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HomeMy WebLinkAboutMiscellaneous - 178 STONECLEAVE ROAD 4/30/2018Commonwealth of Massachusetts Official Use Only Permit No. - Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 8/14/2015 City or Town of North Andover To the Inspeclor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 178 Stonecleave Road Owner or Tenant Randy Burba Telephone No. 978-808-8176 Owner's Address same Is this permit in conjunction with a building permit? Purpose of Building Residence Existing Service Amps ! Volts New Service Amps / Volts Number of Feeders and Ampacity Yes E No ❑ BLDG PERMIT # Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters v Location and Nature of Proposed Electrical Work: Installation of a 12.426 kw (38 panels) rooftop solar array j Completion ofthe following table may be waived by the Inspector of 117ires. No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW JNo. Hydromassage Bathtubs ER: No. of Ceil: Susp. (Paddle) FansINo' Tra No. of Hot Tubs Swimming Pool grad rnd No. of Oil Burners I No. of Gas Burners No. of Air Cond. Heat Pump .Num.be s:r` Totalii Space/Area Heating 1 Heating Appliances No. of Signs No. of Motors KVA Q Q 1 Attach I li"ires. Estimated Value of Electrical Work: $30,083 (When i Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides. proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such 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 pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: The Boston Solar Company LIC. NO.: 12689A Licensee: William T. Foglietta Signature LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 781-462-8702 Address: 10 Churchill Place. Lynn MA 01902 Alt. Tel. No.: 978-836-6220 *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen 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 Signature Telephone No. PERMIT FEE. $ 42 Mailing: The Boston Solar Company, 55 Sixth Road, Woburn MA 01801 Attn: permits Email: permits@ostons bolar.us 100 — Commonwealth of Massachusetts Official Use Qnly Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev; 1/071 (leave blank). APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 8/14/2015 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) 178 Stonecleave Road Owner or Tenant Randy Burba Telephone No. 978-808-8176 Owner's Address same Is this permit in conjunction with a building permit? Yes ® No ❑ BLDG PERMIT # Purpose of Building Residence 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: Installation of a 12.426 kw (38 panels) rooftop solar array J Completion of the following table may he waived by the Inspector of 11,7res. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ 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 No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumNumber Tons KW No. of Self -Contained Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of bevices 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 11'ires. Estimated Value of Electrical Work: $30,083 (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:) 1 certify, under lite pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: The Boston Solar Company I LIC. NO.: 12689A Licensee: William T. Foglietta Signature 14 LIC. NO.: (Ifopplicable, enter "exempt" in the license number line) Bus. Tel. No.: 781-462-8702 Address: 10 Churchill Place, Lynn MA 01902 Alt. Tel. No.: 978-836-6220 *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen 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 Signature Telephone No. PERMIT FEE. $ 42 — Mailing: The Boston Solar Company, 55 Sixth Road, Woburn MA 01801 Attn: permits Email: permits@bostonsolar.uSi Date ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ... u ......... ... ...... 6t....^ ...... . ................................................................. ........ . ..... .. has permission to perform ....................... ........ 6/ ... ............ . ......... 1.2. ........ q..?( wiring in the building; of ... &,t.- ... ........................................................................................ I ay .... 4 PA Nort ndover, Mass. at ..... ....................................... Fee .............................. Lic. NOZ ........ ... . ................ L..................... - ELEC-FRICAL INSPECTOR Check # 12 5 $ 9-� C�-)P 2—ou— 2-6 k(.,o M !J-1 �K i.: COMMONWEALTH OF MASSACHUSETTS e e o •e e BOARD OF ELECTRICIANS f ISSUES, THE FOLLOWING LICENSE AS :A ` REGISTERED MpSTER-: ELECTR I C I AN j {� THE BOSTON SOLAR COMPANY LLC WILLIAM T. F0GL:I.ETTA 1 1.1 Iq 10 CHURCHILL PLACE:W _ e LYNN MA 01902-27.19 CONTROL # J 2 8 d 18 8 IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected, visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): The Boston Solar Company Address: 55 Sixth Road VVUUUM IVIN V IOU 1 Phone #: 01 r-o0o-1040 Are you an employer? Check the appropriate box: Type of project (required): 1. H I am a employer with 20 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance required.] comp. insurance.$ 5. ❑ We are a corporation and its 10. E] Electrical repairs or additions 3. El 1 am a homeowner doing all work officers have exercised their 11. Plumbing g repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] uit q ] e. 152, § 1(4), and we have no 13.E Other solar employees. [No workers' comp. insurance required.] *Any applicant that checks box 41 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 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: HDI -Gerling America Insurance Company Policy # or Self -ins. Lic. #: EWGCC000153815 Expiration Date: 1/14/2016 Job Site Address: 178 Stonecleave Road City/State/Zip: North Andover, 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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cei fy u��'r__t�ie pains and penalties of perjury that the information provided above is true and correct Phone #: 6178581645 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Cli%nHt• 11131(iQ ROSSO ACORD. CERTIFICATE OF LIABILITY INSURANCE 111312015DATE (MM1DDNMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER People's United Ins. Agency CT Goodwin Square Hartford, CT 06103 860 524-7600 CONTACT Peggy J. Merati HC°NE 860 524-7624 ac No : 844 702-8075 (AIOne mess: peggy.merati@peoples.com INSURER($) AFFORDING COVERAGE NAIL of INSURER A: HDI -Gerling America Insurance C 41343 INSURED The Boston Solar Company, LLC 55 Sixth Road, Suite 1 Woburn, MA 01801 INsuRERB: Merchants Mutual Insurance Co 23329 INSURERC: INSURER D INSURERE: INSURER F: rnVFRApFS CFRTIFICATF NUMRER- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I" LTR TYPE OF INSURANCE ADDL INSR UB WVD POLICY NUMBER POLICY EFF MMfDD POLICY EXP MMIDDNM LIMITS A GENERAL LIABILITY EGGCC000153814 0/03/2014 01101/2016 EEAACHp�OECCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMMISES Eartenoe $1001 OOO CLAIMS -MADE F—R OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY EAGCC000153814 0/03/2014 01/01/201 MBe aFeDn SINGLE OMIT 1,000,000 A X ANY AUTO EAGCC000153914 0103/2014 01101/2016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per acddent) $ AUTOS AUTOS X HIRED AUTOS X AUTOS D PP°e�de DAMAGE $ $ B X UMBRELLA LIAB X OCCUR CUP0001367 0/0312014 01/01/201 EACH OCCURRENCE $5,000,000 EXCESS UAB CLAIMS -MADE AGGREGATE $5,000,000 DED I X RETENTION $1 O OOO $ A WORKERS COMPENSATION EWGCC000153815 1/14/2015 01114!201 X WC STATU- OTH- AND EMPLOYERS' LIABIUT1f ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N E.L. EACH ACCIDENT $1.000,000 OFFICER/MEMBER EXCLUDED? a N I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 I(yes describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: Permit Work Certificate Holder is included as Additional Insured per the terms, conditions and exclusions of the referenced general liability and umbrella policies, if required by written contract or agreement. Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE )OWAO v u lW(t ©1988-2010 ACORD CORPORATION. All rights reserved. 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FAX TYPE OR _1 PRINT OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL D RESIDENTIAL CLEARLY NEW: [J RENOVATION: D REPLACEMENT: E1 PLANS SUBMITTED: YES❑ -f NO APPLIANCES 1 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 GENERATOR GRILLE INFRARED HEATER_ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I- �_^ ----.._._--- --- -- --._ -- _-- �-- � - u--- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES 146, F IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ® BOND�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. CHECK ONE ONLY: OWNER © AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura. to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp) wit IIerti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 12o, V PLUM BER-GASFITTE R NAME "[ % LICENSE #Q�3, SIGNATURE MP [:1 MGF 0 JP Q-/JGF -': LPGI CORPORATION ©# [= PARTNERSHIP ©#= LLC .j#�� J COMPANY NAME: 11-i-- ,��' J _ _ _ ADDRESS ( J CITY (j ii/ _ _ j STATE ZIP TEL FAX CELL W H O z z 0 H U W a w O Z O � w } ~ W �O a O U w �* z F- a I-- w (A a W 5 a O L w w W Cl) r.d o a a a � U x J F., a CL a Cd = w H z° z 0 H U W P-4 O a IR Rj Date. R,,�V/049....... 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION , *04 - This certifies that .. 410.47rrlll�do.lj has permission for gas installspon .................... in the buildings of ... .............................. at ... Tu .. N rthd er,/Mass. Fee.��:©9 . Lic. No..? -U. 3r/�'. �� . GASINSPECTOR Check # -fo 3 8301 s `.h ' 10, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 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 eiployees (full and/or part-time).* have hired the sub -contractors 2. [� am a sole proprietor or partner- listed on the attached sheet. I 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.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. P Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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: fob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a :me 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 )f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby cert' upd r the painsan a allies of perjury that the information provided above is true and correct ii nature: �x� T1ate� �Si J M 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): I. 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 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 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 # 617-727-7749 www.mass.gov/dia Idltill."1*1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: CIO �-) e/- MA., JD ate: Permit# Building f �CJ '' \� Location: Owners Name:A�cG Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ ResidentiaJ,� New: ❑ Alteration: ❑ Renovation: ❑ Replacement: JA Plans Submitted: Yes ❑ No Ef Idltill."1*1 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes�No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policyA 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. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I herebv certifv that all of the details and information 1 have submitted (or entered) reaardina this aoolication are true and accurate to the hest of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title Pflolumber Signature of ns d P6#nber Cit /Town aster !l City/Town ourneyman License Number: J �17 APPROVED OFFICE USE ONLY DEDICATED z SYSTEMS Ln O LU Z z� � Q +` > Vf a Y Z of Z t- Y of Q = of Q H Z vi UJ Z p o cc Z � Z 3 W Q Z H W_ V1 Q Z 9 to 2 C♦ H � Ln i W H O Q W W W O W U H = a N N O 3 U > >O 0 H O 0 Z Z N H Q Q H Q = of O W Q H Q a m m o c LL z Y g 5 15'A� 3 3 3 0 a ID Q 3 3 SUB BSMT. BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR e FLOOR 7' FLOOR 8T" FLOOR Installing Company W 2-i- Check One Only Certificate # Name: 1 Address: wt c)(, Liv' City/Town• 1' �b(i'R-`� State: ,4 , El Corporation 78 U/ ❑ Partnership Business Tel: 14(' Fax: )!ZF irm/Company qct 1,4./C/ J#(— Name of Licensed Plumber: INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes�No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policyA 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. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I herebv certifv that all of the details and information 1 have submitted (or entered) reaardina this aoolication are true and accurate to the hest of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title Pflolumber Signature of ns d P6#nber Cit /Town aster !l City/Town ourneyman License Number: J �17 APPROVED OFFICE USE ONLY 9 9 13 DateAl :�-// ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING .. .. This certifies that .... .... .✓..................................................... has permission to perform ... x1le . ................... wiring in the building of ...... Ae!42 ... 4� .................. at .... ......... . North Andover, Mass. Fee.. Lic. No . ...... �()/ .........EE CAL . .. ..... Check # -1� Date./� ���. 89,53* °•<".� �' :'+c TOWN 9,534 - TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACwu This certifies that...! (t� ..f t'�t .4 ..... P", ........... pr has permission to perform s,, j. plumbing in the buildings of at ... 4.... North Andover, Mass. FeP Lic. No.. . ....... PLUMBING INSPECTOR Check ff `GOMMONWEALTH OF ^MAssAGHUSETTS LICENSED A� 3 A�MA� R PLUMBER IS�UES THE ABOVE LICENSE TO: I ROLAND A JACQUES JR 28 DOCK LN i I SALLSBURYMA 01952-2613 - f 13736 05/01/12 79264 h The Commonwealth of Massachusetts c, ;_ I Department oflndustrial Accidents i AA ; Ii Office of Investigations • i i�'Y�'e i ,U 600 Washington Street Boston, MA 02111 ven , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /. Please Print Legibly Name (Buf%siness/Organization/Individual): ) q tiCD ✓ C y �-�s Address: 4-C, C �, N City/State/Zip: 9 L S U Phone ##: CO 8 — Y 6_15 — / 28 2— 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 321I 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. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] i workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I0.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs " 13.❑ Other *Any applicant tliat 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. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date:. 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 maybe forwarded to the Office of Investigations of the DIA for insurance*coverage verification. Ido hereby cer un er the pains a#jtpenalties ofpeijury 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 '23/1 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 M, w 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' compensationaffidavit 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 cant' 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 pen -nit or license is being requested, not the Department of Industrial Accidents. Should you have any. questions regarding the law or ifyou 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 Deparhnent 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 pennit/]icense number which will be used as a reference number. In addition, an applicant that must submit multiple�,permitllicense 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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen -is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department Of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia I s i Commonwealth off Massachusetts official use only Department of Fire Services Permit No. _ f 9/ 3 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ [Rev.l/07] lea blank ve APPLICATION FOR PERMIT T® PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEA,S`EPRINTIN.INK OR TYPEALL INFOTION) Date City or Town oh : 21/o 19CRII By this application the undersi ed gives no ' To the Ins e of hi�®rher intention perform the electrical work described be Location (Street �& Number) /9,r S'- VAe �� low. Owner or Tenant R ah�% L �, .� Owner's Address Telephone No. Is this permit in conjunction with a building permit? `lyes Purpose of Building � ; n `, No 0 BLDG PERMIT #_ Tin r'_e MOA- Utility Authorization No. Existing Service 91w Amps /pqO / O? qV Volts Overhead ❑ Undgrd 9-�_No. of Meters New Service Amps / Volts Overhead ❑ Undgrd E] No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the No. of Recessed Luminaires following table maybe waived by the Ins ector of l� jo No. of Ceil.-Sus . No. of p (Paddle) Fans � Transformers Total, No. of Luminaire Outlets a No. of Hot Tubs KVA Generators KVA. No. of Luminaires pl Swimming Pool Above ❑ In_ o. o mergency ig mg No. of Receptacle Outlets nd' —d• ElBatte Units No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches �p No. of Gas Burners No. of Detection and No. of Rangesinitiatin Devices No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW d Totals: No. ofSelf-ContaineDetection/Alertin Devices No. of Dishwashers Space/Area Heating IOW Local ❑ 19'Iunicipal No. of Dryers Connection ❑ Other Heating Appliancesy Security Systems:* No. of WaterNo. of No. of Devices or E uivalent Heaters KW No. of Data Wiring: Si s Ballasts No. Hydromassage Bathtubs No. of Devices or E uivalent g No. of Motors Total HP Telecommnnications Wiring: OAR. No. of Devices or Eauivalent Attach additio Estimated Value of Electrical Work: nal detail if desired, or as required by the Impector of Wires. Work to Start: (When required by municipal policy.) InInspections to be requested in accordance with NEC Rule 10, and upon completion. INSLTRANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov,�er is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE � BUND (o OTHER I Bert j�, under the pains and penalties o er u that the information o a this application is true and cone Yeti FIRM NAME: �tG fP I r1', pp p Licensee: ,�j q� �? pW c LIC. NO.; 101,V-6 Signature (If applicable, enter "exempt" in the license number ' e.) LIC. NO. �' • Address: � I � 9a p y�-r-Bus. Tel. No.:_ !2 - �f33 3t *Per M.G.L c 147 s 57 work requires Lsecurity � ,. Alt. Tel. No.: .,.,eparrment of Public Safety "S" Licen OWNER'S INSURANCE WAIVER; I am aware that LIC. the Licensee does not have the liabili required by law. By my signature below, I hereby waive this requirement. I am the (check one) El owners❑ ogwn normally Owner/Agent Signature Telephone No. PERMIT FEE: ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed — ] Failed— [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 2. FINAL INSPECTION: Passed — , Failed — [ j Re, -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. I The Commonwealth of Massachusetts Department of IndusWal,Accldents Office of investigations 600 Washington Street Boston, MA 02111 tvww.rnass.gov/dia Workers' Compensation InsuxaneeAffa-da-vit: Builders/Contractors/JElectriciamfPIx:mbers Applicant Information Please Print Legibly NaM()(B.usiness/Organizaiion/Individual): &10'01 Ndvc-RZA , Address: r�f S l A9� IQL City/State/Zip:_ 030Phone #: Are you an employer? Check the appropriate box: ' L ❑ I am a employer with 4. Q I am a general contractor and I �,rployees (full and/orpart time).* have hired the sub -contractors 2.4'J 1 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.E1. 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.] employees. [No workers' comp, insurance required.] Type ofproject (required): 6. ❑ New construction. 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 1.1. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13. F1 Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeo zmers 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. I am an employer that is providing workers' compensation insurance far my employees elowisthepoHcyandjoh site information. Insurance Company Policy # or Self -ins. Lic. #: rob Site Expiration Date: 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 imprisonmen4. as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eertify under thepains andpenalties ofperjury that the informadonprovided above is true and corr-ect. Simature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official Cita' or Town: Permit/License # Issuing Authority (circle one): X. Board of$ealth 2. BuildingDepartment 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone �rrtnzonweafih ol Ma-66ac u3etEd Permit No. o � �� 7 2eparfineut 4 moire semi e� Occupancy and Fee Checked ✓ i BOARD OF FIRE PREVENTION R ULATIONS ,RE, „,, LEAVEBUWK APPLICATION FOR PERM All work to be performed in accordance PLEASE PRINT IN INK OR TYPEALL INFORMATION: ) PERFORM ELECTRICAL WORK Massachusetts Electrical CodeC), 527 CMR 12.00 DATE: %1a /LO �z City or Town of: /90' h /I "C&er To the Inspector of Wires: By this application die undersigned -_ives-notice of his or ber intention to perform the electrical work described below. Location (Street S Number)__ /%g L5}bne- C/ect/e Ovmer.or Tenant Telephone No. Owner's Address SC me - Is this permit id conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) Purpose of Building S� (v,q2 �t N LAJQ,\ting Utiiit� Anihorization No. Existing Service Amps 1 Volts Overhead- ❑ Undgrd ❑ No. of Meters New Sen1ce Amps I Volts Overhead ❑ Undgrd ❑ No. of INIeters Number of Feeders and Ampacitr Location and Nature of Proposed EIectricalWork: r�—T one- -?u k000"n / Brut* I qTinnm , &6 � ��ti /.3 S -sr-- so) Completion ord:e ollm'i . table may be iranrd br. die In cctor orlTres. No. ofRecesserl.Fixtures Zo No.. of Ceii: Susp. (Paddle) Fans No. of Total Transformers RVA No. of Lighting Outlets No. of Hot Tubs Generators K -VA No: of Lighting Fixtures �� Above In- Swimming Pool amd. ❑ d. ❑ a o mergencr za txng Battery Units No. of Receptacle Outlets '�SO No. of Oil Burners FIRE ALARMS No. of Zones No. ofSwitches No. of Gas Burners i o. of Detection andInitiatin Devices No. of Ranges No. of.Air Cond. Tans No. of Alerting Devices No. of Waste -Disposers Heat Pump Totals: Number Ions I XW o. of eIf ontained DetectionlAlertina Devices . I I No. of Dishwashers SpacelArea.Heating KW Local. ❑ unrctpal ❑ Other Connection No. of Dryers Hesting Appliances ICN Security ystemr. No. of Devices or Equivalent No. ofWaterR.�S, Beaters No. o INN. of Sans . Ballasts Data SV'rring: No. of Devices or Equivalent Nb: Hydromatsage Bathtubs No.- of Motors Total HP TelecommunicationsWiring: No. bfbe vrices or E uivalant OTHER: Attach additional detail if desired, or as required by,dje Inspector of 11 tres ItNSURAINCE COVERAGE: Unless waived by the oumer, no permit for the performance of electrical work rruiy'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 txhr'bited proof of same to the permit issuing office. CHECK ONE: INSURANCE (Q BOND ❑ OTHER ❑' (Specify.) (Expiration Date) Estimated Value of Electrical Work: (When requited by municipal policy.) Wort; to Stare inspections to be requested in accordance vrith MEC Rule 10, and upon completion. I certify; under the pains and penalties of perjury; flat the informationon this application is true and complete- FIRAI NAME: Licensee: PNic Ve P�CaC& Signature (Ifapplicable, enter "exempt" ' ,rhe license n:m� line Address: /y 6(-eY fyn2 U v5 rn vat OWNER'S INSURANCE WAIVER: I am aware that the Licensee does .\required by lase: By my sigmture below, I hereby «wire this requirement. Owner/Anent LIC. NO.: LIC. i O.: , 90 ag � p Bus. Tel. 43�5- Alt. Tei. No: ?Xi' S L/ 0/ not have the liability insurance coverage normally I am the (check one).[] o.-,,ricr ❑ o\rrtcr's agent. nn,nn.rrlr rrr_ - c* C'`t ��G�7 ,.... -0 1 Date..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSqcwus This certifies that fi14, .............. ................. ................... has"permission to perform ... .... .... .. ................. wiringin the b ildi ig of .. i..— ........................................................................ at./� e bu, .... ... . . .. ..... ...... ................. No;thpdover, Mass. Fee..4K:�.��.. Lic. N .. .. ... . . ............. ....... LCALVPE( NSPECMR Check 'I 5497 9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIP (Type or print) NORTH ANDOVER, MASSACHUSETTS Q' Building Location /' (1 c.� /GVI6 C�`ep& Owners N of New Renovation Replacement FIXTURES Date S ' V , IJ t -t✓ �' Permit # I tV AmountU Q Plans Submitted Yes F-1 No ❑ (Print or type) � 9- / 2 Check one: Certificate Installing Company Name 41,E 7' / t eGT �'�/� [I Corp. Address i G D Partner. 64 3 raw n/ Business Te ep o e Frm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the tW of insurance coverage by checking the appropriate box: Liability insurance policy 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 ❑ Agent ri I hereby certify that all of the details and 'information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac"etts Pate Pili *in&p* and Chapter 142 of the General Laws. y: City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License tcense U er Master Q Journeyman j j� I Date .1,5- -© y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform ... ��.�. U...d .. � d �.��-'" .. . plumbing in the buildings of ...!�AAJ .....`.. r.to -- l S�Ot° c�..ve =c .. .. , North Andover, Mass. r - O Fee ../a..... . Lic. No. ac�'J. A(� ........-0102)1 IM 10 (G.v. ! r ^ PLUMBING INSPECTOR y Check # / , x C �4 t MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations G` 7 6 SI H C C. leM New' 19/' Renovation ❑ T FOR PERMH TO DO GAS FITTING Date S rGL Permit # I's Name $ hr's Name 1 ❑ Plans Submitted ❑ (Print Name Addre Business Telephone Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. ❑ Partner. ❑-F1rmVCo. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked yes, please in ' ate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse ' Sae G jde andCup r 142 of the al Laws. .' City/Town (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter lcense um er ❑ Master MIXurneyman 12ND. FLOOR 15TH. FLOOR (Print Name Addre Business Telephone Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. ❑ Partner. ❑-F1rmVCo. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked yes, please in ' ate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse ' Sae G jde andCup r 142 of the al Laws. .' City/Town (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter lcense um er ❑ Master MIXurneyman Date ... S. , CDC( .... Of NORTH 02 ` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..C. ¢.£...IAPc 6-, tCA 1 has permission for gas installation .... ' in the buildings of.. L ..c, b ................... . at.. .... ............... �.... , North Andover, Mass. Fee......... Lic. No. a©3` �. � :�toZ21 I ,UMc Cfl .. V ,} ` GAS INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION (Print or Type) [�C-In �iRC`CZV 2i2 Mass. City, Town Building AT: Location _ Renovation ❑ FIXTURES RMIT TO DO GASFITTING Date 16 -la -04 G Permit # Owner's Name -Row',0Y By r ba Fee `4 a5 ° Type of Occupancy: 22S S J\ t nt ❑ Plans Submitted Yes ❑ No ❑ (Print or Type) Installing Company Name 0 t CONNE LL PLUMBING, INC , Address 19^A Larchmont Road Salem, MA 01970 Check One: Certificate K) Corp. 1631-C O Partnership _ E O Firm/Company Business Telephone (978) 7452655 Name of Licensed Plumber or Gasfitter George O'Connell I hereby certify that all of the detail and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. ALL APPOINTMENTS FOR INSPECTION ARE TO BE MADE BY LICENSED PLUMBERS ONLY. Signature of Owner/Agent I have a rrent liabilit in ce lig to include completed operations coverage. KI OZ�849-4 KA Master ❑ Journeyman El Gasfitter Signature o icensed Plumber or Gasfitter License Number • • (Print or Type) Installing Company Name 0 t CONNE LL PLUMBING, INC , Address 19^A Larchmont Road Salem, MA 01970 Check One: Certificate K) Corp. 1631-C O Partnership _ E O Firm/Company Business Telephone (978) 7452655 Name of Licensed Plumber or Gasfitter George O'Connell I hereby certify that all of the detail and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. ALL APPOINTMENTS FOR INSPECTION ARE TO BE MADE BY LICENSED PLUMBERS ONLY. Signature of Owner/Agent I have a rrent liabilit in ce lig to include completed operations coverage. KI OZ�849-4 KA Master ❑ Journeyman El Gasfitter Signature o icensed Plumber or Gasfitter License Number i Date... ......... ° TOWN OF NORTH ANDOVER 9 PERMIT FOR GAS INSTALLATION This certifies that ..0 has permission for gas installation in the buildings of . !%�.J': - ...� ........ . at � � 6ba4RIft,North Andover Mass. Fee. a?t Lic. No..9`r'.. ..................... . � GAS INSPECTOR Check #14910 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �ix $ ,. ,.u;- `'se q, _. fr ���a k_.i'" '"�...a ��iVitV+�li.i� L'1{r �{u � � s'".. —•-: � .:-vii 'tA� vw�_�k d �' BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: l `7S fi otiEG6&,,q+/E A�/� `�J /O �] /D2 lY D v� c1na/tiioon:: Map Number Parcel umber 1.33 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required I Provided R 'red Provided 3()- ca 1.7 Water S ly M.G.L.C.40. 34) 1.5. Flood Zone Information: Zone Oatside Flood Zone 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System Public Private 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record -7Zici � 1U)QAZ L80&04 79'J 7- ,�rJ ame n Address for Service f 1J— So" Signature Telephone 2.2 9wrter of Record: / —DAJ e 7 9' J1 i e P ' Address for Service: p( 20, Signature 944relephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Ltcens Construction Supervisor. ly 05- 3 PT� License Number Address d Expiration Date Telephone Sig a\\yj 3.2 Pxgistered Home Improvement Contractor. Not Applicable ❑ b T� Company Name Registration Numbe j dress Expiration Date Signature yu Telephone Ma M M W SSV SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bui ding permit. Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check allapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE: _ Location 5 c-l't'g No. Date �aRTh TOWN OF NORTH ANDOVER F • ` L9 Certificate of Occupancy $ ��S'••°''<�' wust Building/Frame Permit Fee $ 42 snc Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 0-2 Check # 3� r 8{ 6 ./t✓1/y1 " " O Building Inspector • 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT �",4� iC//-} �urZB �OPHONEw - 97 V (yG_ y� LOCATION: Assessor's Map Number 0 PARCEL SUBDIVISION LOT (S) STREET TT&A) � CL51q-V F 16 Q ST. NUMBER 1 % 0 ************************************OFFICIAL USE ONLY*********************************** REC90,MENDA CONSERVATION COMMENTS TOWN PLANNER COMMENTS OF TOWN AGENTS: RATOR DATE APPROVED DATE REJECTED FOO NrSEECTOR-HEALTH 4 (N� U_C SEP C INSPECTOR -HEALTH COMMENTS )%,)\i a N DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ a 't,00 u -1 1 ev, c,V-, PUBLIC WORKS - SEWER/WATER CONNECTI DRIVEWAY PE T ✓ FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR -DATE- Revised ATE Revised 9\97 jm M' RTGAGE INSPECT -M BAY STATE SURVEYING ASSOCIATES INC. JOB # 100 CUMMINGS CENTER, SUITE # 316J, BEVERLY,MA., 01915 LOCATION :. lik fzTl�..AAJDO VER.... M,4 - SCALE : 1" _ �� DATE :J.2-1/1-.0.7 .......... REFERENCE :.................................................. K54 E ...................OR)STRIG1 .... .. DF�... To:.. R17 }GE...Go.-OPERWnuE 5AA)K,. ........................................... The location of the building(s) as shown, either complied with the local zoning setbacks at the time of construction or is exempt from violation enforcement action under Mass. G.L. Title VII Chapter 40A Section 7 Al 11 ,• �v ' (AIIEA 5" ;.43�5GOs,F. 74: Ids F DoT NOTES: 1) This is a mortgage inspection survey and not an Instrument survey, therefore this plot plan is for mortgage inspection purposes only. It is NOT to be used to establish boundaries or for the construction of any type of improvements. 2) This survey is based on survey marks of others. 3) Bushes, shrubs, fences and tree lines do not necessarily indicate property lines. 4) Whenever an offset is V +. or less, an instrument survey is recommended to determine property lines, and any possible encroachments. 5) Offsets shown are approximate, and are to be used only for the determination of zoning, Not to be used to establish property lines. 6) In my professional opinion the building(s) are not located In the special flood hazard zone, as defined by H.U.D. MAP# ZS6p9$ ( —2-q3 !1 ()'�M 3% IF THE SURVEYORS SEAL IS NOT EMBOSSED. THE PLAN IS A COPY THAT SHOULD BE ASSUMED TO CONTAIN UNAUTHORIZED ALTERATIONS. THE CERTIFICATION CONTAINED ON THIS DOCUMENT SHALL NOT APPLY TO COPIES. The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of investigaitions Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: c (J, City 1�/i - ��.c..r. -_ - Phone # -5-3 -3 S� I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. v - — Address Phone#' Incl irnnra (`r tom., Alm l i Pol'ICv # V�-x L, f 1 j) Company name: Address City. Phone #. Insurance Co. Policv # Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment-as_welLas_cMljmattiesinlheiorm-f-a-ST_OP.VMRKORDFR_and_aline_of-($1.00M)-a;jlay-igainstmie. i understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do herby cclrtii"y un a pa s and perms of pegury that the informatior; provided above is true and correct. Print Official use only do not write in this area to be completed by city or town official' b .# t, 0 6- -5-3.3 City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Licensing Board E] Selectman's Office Contact person: Phone #• 0 Health Department El Other 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 Number is -that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A.. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector 0-1 to R OL I W-4 MIT Ng .7. 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