. t -fg [� Department of Public Safety s Occupancy b Fee Checked :_r BOARD OF FIRE PREVENTION REGULATIONS 527 G�1R 12:00"Ll (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORT{ All wont to be p WM04 N ac= &nee w (n tno M""'"us*ti Hec=ml Code. 527 CMR 12.90 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date ) .,-,A _ y_~I, , i,1;e,.: yCi To the Inspector of Wires: City or Town of /Ld--ter The undersigned applies for a p Location (Street & Owner or Tenant _ it perform the electrical work descncea a _1 - =zip= Owner's Address Q�l— ❑ (Cha;k Appropriate Box) Is this permit in conjunction with a out g p rmit f Yes no `p �N I Utility Authorization No. t Purpose of Buildin `---�} Amps_J Volts Overhead C1 Undgrd ❑ No. of Meters Existing Service f� J Amps gqo Volts Overhead ❑ Undgrd No. of Meters New Service Number of Feeders and gmoacity q Location and Nature of Proposed Electrical Work s TOTAL I No. cf Hot Tubs No. of Transformers KVA Na. c! liahtina Outlets AboveIn r KVA ISwimmina Pool arnd. crnd L✓ Generators No. of Liahtin Fixtures No. of Errtergencl Lighting No. of Receptacle Outlets No. of Oil Burners (Battery Units FIRE ALARMS No. of Zones No. of Gas Burners No. of Switch Outlets TOTAL No. of Detection and INo. of Air Conditioners TONS Initiating Devices No. of Ranges I-tE,q T TOTAL TOTAL No: of Sounding Devices No. of Pumps TONS KW No. of Self Contained No. of Disposals Detection/Sounding Devices No. of Dishwashers Soace/Area Heatina KW Municipal ❑ ❑ Other IHeatino Devices KW Local Connection .. No. of Dryers No. of No. of Low Voltage No. of Water Heaters KW (Sions Ballasts Wirina No of Hvdro Massage Tubs I No. of Motors T Etat HP OTHER: INSURANCE COVERAGE: Pursuant to the relpirements of Massachusetts General Laws Coverage or its substantial equivalent. YES NO Q I heave submitted I have a current Liability Insurance Policy i ding Completed Operations valid proof of same to this office. YE O Q indicate the type of coverage by c:`ecking the appropriate box. If you have checked YES, please j INSURANCE 11BONO 11OTHER El(Pfease Specify) (Expiration Date) Estimated Value of El Work 5 �y Sta Inspection Date Requested: Rough—LX—). .C- :nal Work to Signed under the pe ties a perjury: LIC. NO -119 FIRM NAM LIC.. Signature "-'"�? _ "r� ^� Licensee f Sus. tel. No._,..�.--r- � Address Alt. Tel. No. jI 'Y' OWNER'S INSURANCE WAIVER: I am aware that the ILcensae does not have the insurance coverage or its substantial ease clhecks req aired by waives this requirement. Owner Agent Massacnuserts General Laws. ane that my signature cn tnis acplicat:on PERMIT FE: 5 elecncne No. �.. Date...: ..1.:... T11 TO 2 3 rNORTI{. °e'� TOWN OF NORTH ANDOVER. o PERMIT FOR WIRING qL �i pp • o+ i r ��SSACHUS� This'certifiesthat �✓J .f.f. d �t C, �z`c f2.. ................... ....................................... t has permission to perforin ....... J.V�W............ W `........ ` C wiring in the building of d 1 ... F'.... c t of ? 177 ROL-e �I ov f A ort do F a.. �.� Fee.C2,:�7. ....: Lic. No. /- ELECTRICALINSPECTOR - - j g��14/96 12:02i9.d0 'PAID WYIITE: Applicant ' CANARY: Bw /1ng :Dept.. PINK: Treasurer GOLD: File