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HomeMy WebLinkAboutMiscellaneous - 179 HILLSIDE ROAD 4/30/2018 (2)l Date. I J.,.2,. !z OF pIORT/� 4 Litt) I N nTOWN OF • 'ANDOVER PERMIT • R WIRING ♦meq` a ��y SSACHUS� This certifies that ..... �c r� .. ��r .............. . has permission to perform. f�,ft�/�.. .���1� :�. . wiring in the building of . ek-)c oaf j .. /Zf-� /. [,T- ......... at .... /-7- ... f f Jj............. .North Andover, Mass. FeeL, ..... Lic. No./. t. i .. ........ . . J EL CTRICAL INSPECTOR Check # V_ 1115 �f�s oil ttse IL `- BOARD OF FIRE PREVEN77ON REGULAMNS Oand Fee Cbecked ptov Un (kavafp m APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORKA,iBrockbbepaE in > � tCb& WtL„c,2.W (t'LEASRPROffX M C ORTFPfiAUWORMATIOM bate: 1% -/ __ P_ Chy or Town nE AL .4,vtbtj A To the ector o Frwes: By this �iieatian the undemgpw gtvg natke of itis or her to th �trieai desmixd below. Y.ocatian PbTL4 & Numb=)_ / jai 446 S OwnerorTeuant L'�POSCi1 44C �Ty TeleghoaeNo. Owner's Address Is thb Purpose of ildm tt in �daon With s h P�1"' Yes No U (Check Appropriate Bor} g Utility Authorization No. Bing Service Amps I Yaps Overhand Undgrd Q Na -of -mete" Net_ Service -Amps I Vuits Overhead Number of Feeders and Ampacity ❑ Unuigrd ❑ Na. of Mefera Location and Nature of Proposed Electrics, Work. ofRecessed Lmmhwbw of Lumivatre Ostlers ofd of Rendu; Offads lorswAchn OfRM%vx of Waste Disposers ofDers of Dryers Hydro Bandubs Esb'mated Vahac o€erica, We& . of Ga4kmp. 9-4Me} Flaw . of Hat Tubs Poa1 ianuL � � . of On inks of Cis Burners ofAirCond. T a Tons Tetdu i��— � ucdArea Heating XW OngAppliances lCyy of n w of Motors TotalHP Of 9 War, wwk to Startby UUMURIM Poicy.) 1NSURAi�it� Cl}YBRAC b be rcgm sted is accatu� va bEC � 1% and W= Merton. the i�9 pmmtfor ibe P oft Walt may issae mtless tmdasigneci cetiiiies that snot cov VkW° image or its NWVak0t. The is in foto, and bas Pwaofsam to dngcrnmt issmag office, CHECK ONE INKIRANCE fib BOND ❑ ( fHM Q M-.4,3 10-4 & =d r thePafwaadpeaaldea of ala tbeirrf©rm�tntrrrt t'strrre and RTRM PiAiillE: VA { 1 t7 ci. u: -T$r CALtvtiT �}� o9nrplete< I uceusee: VAJ to :l JAC. No. : _ Cjf i ®rte- � tlbe a -ram] n LfG NO.: - & 3 Address: _ $r� j �; i1li 2ii•}", NihYt�L rte} . Il ii Bi-TcL trio • 7F *perifrl.G.Lc147,s.57-61,sccmity� ofPttit- AftTeLNa:: S- 373-x'37' OWNER'S INSURANCE WAIVER; I Wan aatare that the �Y "S- ljm No. t. • Bymydwmombtu,Ihccbywaive jbQ °QTY � owndss� L KVA of Zones it s Telephone Na pMwTFEE: moo. The Commonwealth of Massachusetts Print Form Deparhnentoflndrr ftWAcadenis f.i .5 1 Congress Stree4 Suite 100 .Bostons MA 02114-2017 www.mas&govldra Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Let=ibly Name (Businesdomanizationnncfividual): DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST ryvrc In Amuuvr-m rule- u1 mb phone #-. 978-682-6262 Are you an employer. Check the appropriate lox: 1. Q I am a employer with 7 4. 0 1 am a general contractor and I employees (full and/or pa * ime).t 2. [3 I am a sole proprietor or partrum- ship and have no employees working for me in any capacity. [No wcxkeas' comp. insrrtartce rewire&] 3_ Q I am a homeowner doing an work myself [No waakw& coup - Insurance require fl r have hired the moors listed on the attached sheet. These sub -contractors have employees and have 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 esrrpl *mm [No workers' comv- new ante reotruh!d-1 Type of proJeei (required): 6. []New construction 7- ❑ Remodeling 8- ❑ Demolition 9 Q Building addition 10.0 Electrical repairs or additions I Lp Plumbing repairs or additions 12.0 Roof - 13.[] Other --j must also rut out me section below showing their woriame eamPensation policy informations. Homeowners who submit this affidavit indicating they are doing aII work and then hire outside contractus must submit a new affidavit indicatmr=such. 'Contractors that check this bat must attached an additional sheet showing the name of the sub-contrudors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their worlaers' comp. policy number I am an employer that is proviAT workers' coon insurance for pry e7JW10Yees. Below is the infaymad� poFicy andjobszte Insurance Company Name: THE HARTFORD Policy # or Self -ins. Lic. #: 08 WEC C18293 Expiration Date:MARCH 1, 2013 Job Site Address - 7'Y - u S-lDtf- '�'7- City/State/Zip: /``140YAot 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 weld as civil penalties in the form of a STOP WORK ORDER and a fine of rip 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. r-1ruj, ,I ,,.l provided abowe is true and correcL V-2 —17 Phone# pro-atsdl1 ✓ O,�use ouiR Do nawrRe in disc area to be romplef d`by city or toren ojfciaL City or Town: Permimuceuse # hswmg Autborify (circle, one): 1_ Boatr+d of Health 2. Building Department 3. Citylfown Clerk 4. Electrical inspector 5_ Plumbing inspector 6.Other ComactPersos: Phone#: /7�- . Location J � O t No. �.� Date / TOWN OF NORTH ANDOVER Certificate of Occupancy $ ',s'•^ t<�' Building/Frame Permit Fee $ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ „ Check # e— r .i 7787 2��-- -,�.., Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPMR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1%; snow f4T BUILDING PERMIT NUMBER: ^ DATE ISSUED: SIGNATURE: / 11 &&4LML ( I Buildill Commissioner/I for -of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number EzW 1.3 Zoning Information: 1.4 Property Dimensions: Zonin Distrid Proposed Use Lot Area Fronto ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard R 'red I Provide Required Provided 1.7 Water Supply M.QL.C.40. § 34) 1.5. Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Rear Yard Provided 1.8 Sewerage Disposal System: -- ipal ❑ On Site Disposal System 0 t eA y�5, - N& g-/'T!C y /� �1 1/G G Sim L/. �2� Name ( 'nt) Address for Service —419"46C 1,6 d�� —G737 Signature do 2.2 Owner of Record: Name Print I CF.rTFnN I - (YINCTDTT('TTnN CFDVTd-VC I Address for Service: 3.1 Licensed Construction Supervisor: Not Applicable ❑ t Licensed C struck Supervisor: ��- License Number Ad drIF��JJ M/ -4 f ), f ff 6 -7,37 Epi.tion Dat Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company ame -a� i/ �/'© G Registration Number V Expiration Me Address �j/7` c /�/ "/ !f -�P�'O �O/37 Signature Telephone ou M Z O v n M SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check ail a cable New Construction ❑ Existijtg Building ❑ Repair(s) ❑ Alterations(s)� Addition ❑ Accessory Bldg. 0 Demolition ��� 0 Other 0 Specify Brief Description of Proposed Work: - .A, ,,• , "`"'"'"'' A w — I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by pennit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) p?/ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 0 Q , Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. 14, Signature of Owna r.'.' Date SECTION 7b O, • NER/AUTHORIZED AGENT DECLARATION I, t` / as Owner/Authorized Agent of subject property Hereby declare th t the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Nam f Z'UL aALAa Ze /Z/ Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS iST 2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIv1NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Ct O z 0 W ui am a _ H CO) W m W ca y O 'm cm o w C :oma a w a a U C vV � C ev x V) C C2 INC � N O U w rs: w ao w Ea w C: w G w WA a a°o o z. cn i cn ui am a _ H CO) W m W ca y O 'm cm c C :oma c O y C vV •a C ev C C2 INC N O O � Oil 0 CD CD rtn ao mDo Ea C: 'o 0 d t C C E w .0 w .� C; a d H W a O` O m o C.3 $ " c_ :m ui am a _ H CO) W m W ca y O :mm �y cm m C y W : � h ECD w� y m C C2 INC N O O � Oil 0 93 Z rtn ao mDo $ o 'o 0 d t C C E w .0 w .� O� o C d W a O` aMm E z h N C cm m Im cm C CO m 0 c w 0 Z O 0 z I 0 z 0 U Mei �I R .� 0 c! i O Ew = .E cc m a CD CL ~ _•+ 3� as a) L Q CL Q CL CMQ C o ccc C.3ca CL 'C C Z � V y cc c C c y D 0 U) LLI U) W W oc W U) Y — The Commonwealth OfMassachusetts Department of Industrial Accidents Office of ltnrestigatfons 600 Washington Street, 7'l' Floor Boston Mass. 02111 Workers' Compensation Insurance Affidavit: Buildine/Plumbing/Electrical Contractors name: AfR / /41/V QC //�� �/ / 1 , / /y e address: !/ Y f 4-. � s o e, 2� city J(/6 #N16 d v 1!A" state: I -"7)q- Zil): 44 hone # � 6a` —623 7 work site location (full address): XR & g ❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel ❑ 1 am a sole proprietor and have no one working in any capacity. ❑ Building Addition ., .:.- i ..:i..❑ I am an employees providi`ng'�work/ers' compensatioon'for my employees working on this job. compm any nae: r / .1411AL 5/� 77 address: ��/J �l r�/G� �/�4toS%`/ �` S' city: /1'�% /�/ `! (ly 777777 phone # 77f't�� 7c� insuranceeo a� rF� ��.. �U ohc # �f C( 4a y Gs+ `.. .t�,i its M®R M ria °'��VV :i���r:; �� �frt r ���� :t;W����� fi�`�� lli ac e ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company:.name: address city: phoneW; insurance co -:�'t�t'S"�w1•'�i�,?i.��4 �.cau'.ti�:S ,�+iai�'"r.? Px W t� � 3�r 3���' 141Sa(�ah •:y,�n a.011 # �� tx � company name;- address: amesaddress: city uhone # insurance eo �c, ohc # Attachraddrho alit eet"ifc a zeta e.._...'.r sn r:.}.r...}b it ...,t( .....,7t .,..:. p�0i....:.....i17' �.t �l 3 r`�£i5'7•t 7ii Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. 7 do hereby yirrtify 11n,*r th ins and penalize erjury that the information provided above is true and correct. Signature Date STT/f ,e �,> Print name -SA1`'°'J# hone J�- P .. ..>,t-�.{':.:Y�";c). �.'...-x.:Ys'x:. v..X.nxrm•ra....:.a.,e.ra��...,........._.. .. __._..-_.... -. ....... _. _ _-. ........:....n: R....+uarsx�n;L,.<u•f:.c[ia".CYYG1Gt official use only do not write in this area to be completed by city or town official city or town: permit/license # Building Department El check Board check if immediate response is required Selectmen's Office contact person: phone #• Health Department (revised Sept. 2003) ❑Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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. c-} 1 ��`�' �' tr p. > � � ^��I ay{�#c.<,S Y '� •ir'M.�'�f y ��� S�, y''4 x t,�,' rPE:4,4 ✓1tC�`ll torr. k� ...t'.iWS, aF, l�xr, 1 Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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 member listed below. `kg+ `�Fb City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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,7t' Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 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: on of Facility) Signature of Permit ApplicaKt Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector V k/ '"" � ��e �oomv�novuuea/,(� a�,.�aaaac�/u�aetld BOARD OF BUILDING REGULATIONS' License: CONSTRUCTION SUPERVISOR Number; `CS 022680 BI — 1939 ° f 006 Tr. no: 71.0 I ARTHUR J WA j 55 PLEASANT S N ` N ANDOVER, MA c '•`%� Commissioner �1 � � ✓� TDO�i!/IIL(iILIIIC(�AIL nL . (Board of as Regula ioas and qe H0.,1AE, ItMPROV"ENT pep CN�