Loading...
HomeMy WebLinkAboutMiscellaneous - 18 SCHOOL STREET 4/30/2018N O O W O O b 0 0 0 0 c ��� Date ..`2.../e TOWN OF NORTH ANDOVER RMIT FOR WIRING This certifies that e .......................................................................... :!!.. !, ........ ............................ has permission to perform. 6 17k;,� - ..... 4, 50 .................. 7 .................. wiring in the building of...... ...... at ...... ::.2.0 .....ShS C's ............... ^?rth Andover, Mass. ........ ...... .... .. .. ... ................. .............. Fee...!..5..82 N . ........ 91 ....... ..... . ELECTRICAL INSPECTOR . . ........ `Check# Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. u Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MPC), 527 CMR 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: � 6 %O City or Town of: NORTH ANDOVER To the Inspector ofWires: By this application the undersigned gives notice of his o her ' tention to perforpm the electrical work described below. Location (Street & Number) / 5;�_-d T 5C eo s 7—.,^ee Owner or Tenant J vAel lV10,1 nVOA� Telephone No. Owner's Address e Is this permit in conjunction with a//building permit? Yes El Purpose of Building �.O, /y z— Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity and Nature of Propose Electrical No 91 (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Comvletion ofthe follnwinv tahle mnv he wnivcd by tha Tn.cnortnr of Wirv.e No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No, of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. IN0. of 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 g No. of Waste Disposers He Pump Totals: Number.• .Tons . """ ' "'" KW "' """' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify, under thepains andpenalties Of��'erjury, thatthe information on this application is true and complete. FIRM NAlVW. Q / LIC. NO.: Licensee: i,t Sign LIC. NO.: (If applicable, enter "e empt" in the license n tuber line.) Bus. Tel. No. • 78t—�f Y % f fi Address: Lt�iie>o� /�O /����"� Alt. Tel. No.:`jl Mfr- 7 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent G Signature Telephone No. PERMIT FEE: $ I ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass F?1 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: 2OUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP 1V: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: — 2 -S DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth ofMassachuse'Us , Department of fnrlustrialAcciknis Office oflnvestigations 600 1%Yashington. Street Poston, MA 02111 www.mass gov1dia Workers' Compensation. Insurance Affidavit: 13uiXders/Contractor6/Eleetri p-lanslPIumbe>rq Appheant information Please Print Legibly Name (Business/Organization&dividual): .Address: City/State/Zip: A -)b . 141td a orl� •v*"- v4 ' Phone : 7g7 — 8 f y 7 g F 9 Are you an employer? Check the appropriate box: Type of project (required): LN -1 am a employer with / 4. [] I am a general contractor and I 6. ❑ Now construction employees (fall and/or part-time).* 2. [] I am a sole proprietor or partner have hired the sub -contractors listed on the attached sheet: 7. ❑ Remodeling ship and'lave no.employees These sub -contractors have 8. ❑ Demolition working for me in. any capacity. workers' comp. insurance. S. ❑ We are a corpora�on and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised.their 10.❑ Elecixicalrepairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself o workers' com . y p j.N c. 152, §1(4), and we have no 12.❑ Roofxepairs insurancerega1red.] i employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicantthat checks box#1 mustalso filloutthe section below showingtheir workers' compensationpolicy information. 7 Homeowners who submit this affidavit indicatingthey ke doing allwork and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached on additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am are employer that is providing workers' comquensation insurance for my erriployees Be1'ow is the policy anal joh site information. Insurance Company Policy # or Seli ins. Lie. #: job Site Address; / `�' a q- " SG ExplrationDate: Attach a copy of the workers' compensation"polley declaration page (showing the policy number and expiration date). failure to secure coverage as reguiredunder Section 25A ofMG`rL o. 152 can lead to the imposition of criminal penalties of a tine up to $1,50 0.00 and/or one-year imprisonment, as well .as civil penalties in the form of a STOP WORD 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 7uvestigations of the DIA for insurance cgerage verification. X do Hereby ceytafy uyh(er file Phone #: 7 r,/ - g",�ey - 7 s� i iat 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: Permiaicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other - - - Contact Terson: Phone Information and Ins�rn� ions 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 ofhire,• 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 j oint 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. Owever 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 deemedto 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to the contracting authority." Applicants Pleasefill• out the workers' compensaiion affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) narne(s), address(es) andphone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other that 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 thatthis 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 obtaina 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 Whichwill be used as a reference number. In addition, an applicant thatmust submitmultiple permit/license applications in any givenyear, need only submit one affidavitindicatiug current policy information (if nocess my) and under "Job Site Address" the applicant should write, ,all locations in (city or towh). ' 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit 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 shpuldyou have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: `rho CQ oJI-wealtkL OfMomafihwe"tts - DepatlZelil ofhtdwWal Accldonia office ofI-avestigavom 60 Wuhiag� Steen Boston, MA 02111 TQJ. # 617-`Z2,7-4.900 Qyt 406 ox X-8.77,:MASSAFE Revised 5-26-05 Fay ,# 617-727-7749 • w�vc.�aa�s,gov�dia • " n -. ./ P � C. C TOWN OF NORTH ANDOVER Building Department 1600 Osgood Street Building 2- Suite 2-36 Building Dept Oreo �� North Andover MA 01845 SACHUSE Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION II DATE: �, � I `(� I I (..I TEL #:1 i NAME OF COMPLAINTANT: Ula c-xqm,,, ADDRESS:S+V�Q�, COMPLAINT TYPE: Electrical: bsqS bI�.1 Y.R�U�G„(� n0 Qaw to --�Jx oux Plumbing: Gas: Building: Property Owner: Address: � i C q{ts ww� I��` ASO 9 Date ..�2 .. Z... Z......... ;�t;`" {'�: �,TOWN OF NORTH ANDOVER PERMIT FOR WIRING o s f. �ss�cMusE� This certifies that ..... .... t ................................ has permission to perform �--. Ga` - .fes .:. - - Pe pe ,... ...............X .................................. wiring in the building Of.. .:: E'.*�' : •:.--............................................ --� -� -� - '` ............. 'i.. North Andover Mass. Fee- ...�.........Lic. No.G.n'�......... P�6�i .... , ,.... ECTRICAL INSP Check # - 9264 C'ommonwea& o f Mamac4uae>fa Official Use Only r ...__ ' cc�� c7 Permit No. Apartmenl o1 }ire Service 9 t/ I Occupancy and Fee Checked 1 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), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /0 0 City or Town of: l de—f' 4,.1J6 vG/ To the Inspector of Wires: By this application the undersigned gives notice of hisorher intention to perform the electrical work described below. Location (Street & Number) .2 Q Sc ha o S Owner or Tenant JZ,,., e, % � o �h 7�Drt Telephone No. cF 7 fj'- `g4, DI o Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No [jK (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ .. No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 'x p yt L, k; fe LQn Completion of the fn1lowing, table may be waived by the In ector f W' No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans o ares. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. ot 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 g No. of Waste Disposers Heat Pump Totals: Number ..."' Tons ' � ' """* KW "" * ......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water Kms, Heaters Heating Appliances KW No. of No. of Si ns Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: —7 Attach additional detail i f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: .� D. a'a (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 [K BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: e c ,0 �,' fTr Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.- Alt. o. Address: !oo Co/ayt.a[ ��. T.PJ'i4l,C4 ^4 olp ,� . Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: NAL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4f01q �iQ V;t� ( Address: Id 9 ,f o / ?7 -_� / D t City/State/Zip: �Ee Sr l,`c MR,. of 9,1.9 Phone #: 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).* have hired the sub -contractors 2. [ 1 am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees 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.] t These sub -contractors have workers' comp. insurance. ❑ 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 10. ❑ 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. 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' compensationn insurance for my employees. Below is the policy and job site information. Insurance Company Name: Polity # or Self -ins. Lic. #: Job,Site Address: 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 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. 1- 112 ! 1Z I> : -2-/ V110 y Phone #: 279 ,7,4C D — 3 C ,2 -3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Location��r Q No. a �� _ Date TOWN OF NORTH ANDOVER a ; . Certificate of Occupancy $ s�CNUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # • G1 2r) v 15637 i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / D DATE ISSUED: SIGNATURE: C C Building CommissioEEIEEL=tor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 04 Map Number Parcel Number 1.3 Zoning Information: Zoning Maid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.LC.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2'1 Owner of Record \ Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone O Z rn 90 O on r v rn r r Z 0 1. 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 permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ' " V f . SECTION 6 - ESTIMATED CONSTRUCTION COCTC Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical (HVAC 5 Fre Protection 6 Total 1+2+3+4+5 — Check Number iivilq is "VV 11r.n Au JLn%jr lL'AI1V1\ ILO Dr UU1VJYLLIhl) WMIN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on i irime�elative to wo�aulhon�zedbythis building permit application—, Si nature of Owner e SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/ ea 1 NO. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR TITVIBERS 1 ST SPAN DIMENSIONS OF SILLS DWIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Date SIZE 2 THICKNESS X ,11V 0 D. Robert Nicetta Building Commissioner (978) 688-9545 ...'(978) 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION Please print DATE l t I'l C9 �j rJ` O JOB LOCATION�Address Number Street "HOMEOWNER Name Home Phone PRESENT MAILING ADDRESS n City Town imr_ / Map / lot Work Pho L Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,, provided that the owner acts as supervisor. (State Budding Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm stnx:tures. A person who constructs more than one home c a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE ---\ ,� APPROVAL OF BUILDING OFFI FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/ erl Boards and Departments having jurisdiction have been obtained. This does not from relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION************* APPLICANTy Y\qz IA -JD r, U\,l Vy%_ LOCATION: Assessor's Map Number �?62 SUBDIVISION STREET PHONE_52a I �� PARCEL ©c� LOT (S) ST. NUMBER ***************************************** OFFICIAL USE ONLY*********************************** ;4ERVATION MENDATIONS O ADMI 1 COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH • COMMENTS AGENTS: ATOR DATE APPROVED � DATE REJECTED i DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO DATE Revised 9\97 jm v C � d y Cl) CD n Z y Ep O -0 a. r �� o CL =• y O n 0 v CD CL O CD o cc)CD ye Q v CCO2 CD I v CA O `v Z O O o CD 0 \Y O C W-- c = --4O c• to O O• N _ 5 norm to =�m0 m n C m 0 CL C � m CD c Z n c CD a m y CD O m y p -I O :E mn > >CA Vm� <G O 0 = O OzyO 0 �O m :Q C �N� S. _. a cc O CD m N 1 o m' • O d y N ) a��CT d C N m N141k :E y Q = Q ,: :1 mCD CD d y = m :Z O CD o it1 �O CD -- � n C, O m CD o _C: cu 0. cc . CO) 1 c O CD 2 0 r CA Z z nocr 0 jo.sep" m a L N 1-'Lat.,4 or- WArZr.?y Q. DOW 320 Er. u STEWART P 'oWILSON ET L' WORT14 ANooverz ca., I Er I-eo, /�A99 -Ut- it -W -j I 16 N 1-'Lat.,4 or- WArZr.?y Q. DOW 320 Er. u STEWART P 'oWILSON ET L' WORT14 ANooverz ca., I Er I-eo, /�A99 -Ut- Location / 8 7 0 ° / `S No. &56 Date NORTIy TOWN OF NORTH ANDOVER Certificate of Occupancy $ _ 1 CN t� Buildin /Frame Permit Fee $ sSAUSE Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ �S Check # 6c) (0 r v # (�� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING p k . t^z: I'2,, %a....y'i"'°3�-%Diw�4/ ,.:i'4v .2°..5 k'^ wi .•p+d,.a .t r g¢r BUILDING PERMIT NUMBER: � � � DATE ISSUED: SIGNATURE: T—C2�— BuildingCommissioner/In or of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map Map' umber and Parcel Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) C% Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Addretss Signature Telephone Not Applicable ❑ 0 - License Number 2n n 2 Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address V0 Expiration Date tgnatur Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506) 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 buildin rmit. Si ned affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work. r �1 & � P Z SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFiCIAI. USE ONLY =, 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf. in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name i nature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I ST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Dgartinent of Industrial Accidents Mice offnvesUnatfons 600 Krashington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit I ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have - - -- -- ------------ - •nilure to secure coverage as required tinder Section 25A of MGL 152 can lend to the Imposition of criminal penalties of a fine tip to 51,500.00 and/or one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement inay be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and,pgfialties ajperjury that the information provided above is trite and z ect. Signature /��L�' v 2'. ,7 �/GT r1''Is% Date Q" Print name I Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # 08uilding Department oard O check if immediate response is rtquired C]LIcenpSel ctsm n''ss Office 011calth Department contact person: phone #; nOther (,Msed 7195 PIA) T _ U cic Cx� do OO v o U) � o p gw \ Z O v- OO Z"� O 4. O LLA o �- 1 W. 3 cc co g O ' m w U to f. 6�o o a ro o .+ 0 > • � a-. �.-i F -Y U �— = O � to _ y m cc Lu •.--i ¢ C1 ?. t 7 in rn r o N 1 oZNaar Q V 00 U U '' m ix LO Q pro d z a Z - O o y a N Q } do OO U) 0 o r p gw 0 ig I �a W 1 d\ Z O ' , o C) Q o t 7 in rn r o N 1 oZNaar V 00 U U '' m ix LO Q pro m a r a Z - O o y N Q W rQ L� J N U F- w • p p U Z gi Cl) m C/) 0 m C2 t/! d C .0 d CO) o CD St Z y C'0. r� CO S. c y ,o o CD O � Q,Q O CD CD 0 CD C CD y a v CCA �CD I C W 1*� p -1 O C.y0Q � _ CL n m Cl) Q CA C2 060 S"o W -� o, 1*= d ... m N T �a-+o. 0 m CD �0 an d C y CA ND mm o n > >� o C o 0% 1 = .. o iiz y CD C y .�•., it V ic = a ''^^ o =� :� /V/�J m H C/) m OO n� CD a Q o mh: Q d: cz d.W d CA w� o ems'• � � � y C y 6,� z n ._ A: 1 Q �' r o CD: H CD O od stn y CD CD W Q n -m :^ C-) cl) o CA _ o m � cn cn by 0 M 'z7 z �O 04 ro 7d 0 Z ro 0 p' O - S. O O a w z c 'd " C O O a x C1 d x omi 0 9 0 c Tel, 682-4266 STRICONE ROOFING & SIDING CO. 31 Court St, No. Andover, Mass. 01845 I