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HomeMy WebLinkAboutMiscellaneous - 180 BERRY STREET 4/30/2018 (2)I-- Location I TD t, No. Date L" )jq Check # ani 24L,C'/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: — 0 Date Received Date Issued: ANT: Applicant must complete all items on this LOCATION l d e � � s 1 111 L PROPERTY OWNER �r 9s �/ Print MAP NO: 1116D PARCEL: 76 ZONING DISTRICT:_ G e - Historic District yes Machine Shop Village yes NM TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family i'Addition���s�+� o PTIT ❑ Two or more family ❑ Industrial "Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic EjWell ❑ Floodplain D Wetlands p Watershedfpistrict' Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name: i�(I"g s ® Mt `lary r� res L,L c _ I -b y �� c,•osWPhone: &-O 3 Address: F0 RCx (e(o CONTRACTOR Name: Phone: Address: Sri Supervisor's Construction License:? Exp. Date: Home Improvement License: ARCHITECT/ENGINEER Address: Exp. Date: Phone: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12. 00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S. F. Total Project Cost: $ / ®� FEE: $ / T/, Check No.: Receipt No.: NOTE: Persons Persons contracting w' reregistered co actors do not have access a guaranty fund �gnature of Agent/Ovyn---iSignature of contrac Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED ❑s DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decisio Comm Comments Wates" & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS z 0 F.2 E � N N 0 c N C O cmm 12 Cf m 0 O! C C N O Z O Z 0 Z 0 U C/) W ._l 0 U 0 O i..l ay 2 0 c y- o O U g� c cr- L O O w v Z w O D CO) � r.+ O Oa_ O LO O W uN o w° a C/)w° � _ o cz a U �' w a a w°' CdW ii 0 a2 cn c w cmQ w2' C,3o w m w O. = o ci) v cn z 0 F.2 E � N N 0 c N C O cmm 12 Cf m 0 O! C C N O Z O Z 0 Z 0 U C/) W ._l 0 U 0 O i..l ay 2 0 c y- o g� c cr- L O c v Z = H O D CO) � r.+ O CI cm O LO i ev R Cal- O L � _ c %a %a L 0 r : N A �- E 0 L m O o a CL cmQ co c m w O. •' CO O O c Z s � t V to � C 17 m � 0. c —o y CL— C=2 C' m 3 a m _ N W N N m 'fl N N S acz CCD ca 'M Z ca O. H15 S ® m = p coo 4- =0 N m w~ LL 'N O W A w+ •dt H N C .m v o ® c ti CL m O 10 •_ S R CD L y = � a4m z 0 F.2 E � N N 0 c N C O cmm 12 Cf m 0 O! C C N O Z O Z 0 Z 0 U C/) W ._l 0 U 0 O i..l ay 2 0 LU 0 LU cc W W 19 W ca O cr- L O v Z CD CL O D CO) � I CI cm O LO •E m m L � _ 0 0 � CD 0 e_cv o a CL cmQ co c o � � Cca v c Z s V to � C O � 0. y LU 0 LU cc W W 19 W ca Im O z S.7i t- ol --,� "I,\, �7' /\ 4 14 � C ;;C O O 7 t C H O C oz. Cc O C3 cD •ate \A O �: M �� ;-, . r o V\ w w ` :off " '\O co CO2 2 -- C > L lt�W U ADOCA- : CD C w o G O w° o c. w° U ° w id w°'w cn iu ° c� m cn E C-0 /\ 4 6 0 SII co O E OC i 0 'S c Z o CL O y C C cm I C C ca Q CD — MO) O O E m m = O � 3� O O � i oy o a Cc CMQ c o s c cv o .a O }? c Z m CD V y O C cc CLCO2 0 a, W N d' W W 19W W CO) O � C ;;C O O 7 t C H O C Cc O C3 cD •ate M Cc r o :off co CO2 2 -- L : CD C o c. y • o m .oma e.% : os CD c • y 4a ® � C O x_`03 y M (� Y y C m CO2 C4) O O Eca m � AaI` y m c m tcm �O C a 32 Cc :mL c o c_ ..: CD yCL= C = m m `m IV ~' Q y O m COD w 0 �O. ZJZ22 Z .y -Mc �- O w H dt C Z co C3 H Q o� CO2 co cc L. =..�a� m � 6 0 SII co O E OC i 0 'S c Z o CL O y C C cm I C C ca Q CD — MO) O O E m m = O � 3� O O � i oy o a Cc CMQ c o s c cv o .a O }? c Z m CD V y O C cc CLCO2 0 a, W N d' W W 19W W CO) CERTIFICATE OF USE & OCCUPANCY Building Permit Number 493-2011 Date: June 30, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 180 Berry Street, Lot #2, North Andover, MA 01845 Kings Oak Properties, LLC MAY BE OCCUPIED AS single-family IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS ' MAY APPLY. Certificate Issued to: Fee: $100.00 p!,v. ut4tz,4j Qac.tC Receipt: 23805 Kings Oak Properties, LLC P.O. Bog 166 Hampton Falls, N.H. 03844 Building Insp ctor J' W s: wl LLJ O 0 • L O O v Z a3 CL O C y C :moo G3 cm CO) 0 '� m c O O �E m m c C3 co ~4-a O ` O � CD o OC H O_ 0 o cc a r.+ O NJ V C.3 cmQ c �•nc t c C.3 J •p •O. O f0,. C i eav ea o CL C..± CO) G C �C n�•^t Oy �mr Ea PO u m G tsn� a +-; o Q • Y O k � w w V iti w H z N 0 a O _ L2 cin w2 , cn w cA cn cn LLJ H _ 0 CD O 0 • L O O v Z a3 CL O C y C :moo G3 cm CO) 0 '� m c O O �E m m c C3 co ~4-a O ` O � CD o OC H O_ 0 o cc a r.+ O NJ V C.3 cmQ c �•nc t c C.3 J •p •O. O f0,. C i eav ea o CL C..± CO) G C �C n�•^t Oy �mr Ea L CD o tsn� a • Y y O m 2 _ y.cc L m C2 Z' ^ c m 3 �: .. y 12J C m zip Ub `b y O O • V! m m CD cr. w a+ O Cf C O c= S ny a momCIO ..: c o c Q m y m c O = m :m 3 CL O N ~ e0 + W w LL ym O O LC •E C •y O Li y a CO 3 -p V cm m�0 g A = co = C = 0 F- = w0.. O.y=..m ? H _ 0 CD O 0 • L O O v Z a3 CL O C y C G3 cm CO) 0 '� LA O O �E m m a C3 co ~4-a Z O � CD o CD 0 o cc a a cmQ c cCc t c C.3 J •p •O. O f0,. C Z CD CL C..± CO) O C �C C cc CO) 0, ,LED I I'NO APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION R^rEo°Py45 BUILDING PERMIT �SSACHus ADDRESS/LOCATION OF PROPERTY: so�'��7 S I Map %0 6',0 Parcel SUBDIVISION: ky,, R . I(I Lot Number C -z- DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: I , C;� d // FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued ROUTING /! TOWN ENGINEER, SITE PLAN — DRIVE -WAY REVIEW `�' � 1414- CONSERVATION '0 & `� c _0/ PLANNING DPW -WATER METER SEWER CONNECTION �' (0130b' DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW SIGNATURE File: Application for OC form revised Jan 2007/2011 r v O C C (O O co� O poi V U ui Zr z = z Q v O V L J V 0 3� v pO O Xco Q00 ,73 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use Ll Notified for pickup - Date Doc:.Building Permit Revised 2008mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi 7 6 y 4 Date...R -�3...��..... TOWN OF NORTH ANDOVER . + PERMIT FOR GAS INSTALLATION This certifies that ?4P ......... . has permission for gas installation v -s" in the buildings of ...P:M�)&Q-�. .... at .�.C? ..� -.`� .. j. -G S .. , North An ver, Mass. Fee o4.S.Y: . Lic. No.1ALAk.... ...., .. . GAS INSPECTOR Check # 2ND.*07% A0,F.LpGit -'.... ,Y,.TK F1;OOR • STH.Ft.O'Ofi GTM FLOOR 7TH FLOOR I,'$ T K. F.L ©.0. Installft Cony Name t^r� ,Ia '� r: Check tinc. Certtflcate Corporatlon :...._._._` 4 1=4 Q.1 Q D • •Partnerohlp Easiness Tet6phone,:0.$— Firm/Co. .� Name of • Ucenao.plumber or Gas Fitter INSURANCE- COVERAGE; ' I have a current liability,•fnsurance pol.icy-or.1ts stibstaritial egvtia+ent.whickt.meets the requirements. 01 MGI. Ch, 142: Yes No U If you have• chocked yei, please indicate the type coverage Oy checking -the appropriate box. . A IlabUlty insurance policy X) (gther type of -indermraity ❑ Bond Q OWNEMINSURANC€-WA;►EA: I am'&.ware 'that -thei 'licensee,doss.riot have ---the.ansUr'ance coverage'required'by Chapter 142 of the Maf.;, General Laws, and'that my slgrtature on this peer ft application waives this requirement. Check' one; OwnerO Agent .0 Slihapire'61.0wher or :.: mer s 4ent I'heretyarrtify that ail:of the.;detaiis and information I have submitted-lor-enteredl in atrove arrplication are'tnre and accurate, to'the best of my. knoMaOO,ahO th'trt;all'-piui�it7irtg work .and installation; perforr d unde7 "e-per{rrit issued fnr .this.applicat on will be' in:cortrpliance with all pertinent•provisionsolalte:>hk s hfi setts, Star OQ Ai-s:Code and OT ier 142 ofah'e Si!T of Ucense; . Plumber r.v� Gas after Title flitter . Master Ucense Number k A. C3, m Joumeyman 7 7 L' 6 Date....4.: ..i.l..... . ` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . l? V" ..0 :J.(! % z has permission for gas installation :: � a. -.. ! - -( ............... in the buildings of �...................+... . at..� ......... Nopprth ndover, Mass. Fee. I?a.. Lic. No..3 b? .. .. .5... ...... GAS INSPECTO Check # I ) l /, 4t L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS F11"I-KING CITY/TOWN: STATE: MA APPLICATION DATE: JOB ADDRESS: % s`�y OCCUPANCY TYPE: COMMERCIAL RESIDENTIAL PLANS SUBMITTED: YES[] N/OIV NEt ALTERATIONO REPLACEMENT❑ REMOVALIDEMOLITIONO F NATURAL& LIQUEFIED PETROLEUM GAS: PIPING --EQUIPMENT - APPLIANCES - SYSTEMS Z ENTER TOTAL AMOUNT FOR FAM4 RFI FrTIn1J n 11hTFn Tn Givam All RACDAI c AIR ROTATION UNIT FURNACE: ALL TYPES TEMP HEATING EQUIPMENT BOILER: ALL TYPES GAS PIPING THERMAL OXIDIZER BOOSTER GENERATOR STATIONARY ENGINE TURBINE BROILER ILLUMINATING APPLIANCE UNIT HEATER BURNER: ALL TYPES INCINERATOR WATER HEATER: ALL TYPES CO -GENERATION UNIT INDUSTRIAL AIR HANDLER EQUIPMENT OVER 12,50OMBH COFFEE ROASTER INFRARED HEATER 9 I OTHER NOT LISTED? COOK APPLIANCE HOUSEHOLD KILN I GLORY HOLE I CRUCIBLE COOK APPLIANCE COMMERCIAL LABORATORY COCKS DECORATIVE APPLIANCE MAKEUP AIR UNIT DIRECT VENT APPLIANCE MECHANICAL EXHAUST EQUIPMENT DRYER: ALL TYPES OVEN: ALL TYPES FIREPLACE: VENTED I UNVENTED POOL HEATER FRYOLATOR ROOF TOP UNIT FUEL CELL ROOM HEATER-VENTEDNENTLESS PLUMBING / GAS FITTING FIRM INFORMATION CHECK ONE ONLY NAME ,EnergyUSA Propane Inca ADDRESS:'1000MMyles Standish Blvd yd lCorporation Business # CITY: TaUntOnW " ,..,_ -- j Partnership Business STATE: MA ZIP. 6.Q27„8Q - _,—� ”" ElBusiness # TEL: 5088.44465,0..„ FAX5.0088241028 EMAIL.:Lk orson@e..ne_r r,opLn ,,, mus ODBA IUnincorporated NAME OF LICENSED PLUMBER I GAS FITTER: William Kent Corson INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESX® NO E] If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy l 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. XXXXXXXXX CHECK ONE ONLY OWNERE] AGENT Signature of Owner or Owner's Agent 0-71 3 OWNER'S NAME ! .XXxXXXXX . -� . �� .�d.�...�,. TEL: ' FAX 1 hereby certify that all of the details and information I have submitted (or entered) regarding this permit application is true and accurate to the best of my knowledge. I certify that all plumbing work and installations performed under the permit issued, will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. (OFFICE USE ONLY) Type of License: Permit# OPlumber XOGasfitter Inspector ®Master Journeyman Signature of Licensed Plumber/ Gas Fitter ❑ Y Fee: ❑Undiluted LP Installer License Number:�370� 0 Limited LP Installer ti I � 1 I � '4 ' I z I � T m m ❑CD C N ❑Z O 886L3 Date 37A - I (.. . TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING •, •r r o+ SsACHUSE� This certifies that . -De n -:%.F. S .... Va el. v 1G ....... � -�� �? v ► has permission to perform ... C Sf.' ..4.c.vt; , . , , LC1 i,I, plumbing in the buildings of ...( I V)� ................ at. �... �. `'�.. l ............... . North Andover, Mass. Fee .5'5 . Lic. No.. �.�. f2, .......................... Check x a5-7-4--' PLUMBING INSPECTOR FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: UJ eE�� , MA. Date: a ' a S '/ / Permit# Building Location: Owners Name: Ali NJ , Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: E4— Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes O -No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy '1- 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 ❑ Pi—+— of r)... cr nr n... oro A—f that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Signature of Licensed Plumber City/Town ❑ Master APPROVED OFFICE USE ONLY ❑Journeyman License Number: 7 DEDICATED Z SYSTEMS D LU O'^ LLJ Ia" Y a ' X U Ln w Ln l7 LLI VI d' z a z W a' Z V) S Vf Q W CA W Vl Z Q a Ln Y a Vl Z a X U QQ N Q a V) W W F. a to OC 0 Q W ° Q Z a' ° o W°°° 3 C C W Z N V1 z U a U. a_ \ S J Q W 3 3 a x 2 UjU'= a o = z Q '� 3 °x a Y Z Ln a ~ a H W a, u I Q > ~ a a m m o o 0 °x Y g g° ° a oc < 3 3 I- 3 o (- a z" SUB BSMT. BASEMENT 1sT FLOOR 7 2ND FLOOR 3RD FLOOR 4T" FLOOR 5TH FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR ✓' �' �/ F(��ust/ Check One Only Certificate # InstallingCompany p y Name: v5�� I V,7�/�G Q �CVOO/9S`UCity/Town:✓ �f�°/� Address: ��%U /I Stater El Corporation ❑ Partnership Business Tel: p/7 3% 3 �G/// Fax: ❑ Firm/Company Name of Licensed Plumber: S v 5 1A v/ 6 /-/ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes O -No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy '1- 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 ❑ Pi—+— of r)... cr nr n... oro A—f that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Signature of Licensed Plumber City/Town ❑ Master APPROVED OFFICE USE ONLY ❑Journeyman License Number: 7 C�MA'ONWEAALTH (jF .. MASSACHUSETTS • - IN PLU �o :... � �AUD GASFITTERS PLUMBER DENNIS R SUSLAVICH 47 VILLAGE WOODS RD ; HAVERHILL i. MA 81832-1079 Foga, Then Detach Along All perforations l_ J 0 . 9928 :�-- AS--- // Date.................................. • .."�oL TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatR G kzzc.4F. Gi X has permission to perform ......... N��~ _..........��...� �............................. wiring in the building of .... .....�,..............................4 , .......... pp at ....1.0 0...... �� }. .......S.1 ............................. North Andover, Mass. av l// ......... ..... . ELECTRICAL INSPECTOR Check # _ L ?/7 ((( w .A ROM C'®mmon wealth of Massachusetts Official Use Only Department ®f Fere Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFO TION) Date: -z- City Z, , or Town of: WA To the Inspector of Wires: By this application the undersi ed gives no ' e of his or her intention to perform the electrical work described below. Location (Street c& Number) I �p�r S 10.7• 2- Owner or Tenant �� S Telephone No. Q,4 krD� (.. LG Owner's Address '_/ rvc� jg / m.p16A P.1115 A111 \� Is this permit in conjunction with a building permit? Yes e No [] BLDG PERMIT h Purpose of Building S i` n Y ry 140yj Utility Authorization No. t,,,' Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Zo'/ Amps )7'9 / Z IO volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,/t/e(-, Now e- 1----7- .--- - Compleion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceff. Susp. (Paddle) Fans No. of Total. No, of Luminaire Outlets No. of Hot Tubs Transformers KVAGenerators KVA _ No. of LuminairesSwimming Pool Above ❑ In- ❑ o. o mergency ig ing rnd. rnd. Battely Units No. of Receptacle Outlets No. of Oil Burners FSE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond. Total Initiatin Devices Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number on KW No. of Self-contained Totals: """'"""" Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑Municipal Connection EJ other No. of Dryers Heating Appliances KW Security Systems: No. of Water No. of No. of Devices or Equivalent Heaters KW Si s Ballasts Data Wiring: No. Hydromassage Bathtubs No. of Devices or E uivalent No. of Motors Total HP Telecommunications Wiring: OTHER: No. of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electri al Work: (When required by municipal policy.) Work to Start: .Z 2¢ ZhTS1 / Inspections to be requested in accordance with NEC Rule 10, and upon completion. ' URANCE 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE KI BOND ❑ OTHER ❑ (Specify:) I cert, render the pains and penalties ofperjury, that the information on this a FIRM NAME:re w pplication is true and complete - i �, ,- �e LIC. NO.: 4- �,� Licensee: S c ewN a Signature (Ifapplicable, enter "exempt"' the license umber lie LIC. NO.: Address: j t MA us. Tel. No.: 4�8 9-62452`] Sa �v�yAlt. Tel. No.: S9K z,?n ?5 77 *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 (che Owner/Agent ck one El owner El owner's agent. Signature Telephone No. P ERMIT FEE. ,$ I' M, )�tv .A ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed — Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: C, (Inspectors' Signatu - no ini als) Date Alv 2. FINAL INSPECTION: Passed — [ Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: Aw (Inspectors' Signature -no initials) Date' 7,- I i // 3. UNDER GROUND INSPECTION: Passed :Ps Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspect s' ignat e - initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - initials) ate 5. INSPECTION - OTHER: Passed — ( ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: 1 (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. The Commonwealth ofMassachusetts Department oflndustrial,Accidents Office of-Investigations 600 Washington, Street Boston, MA 02111 Ujp www.mass. gov1dia Workers' Compensation Insuranve Affidavit: Buzfders/Contractors/JEXectricians)PlumbeTrs Applicant Information Please Print Legibly Naille(B.usiness/OrganizationQndividual): Address: City/State/Zip; Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑. I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] .. i Type ofproject (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. [] Plumbing repairs or additions 12. F1 Roofrepairs 13.❑ Other *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 their workers' comp. policy information. I am an employ erthat isproviding workers' compensafion insurancefor my employees. Below is thepolicy andjob site inforfnation. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: lob Site 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. I do hereby certify under thepains andpenattles ofperjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town offzciaZ City or Town: PermitUcense # Issuing Authority (circle one): I. Board of1fealth 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other 11 Contactrerson: Phone #: 11 76Uu Date. / ! .......... TOWN OF NQRTH ANDOVER PERMIT FOR GAS 1 ALLATION This certifies that ..C`` .� «/�! :.. `a! .............. has permission for gas installation ..�. �. �. 5 ............... . U in the buildings of ...l. ! '. . l%!�' t4 ........................... /Nat J-4.( .? .... r'�� !' `� .. ........... North Andover, Mass. Fee. ..2. . Lic. No. L....... GAS INSPECTO4� Check # 2 S S S / 11 i FIXTIIRFS nwi Wco W2 Z � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: LID d01 MA. Date: 3 g Permit# Building Location: L b Z 4 a g/2/? / 57- Owners Name: /F( N6 dl--�S P/26P/,42ur Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential 0— J New: Q' Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTIIRFS nwi Wco W2 Z � Cd =Cd � J N M1.1.1 O w W U v U) H O= X w f O Z Z O iY W IX W O l'- n 011 W W w lX> M U Z W W m O 0 a W U) a O H Q O W P o w X =� I— W w > U W Z J i— Z F- O Z m W = --I O W 0 Z I— LL O N 1-- W W > W Z W IX W w x O w Q Ir U D D u_ 0 C9 w = w Z J O a OW WEZLU F- >>> O 1 1 Ll I I I SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR --9 'FLOOR 6 TH FLOOR 7 1 H FLOOR 81 H FLOOR Installing Company Name: C/�'LLf-�-%tN-,f�Ac- f ��j� Check One Only Certificate ## El—c—orporation Address: �� x(,/`10 it 5/ City/Town:• Z7A�L% — State: 7 Business Tel: �J (� b [ ��-�3 Fax: El Partnership t� ❑ Firm/Company Name of Licensed Plumber/Gas Fitter:�]�C f-- / L 1 INSURANCE COVERAGE: I have a current liabifily insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes B'No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy EB--- 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 Signature of Owner or Owner's Aaent Owner El Agent E] By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to ine Dest or my r nowieage ano tnat an piumamg work and installations pe ormed under the permit issued for this application will be in mbing compliance with all Pertinent provision of the Massachusetts State PluCode Chapter 142 of the General Laws. Type of License: By plumber IN Title ❑ Gas Fitter Signate f L cense lumber/Gas Fitter ❑-Master I City/Town ❑Journeyman License Number: APPROVED (OFFICE USE ONLY) ❑ LP Installer