Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 180 MILL ROAD 4/30/2018
N O O � t O b Q r 69 CD v 0 J4 01. Thursday, Jul 14, 2016 08:12 AM o-i(I haps(jnoi*hand verma vrcwpamtdoud and*lrewd(20916 pl i�' fktes HTf AccnurRl Email0 ...lg %FIMiYCamect.lMox(17) I-MmibVgPerm&*26916-tl X- -- W . i Town of North Andover, MA Q search 20916 *Plumbing Permit - Renovation/AlteratioNAdditlon Fixtures and/or Appliances (Commercial or Residential) - - TIMELINE - V submission received Your request is In progress )u! 14, 2016 at 8:12at We'll let you know of any updates via email. Feel free to check the . . status at any time by coming back to this page. 0 Plumbing Review _ - 1n Progress . Permit Fee . Permit Issuance - App!kar Locailon . Richard Colmer 180 MILL ROAD, NORTH ANDOVER, MA outer GOLDMAN, HOLLY H t Attachments ( -. -OTGOOFI001F Thujul_14_2016 12:12:.PDF Uptoaded;'�'}'14: 2016 by Richard {c!mer _ 8:12 AM 711112616 Thursday, Jul 14, 2016 08:12 AM WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -- - - IF - �. I - __._ _.4 ____..( _! __ _.__----_-_(......... - — — - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [eNO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D( BOND E] 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 [31 AGENT J0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in�� a wi a Pert' e t provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ "Gh'--w._►_� V LICENSE # SIGNATURE MPD JP ul"-' CORPORATION F.] #©PARTNERSHIP 0# _ _ i LLC COMPANY NAME _ � E j'jgam, A 1 4 1 _j _; ADDRESS CITY - - . _i STATE _� ZIP G T_ .— _ ► TEL FAX _ ._. ___ CELL _ i MAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY r^ d MA DATE ���f( PERMIT # JOBSITE ADDRESS ��_ /1 t / �. �� j� OWNER'S NAME POWNERADDRESS ''��AV TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: © REPLACEMENT: M/ PLANS SUBMITTED: YES ® NO© FIXTURES "I FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM l _ (___ I __TJ _�-,,._ i _(- _ j __..._! DEDICATED GREASE SYSTEM _._ ( ____J ___..J I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN .... ...... _! FOOD DISPOSER E-_ !E __l FLOOR/ AREA DRAIN 1 J F __.__ l _-_J _._ ( (__..._-i _--_ __1 ..._....._ (' __.._._J _J INTERCEPTOR (INTERIOR) _ I 1(._.-.._,_! I _.__._l _.__J ___._` ____-_.( __._,. J .._...._..f k . ► ._.__-. i KITCHEN SINK .I ...___1 �� ..—I ._---J _. f - ----( ------_i ..__..--( --{ ___ J _.__ ._E ------ ( ---.-J LAVATORY _ (- --( J _.__._.._ ---_.__---._-_( J EJ .._(----_... _1 @ I -..-- ROOF DRAIN SHOWER STALL (! J __j= SERVICE / MOP SINK 1 _._.-1 _._ _.1 ( �.1 J J _._ .J rI _...._ ._ ._—J ._ _.__1' TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -- - - IF - �. I - __._ _.4 ____..( _! __ _.__----_-_(......... - — — - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [eNO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D( BOND E] 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 [31 AGENT J0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in�� a wi a Pert' e t provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ "Gh'--w._►_� V LICENSE # SIGNATURE MPD JP ul"-' CORPORATION F.] #©PARTNERSHIP 0# _ _ i LLC COMPANY NAME _ � E j'jgam, A 1 4 1 _j _; ADDRESS CITY - - . _i STATE _� ZIP G T_ .— _ ► TEL FAX _ ._. ___ CELL _ i MAIL °z z 0 H U W LOD A W � o z a Z tn T❑ rA LU O W a Z u uj _ ~ Qtai M W Ra ® > w � w co O o a a � W a � U J IL a- < U) w aE w F- a H O Z z O H U a C40!) a a c�7 IV " The Commonwealth of Massa chusetts F Department oflndustrialAccidents y : d 1 Congress Street, Suite 100 Boston, AM 02114-2017 .. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: ) _I fAYI" City/State/Zip: /'-M -C v Are you an employer? Check the appropriate box: Phone #: �,�p -3 3 7 3-0a6 J 1. ❑I am mployer with . ,.. � employees (full and/or part-time).* 2. ;nma sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself [No workers' comp..nisurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its officers.have exercised their right of exemption per MGL c. 152, § 1(4), and Nye have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. El New construction 8. R Remodeling 9. ❑ DemoIition 10 Building addition 11.0 Electrical repairs or additions 12:0 Plumbing repairs or additions 13Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. . I Homeowners who submit #his affidavit indicating they are doing all work and then hire outside contractors must sabmit a new affidavit indicating such, tContractors that check this box musftttached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-cofi6ac`torshave 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: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby c(�e/{�/�/}fy�u ,dner z pa s//✓a//9J',)jpenalties of perjury that the information provided above is true a/nnd' correct. C:.... ni...e• 1 ILLI //[.J�// / r / 4i 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 #: 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 ihe'boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees 'other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi• 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia } Date ..... . 3�.. o.. :..... ".;° "ao� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUSE'� IJ1 This certifies that ...C---(....:................'................................. has permission to perform ... .r....... wiringin the building of..................a........................:........................................ at ...... ��...ko .... .....!....`...... ......... , North Andover, Mass. Fee......v.o. Lic. Noao......`(3 R ...:...................... �............... ELECTd�SPE R Check # 1�7 f 754/ .1 ..y 4 Commonwealth of Massachusetts TVIELM Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked 557ZI [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MW), 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7/51/07 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 to electrical work described below. Location (Street & Number) / gga/ A t, j j U Owner or Tenant µp LL m G o LA ^A1, Telephone No. Owner's Address T��in IaL ea Is this permit in conjunction with a buildiK mit? Yes No ❑ (Check Appropriate Box) Purpose of Building Iv7C-kr-N ad e L Utility Authorization No. Existing Service U9 D Amps [Z.G/ Z40Volts Overhead 9 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: �('t7CAL-h,,,, Q/eL o%.Jc,c t 2h • CC) !e inn Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electr'cal Work: ZC900- O O (When required by municipal policy.) Work to Start: /30/ 7 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 �T- BOND ❑ OTHER ❑ (Specify:) I certify, underthe&!bA^1-C4 ims and penaltie of perjury, that the information on this application is true and complete. FIRM NAME: PS.,., t it'" LIC. NO.: 26.f i ^d Licensee: `t•��,�1� u/,I✓p� /� Signature �� e LIC. NO.: 5 (If applicable, nter "ex nipt" in the liven ember line. ' N Bus. Tel. No.: i� 1 '67/6 Address: t�3 i "r- a o!G /�1G ,KIS 17?f4a/sfv Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safe y "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: $ -- ---- 111c,14 runt U rr truly. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires'L Swimming Pool Above ❑ In- ❑ o. o Emergency Lighting rnd. rnd. 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 Number 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. No. of Water No. of No. of of Devices or Equivalent Heaters KW 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 Electr'cal Work: ZC900- O O (When required by municipal policy.) Work to Start: /30/ 7 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 �T- BOND ❑ OTHER ❑ (Specify:) I certify, underthe&!bA^1-C4 ims and penaltie of perjury, that the information on this application is true and complete. FIRM NAME: PS.,., t it'" LIC. NO.: 26.f i ^d Licensee: `t•��,�1� u/,I✓p� /� Signature �� e LIC. NO.: 5 (If applicable, nter "ex nipt" in the liven ember line. ' N Bus. Tel. No.: i� 1 '67/6 Address: t�3 i "r- a o!G /�1G ,KIS 17?f4a/sfv Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safe y "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: $ i 7-31—c97 P/1-1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information -t Name (Business/organization/Individual): �On.gr �/' Please Print Le ibll s�.�1�1 i Address: 9n� '�t'5•G� n,\ City/State/Zip: O ISW l Phone.#: Are you an em 10 er? Ch k p y ec the appropriate box: 1. ❑ I am a employer with 4. ❑ 'am a general contractor and I �smployees (full and/or part-time).• 2. [4. have hired the sub -contractors 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. employees and have workers' [No workers' comp. insurance comp. insurance.x required.] 3. ❑ I am a homeowner doing all work 5. ❑ We are a corporation and its officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] U__ fMy applicant that chxlot box #1 moat also fill out the section below ahowing their workers' 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 mcoion wners who aubrrat thus affidavit indicating they are doing all work and dm hire outside mpensa contractors rs POflcY mus submit new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether w not those entities have employees. If the subcon6actora have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insuran information. ce for my employees Below is thepolicy and job site Insurance Company Name: Policy # or Self -ins. Lic. M Expiration Date: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration d Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of p date), fine up to $1,500.00 and/or one-year ' � �P criminal penalties of a of up to $250.00 a da a Y m�pnsorunen as well as civil penalties in the form of a STOP WORK ORDER and a fine Y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investit►ations of the DIA for insurance coverage vp.,n ;ret; -- I I do hereby certify uunnder,Nje p !ns and penalties of perjury that the information provided above is trite and correct Si aiure• 1_12'" � �/ � <�3�%C� � Date: Phone Official use only. Do not write in this area, to be completed by city or town offlclaL City or Town• Permlt/License # Issuing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: - Phone #: Commonwealth of Massachusetts I Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS ------ (1llieial I sr I hcl� Permit No. t Occupancy and Fee Checked _ [Rev. 9 051(leave htank) -- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK SII .cork to he hCrlorn.ed he accordance with the %l;c»aChu'�Ctt; 1]CCuiC,c1 loti i_' C' IR 1'--.1)0 I'LE.ISE PRL\T L•\ l:V OR TYPE. ILL 1, Fl)R.ILITI��,\; Date: � 1 Cih or Town of: IUDfi-� �Javy- TO /hr hTSIVOOP 01 By this application the undersigned gives notice of his or her intent 11 a perti�rm the electrical \%ork described help, . Location (Street & Number) I 1)t,af / �� (honer or Tenant /Vyi-I e N l) tld d d( ' Telephone No. Owner's Address Is this permit in conjunction with a building permit'' Yes No ❑ (Check Appropriate Box) Purpose of Building Utility authorization No. Existing Service ;imps / 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: LII, t -c, jyi r -e al,o A ('oar )l elio,l of I/ It .'i,llou il,+( 10b It IluV h(- 1101 L iw //It' Grs) AI'lvl' r,/ t l'irr No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Cwimmin %bo%e In- g Pool „rnJ. ❑ rad. ❑ o. o mergency ug Ing Batter Units - -- 4FIRE ALARMS rNo. of Zones _ No. of Receptacle Outlets t) No. of Oil Burners No. of Switches (� No. of Gas Burners �No. of In Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals:Metection/A Number Tons j.KW.. ". No. of Self -Contained lerting Devices No. of Dishwashers i Space/area Heating KW Local ❑ Municipal Other Connection ❑ No. of Dr ers Y Heating Appliances KW Security' Systems:* No. of Devices or E uivalent No. of Water Heaters Kw No. of No. of ns Ballasts Data Wiring: No. of Devices or Equivalent _ No. Hydromassa a Bathtubs g _Si No. of Motors Total HP I ciccommunicatons Wiring: No. of Dcv ices or Equi. alent OTHER: .Ill(Irlr /r+,rM, r6llr,r1111',t ,llr F:,timated Value of Electrical Work: 1 khen required by municipal policy.) %ork to Start: Inspections to be requested in accordance with EIEC Rule 10. and upon Completion. INSL RANCE C'OV'ERAGE: l mess waived by the owner. no permit lur the pert'Ormancc ofelectrical work iiia) i::sue 11111c5 the licensee provides I'roofof liability insw-:utCC inCludim, "completed operation.. Covera 1C ur its,ubstantidI equivalent. 11W ntdcr:,i..nc l certifies that ',uch Cu�era",e is in fr.rcu.:rn.l h:u �:" hihitcd III—notfof :,lmc tr the Permit i::, uin" ottice. I IFt:< O.vi:: It �I�ecitb:;Lecth+ �06 ext'' the 'l/!: /I,S !'JJ![�,r,<.Y;l.r!l;,,,: )1'pe1jm:v, :fiat /he ��e r � —,��.:�- _Icensce: Qctiretl f'is: ;_ �iPn:artil! - ;A�Lt _ C. V0.: -- ig.' ;r.ic r, IL i nil rr— -----13us. Tei. ',io.: !.ddress: t,. X 3': 7 (n'i (c�C�1 /Y7 C) 4,T \1t. Tel.---- ::Scetu•it) S),,t in Contractor 1iCenr,e required Ior tl-is Viol -k; if applicable• Cntcr the license number here: OWNER'S INSURANCE WAIVER: I ;till aw;irc that the Licensee doc.- l bare the liability insurance c,.,vera c 11 'malty rctluircd by lavv, By my': ,mature below, I here') waive till'; requirement. I am the (check onc) ❑ owner ❑ owner :, .uzcn Owner,'Agent r :'igilatuge . _'�l);i: rat ..>. PF R.'LIIT FV.F % Rv-t-,rli &/-" S-�- DatXe. "oRTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 This certifies that ... �'are- •-r-.....•... ..................... has permission to perform .,t : ... -.! ............ ...... . plumbing in the buildings of .................... at r........ ,.North Andover, Mass. Fee3/ .... Lie. Noa? .„�: ............ . PLU, B;ING INSPECTOR Check # 7470. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS d �6 --II ) Date Building Location � %L! ��% .�j�-' Owners Name N M a 'Ll Permit # df70 Amount Type of Occupancy S N �j �( New Renovation ReplacementPlans Submitted Yes No FIXTURES } (Print or type) / Installing Company Name /{iii! `I /9"1 )) f2/GG X-- ,` ` Address 3 cLos4" 14ye�- fir' Check �o Certificate 3 Partner. Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the ty insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity D 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 IOwner 11 Agent 11 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 Mass�chuse t to Ing C e and Chapter 142 of the General Laws. By Signature i nsFlumoer Type of Plumbing License Title 4, City/Town L cin umver Master Joumeyman APPROVED (OFFICE USE ONLY 1-3 Date TOWW'of OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... i., ............. has permission to perform .... 3) A -A .. . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . ................ at .... ............ North Andover, Mass. Fee. Lic. No. JP ........... PLUMBING INSPECTOR Check # C7 -7 6713 \3o r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT .TO. DO PLUMBING (Print or Type) I r� -- Ale AdNvu— — adoS 6 it 3 f -lam , Mass. Date �� 1� Permit# Building Location __ Owner's Name Type of Occupancy New ❑ Renovation ❑ Replacement Wl-� Plans Submitted Yes ❑ No ❑ Ia J FEATURES Installing Company Name FfT-�� P QL & =0C� Address 1,15 Pr►n(1p,L%- to 1<<1 NO 01hpjms 4� r -J u A- o t 8 fo 3 Business T • MA Check one: Certificate orporation ❑ Partnership ❑ Firm/Co. Name of Licensed Plumber INSURANCE CO CO ERAGE: I have a curr liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please in icate the type of coverage by checking the appropriate box. A liabilityinsurance policy Other type of indemnity ❑ Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of. the Mass. General: Laws and thatmy signature on this permit application waives this requirement. ` Check one: _..... Owner 0.. Agent ❑ Si nature of Owner or Owner's Agent , I hereby certify that all of the details and 21na ationtiVensewlqumoe bmitted (or entered) in above a ica n are: true and accurate to the best of my knowledge and that all pluw allations performed under the ued for this application will be in compliance with all pertinent provissetts State Plumbing Code a ter 142 of the General. Laws. By Title Type of License: Master Journeyman ❑ City/Town License Number APPROVED 0FFICE USE ONLY ■■■■■■■■■■■■■■■■■■■■■■■■■■■ no 11 Installing Company Name FfT-�� P QL & =0C� Address 1,15 Pr►n(1p,L%- to 1<<1 NO 01hpjms 4� r -J u A- o t 8 fo 3 Business T • MA Check one: Certificate orporation ❑ Partnership ❑ Firm/Co. Name of Licensed Plumber INSURANCE CO CO ERAGE: I have a curr liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please in icate the type of coverage by checking the appropriate box. A liabilityinsurance policy Other type of indemnity ❑ Bond ❑ OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of. the Mass. General: Laws and thatmy signature on this permit application waives this requirement. ` Check one: _..... Owner 0.. Agent ❑ Si nature of Owner or Owner's Agent , I hereby certify that all of the details and 21na ationtiVensewlqumoe bmitted (or entered) in above a ica n are: true and accurate to the best of my knowledge and that all pluw allations performed under the ued for this application will be in compliance with all pertinent provissetts State Plumbing Code a ter 142 of the General. Laws. By Title Type of License: Master Journeyman ❑ City/Town License Number APPROVED 0FFICE USE ONLY 6265 Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................... ...... 4/-r. -I/— I ..................... has permission to perform ..... P/. ................................... wiring in the building of ......... fl ........ ... ................................. at ....... .A.6... ,North Andover, Mass. Fee..: .................. Lic. No. ....................... 4.�. .. . . ...... INSPECTOR ...�.... ELEcrRICAL NSPEcroR Check# Z: -.c R The Commonweaath Of may sachusetts _ vzparrmenr or Public Salary Office use only ' BOARD OF FIRE PREVENTION REGULATIONS -•�- PErmit No. 2— _ i C rv[ R -12:00 Nancy 8 Faa CI-16ck4., APPLICATION POR P E R �d I T T IS P 3/9a (laavz Blank) All \\'OrA 1� Oc vL11�frlloJ if1 a�� E R P O �`Y �I (PLEASE PRINT oraauca \\ m Ilio Aly��dcnu>Gq� L=la ental C0'3 ELECTR I CAL IN INK OR TYPE ALL INFQF�M. TI N 5P7 Cn[R to ou ■ • O City or Town of— 41d i*406r`/�� _j 6 `-- Tea unJarsig Date / CV J ynaa applies for a permit Io -.... —.. _. -- pal10lm Inc Location (Stree( 3 rn/�WJ- Numoaf)_ 18pj J CCnbb cd - —1 o the Inspector of Wires: M4 Ownar at Tenant _ �� C tiG/ - �O 4 --- r:wnara S _ 4A - — -- AJcrass_-- Is [nis permit in conjun_t-•on wilnF. buildin — ---- 9Parini[ yas U PurpJSa Jf builJing--- nD �-- - - _ (Check Appropriate Box) Existing Service----"--Utifty Authorization No. Now Sorvico _ Arfl , QI:c;"h"ixd LJ Undg(d p — -----Volts No. Of Maters_ NumDa! Jf FaaJars ane � Overhead Meters --- -9 U Undgrd ❑ No. of Meters_ LDJaIIJn ane Naw( of Pro ----- . Posed Electrical WDrh-----. . NJ. of lign(inq Ouuats --- -- ./ v NJ. of Li ntin Fixtures No. Gf Ho[ Tubs -- — -- No. of Transformars TOTAL No. Of Swlrnming PGGI Above In y' Recaptacie Outlets Arnd. grnd ❑ KVA No. or oil Burners Generators No, Of 5witcn Ouua(s No.of Emergency Lighting No. of Rarnes umars KVA No. of Gas B Bauar Units No. Of Air Condi TOTAL FIRE ALARMS t TOTAL No. of Detection a.;d' No. -of NJ. ui Disposals HEAT TONS No" of Pum TOTAL Initiating Devices Ps TONS TOTAL No. of Sounding Devices No. of Disrltivashars NI(W No. Of Salt Contained • SpacaiAraa Hearin alaon7SGunding Device, o. at Dryers Hearin Device; Kyr Dc•ti No. JNo. of Vv f Water Heaters K --- - K4v No. of Local Municipal ❑ Si ns w Voltage Connection ❑ Other Ivo. Of H?'oro Massage Tuo, Ballads Lo - Wirin No. MotofS hTHER: Jf Total HP-----�_ 'vSUR;NCt COVERAGE: Pursuant to the requiremants of Ivtassacnuse(ts General La nava a cu(((lt L15bili[ � In '1---- urance Policy including Completed O 'ata prof cr same [o t ofrice. YES NO ( operations Coverage oats subs ntial er uivalant. YES L you nava cneckaJ S, please inaicate t _ - he t • a l )Pe Jf coverage by ehack;n NO !u I heave submin.ad tSURANCE I_ 60ND ❑ OTHER ❑ g the apPIOPnate box. (Please Specify)___ 5[Imato.7 V31Ua of EIvCIlICaI 4VGfk ,�" � _ ofk f0 Start_ - (Expiration Dare) �. gnea unoar InaInspection. Dare Raqu panan'as Jf perjury: es(ad: Rou RM NAME 1 f I (-� >�� /U3 !l ��- C. r �] drass_L 7 -i t / S S19natura y)f LI �0._� U 7 vNER'S INSUR-ANCE WAIVER- I am Rus. tel. No. -a S/ aware Ina[ the Licensee does not have the Insurance Q� "saCna[lj lianefal Laws, and (hat my signature on (his application waives All, Tel Plo. � a N Iflls requirement. ur its subsian[ial 3quivalenf.as required by r�� ---- qulramant. Owner Sign°tura Talo hon Agent (Plaase check one of vwnar or Aram) P 8 IVo.___ p - WIT FEE $�— N2 1899 Ir TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ........... 4 ..../.,..1........................................................ has permission to perform .............. wiring in the building of .... -.1 .................................. at ...11r'�?..r<: p, �". r-. .. ...................... . North Andover, Mass. Fee .... Lic. W2.?1-,.. ...... ............ INSPECTOR 10/06/99 16:17 3100 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer u\ Office Use , a4e %Ommanwealt of musar4usetts Permit No. �— Etpartmtat of Vublic $nfttp Occupancy A Fee Checke BOARD OF FiR9 PREVENTION REGULATIONS 527 CMR 12:00 "0 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dile 9/22/99 City or `Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street b Number) 180 MILL ROAD Owner or Tenant RICHARD GOLDMAN Owner's Address (978) 682-0153 13 this permit In conjunction with at building permit: Yes ❑ No (Check Appropriate Boit) Purpose of Building - Utility Authotisatlon No. ExtstingVervice _ Amps I Volts Overhead ❑ * Undgmd ❑ No. of Meters New Service Amps _J Volts Overhead ❑ Undgmd ❑ No. of Meters i Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Not '116" of LtghWV Fixtures AbovNo. 8wlmmIng Pool grad. ❑ �, ❑ No. of Receptacle Outlet No. of 00 Burners - NoJ Switch Outlets No. of Gas Burners No. ?I Ranges No. of Air Cond. tons No. of Disposals Host No.ol pumps To KW No. of Dishwashers Spece►Ares Heating KW No. of Dryers Heating Devices KW No. of Water Heaters INV No. of No. of SWW Ballasts No. Hydro Massage labs No. of Motors lbtal HP OTHER: ONE SMOKE DETECTOR AND ONE HEAT DETECTOR No. of la swo;srs KV Generators KVA M;a No. of Ernargenay Lighling Battery Unit FIRE ALARMS No. of Zones s; No. of Detection and In kit Devices No. of Sounding Devices No. of Sett Conialned =- Oetsetionf9 m unding Devices LOW ❑ Mw"Pwc t ❑Oth.r tAw Vthltage VArIng BURGLAR ALARM & DEVICES .INSURANCE COVERAGE: Pursuant to tin regWnwwnts of Massachusetts general Laws - 1 have a current Liability Insurance Policy including Compbtsd Operations Coverage or its substantial equivalent YES G NO O 1 have submitted valid proof of same b this Office. YES O NO O It you have checked YES. please Indicate the type of coverage by checking the spproprlale box. INSURANCE O BOND. O OTHER Q (Flew Spedfy) •. (ExpkaUon Oae) Estimated Vatu,e of Electrical Mork Z 669.00 Worts to Start 9/29/99 • inspection Date Requested: Rouoh Final 10/2/99 Signed under the Penalties of penury: LIC. NO. t 41 r! FIRM NAME Licensee nnnwl d A- Urnnks stenature _ - UC. NO.-. 1231G_— Address 111 Morsa Street, Norwood. MA A& W. No. OWNER'S INSURANCE WAIVeR: 1 am aware that the Licensee does not have the Insurance cawrpe or Ila substantial equivalent as ra quired by Massachusetts General taws. and that my signature on this pemA application wetws this repulrernent. Owner Ag!nt (Please ctwck one) ,» Tblephons No. PERMIT REE t .35.00--- - Date........�A/I.......................... 90 Y pORTM TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that....,......P ................... .... ..................... ...... ....... ...... has permission to perform 111'.1 .��.6).,t.i... f.. � YIl.�),I??ZTI.lil..l..(-(�..%/ L wiring in the building of ..:: `. . �� .: � ..,..,.: � .., ....... w/ ............t:�, .. ...� at ...4/ . / .�!! �t..�... ........... ,North Andover, Mass. ...rr. ,, rr .....:................... Fee .. .:.'.Z.'U Lic. No. ��/, fi .k- ...................................................... fa / / ELECTRICAL INSPECTOR Check N V 01 -e t�oryt!lsonWeaLlh O� �adeaCnludel'f.S � OfilCl'Jl UsC illy �t.Japart`narsni< a�..tire �orvice� P, rrrltt N0. Occupancy and Fee CheckedU t! BOARD OF FIRE PREVENTION REGULATION`; [Rev. 11199] Cleave blank) APPLICATION FOR PERMIT TO P4 *ORM ELECTRICAL WORK All work to be performed in accordance with the MassadV`tts 1 k-etrical Code (1NIEC), 527 CNIR 12.00 (PLE.ISE PRINT IN INK'01? TYPE TILL INl"OlUL-I77ONj Datc: Citv or'Town of: 000C 4:s'�; �c��v e� To the Inspector of Wires: By this application tike undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 0 Owner or Tenant�\ t,6 x_44 Telephone No.� 7rl - co'ia - Owner's Addresses , i1 u� CX C z Is this permit in conjunction with a building pernsif? 'Ves No ❑ '(Check Appropriate Box) 1'uroose of Building Utility Authorization No. Existing Service Antps / Aroits Overhead ❑ Undgrd ❑ No, of Meters'. New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters.' Number of Feeders and Ampacity Location and Nature of Proposer! Electrical Work: Completion o_fthe follunbrg tablemay be walvcd by the 1ns00ctor of ]Vires. No. of Recessed Fixtures No. of Ceii. Susp. (Paddle) Fans! a• of Total Transformers KVA No. of Lighting Outlets No. or Hot Tubs Generators KNIA No. of Lighting Fixtures Above n- Swimming Pool ensr3. ❑ rnd. t o. a snergenev Ig r mg Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARIMS No. of Zones No. of Switches No. or Gas Burners t o. ete o ction an Iuitiatin Devices Nu. of Ranges Tot No. of Air Cont. Tons Na. of Alertissa Devices No. of Waste llis Diens p . eat Pump Totals: s umber Tons No. o elf ontainc Detectiou/Alertine Devices _1 - No. of Dishwashers Spactdeirea Heathig XNV Local ❑Municipal0 Other Connection No. of Dryers Heating Appliances KNy ecUrity ystenu: No. of Devices or Equivalent No. of Water Heaters heti t o. o t o, o Sioiss Ballasts Data Wiriu No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Rlotors Total HP Telecommunications Wiring: No. or Devices or E uivalent OTHER: Allach additional delail lJdesired, or as required by the Inspector of Wires. INSURANCE COVEEUkGE: 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 e:tln'bited proof of same to the permit issuing office. CHECK ONE: INSURANCE� BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estitimted Value of Electrical Work:. —70D.— (When required by municipal policy,) Work to Start: a Inspections to be requested in accordance with MEC Rule 10, and upon completion. I ceriif}-, un tier the pains and penalties of perjury, that the information on this application i, true and complete. FIWNI NAME: AA I VN v C,,'-Ci2 e. LIC. NO.:�A aN1 Licensee: �Ao r K. k� .. Cr�� a� 2 Signature . �i 0.: 'j (lf applicable, enter "ercuipt" in the lrcennse ntmtber tine.) Bus. Tel. No.• Seij O Address: �i \ a'- �.. t Z '�� O �ti Z Alt. Tel. No.: ' Y a '` )1. � OWNER'S I SU aNCE 1VAiV t: i am a�tarc flint the License, does not hate the liability insurance coverage normally required by law. BY sny signature below, I hereby waive this requirement. I am (lie (check; one) ❑ owner ❑ 0%viler's agent. Owner/Agent �1, 25D -b-7) Signature 'I'clephone No. RMMU E: 5 Date.9-..,.,?-: e'' No 454'4 TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING 'tr +0+, n ° .• `,fig ,SSAcmus This certifies that .. Y. !... ...................... has permission to perform ..w-'''�—'!'''............ plumbing in the buildings of, ........ ................. at .../P.... ?`• ... — .......... , North Andover, Mass. Fee�.5...'F.. Lie. No........ . .I .. / . .............. . PLUM IN' INSPECTOR Check # j/ WHITE: Applicant CANARY: Building Dept. PINK. Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print o Type) �JQ AIW(Wr Mass. Date'_ Permit # •� Building Location !' Owner's Namellv" (n4��� ype of Occupan _ , New Renovation ❑ Replacement ❑ Pla Submitted: Yes ❑ No El SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STSTHFLOOR �__ 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name C ck one: Certificate Addfess Corporation ❑ Partnership Business Telephone /1- Firm/Co. Name of Licensed Piumber INSURANCECOV RAGE: I have a current ' bility 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 coverage by checking the appropriate box. A 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 Fmit application waives this requirement. heck one: Signature of Owner or Owner's Agent Own ❑ Agent E3 I hereby certify that all of the details and information I have sub (or e t e in a ve ap lication are true and accurate to the best of my knowledge and that all plumbing work and installations performe nder p rmi ed f t ' p ' atio will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code - nd Ch pt 2 - t e G s Title Signature of License umb City/Town Type of Licens : Master urneyman APPROVED (OFFICE USE ONLY) License Number i (n Z �n N Z O Y Z Q y N (/JZ N Q ¢ a x O y tt ON W N f- fn W T y cc v rt W y ur Y a N O - x d z a V � W O D ¢- N W F- W W o Q to a < x o Q 3 F- Y < J Q m+ 11 = Nl 1I1 N O� y> > N O Z O O N Z W H O Q S p -j 3= N N, LL C7 O Q� 3 m O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STSTHFLOOR �__ 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name C ck one: Certificate Addfess Corporation ❑ Partnership Business Telephone /1- Firm/Co. Name of Licensed Piumber INSURANCECOV RAGE: I have a current ' bility 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 coverage by checking the appropriate box. A 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 Fmit application waives this requirement. heck one: Signature of Owner or Owner's Agent Own ❑ Agent E3 I hereby certify that all of the details and information I have sub (or e t e in a ve ap lication are true and accurate to the best of my knowledge and that all plumbing work and installations performe nder p rmi ed f t ' p ' atio will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code - nd Ch pt 2 - t e G s Title Signature of License umb City/Town Type of Licens : Master urneyman APPROVED (OFFICE USE ONLY) License Number m m m M.H. Falardeau Electric 17 Blue Jay Way Litchfield, NH 03052 Phone (603) 595-6680 Ma Lic 37294E Fax (603) 8824115 Ma Lic 912MR NH 11131M February 2, 2004 City Of North Andover Electrical Inspectors Office 27 Charles Street No. Andover, MA 01845 Dear Sir: An electrical permit is needed for the following address (Goldman, Richard & Holly's Residence, 180 Mill Road, No. Andover, MA). A copy of my insurance binder is enclosed to update your files along with a check for $30.00 made payable to the City of North Andover for this permit. My Electrical License Number for the Commonwealth of Massachusetts is #37294E and #912MR. Kindly mail the permit to Mark H. Falardeau, 17 Blue Jay Way, Litchfield, NH 03052. */p Thanking you in advance for your timely handling of this matter. Sincerely, Mark H. Falardeau cc: Champion Room r y Location No. _ I V 0 %d t X0,0 3'-iq Date 14ORTN TOWN OF NORTH ANDOVER � OL Certificate of Occupancy $ s,cHust<Building/Frame Permit Fee $ y 3b Foundation Permit Fee $ Other Permit Fee $ — D � TOTAL $ Check # ! a 0 Am (�¢�.---- 16933 Building Inspector 1.1 Property Address: 1.2 Assessors Map and Parcel 107 C Map Number Number: 060/ Parcel Number 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Rzqtlired Provided R 'red Provided Yo)- ss- �6 1.7 Water Supply M.G.L.C.40. 54) Public ❑ private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone . ❑ 1.8 Municipal Sewerage Disposal System ❑ On Site Disposal System ❑ NULL MINL-YKUYEKIY UWNEK5nW/AU'JMU1UMDAGENT Historic District: Yes No V 2.1 Owner of Record �- Name (Print) Address for Service: A- _ Signature Telephone 2.2 Owner of Record: Name Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ #� cS— ncensed Construction Supervisor: 7 7 7 Z �J License Number G � .�ilt�Kw o �/J ,.4 ✓ , Address Expiration Date e Telephone ' 3.2 Registered Home Improvement Contractor Not Applicable ❑ ���j.Yt�i cam✓ � ?-/ � Com"ny Name �2 7/7 Registration Number Oil% /l� �< <.rs-r. c cwt Address l 7Y 3 �� Expiration Date I 0 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 buoing permit. Signed affidavit Attached Yes ..... No.......❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑Alterations(s) ❑ Additio Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be lop Completed by permit applicant r� N s n 1. Building (a) Building Permit Fee Multi Tier 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 VE Check Number SECTION 7a OWNEK AUTHOKIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWr Date act on 1, C Z— — as Owner/Authorized Agent of subject prope 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 Date 168. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3RD SPAN DIMENSIONS OF SELLS 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 If 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`** -k**-***-*-**-** APPLICANkPHONE7/�Y(';'Z66 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET<< ST. NUMBER ***********************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIS TOR DATE APPROVED DATE REJECTED, II / COMMENTS h= d 1�0f Cfec9 �� TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm A DATE f r` kAnnTGAGE INSPECTION FLAN ' AOuv . � ,tip cf' _.► i THIS PLAN IS BASED ON A TAPE SURVEY (WT AN INSTRUMENT SURVEY) AND IS TO BE USED FOR MORTAOE PURPOSES ONLY. THIMPFOAE. THE OFFSETS AS SHOWM SHOULD NOT BE USED TO ESTABLISH PROPERTY LINES.r._ --r'T COUNTY Q ILI 46ii O r - - ---------- Q Customer: gni nnA A AI A WALL D D 0.625 + 4.125 (fill) + 0.625 + 63.5 + 5.0625 + 63.5 + 6.5625 = 144" B WALL W W W W D 6.5625 + 2.2188 (fill) + 0.625 + 63.5 + 5.0625 + 63.5 + 5.0625 + 63.5 + 5.0625 + 63.5 + 0.625 + . (fill) + 6.5625 = 288" C WALL W W 6.5625 + 63.5 + 5.0625 + 63.5 + 0.625 + 4.125 + 0.625 = 144" City: hnS#nn Job Number: 2241 Order Date: 10/31/03 FACTORY DIRECT QSINCE 1953 ' WINDOWS, • SIDING PATIO ROOMS To / � �Al �f(J 07VI Countylrvmshp City At. 10& ACkWt StateAL— Trp 6/EVE CHAMPION WINDOW CO. OF BOSTON NORTH LLC. 35 Dunham Road • Billerica, MA 01821 978.663-1495. 1-877-846-3699 M.I.C. 127172 / T.I.N. 58-2442642 Date 2• d 3 Home Phone g • �� ` 0 �S Business Phone (Mr. / Mrs.) Replacement Windows • Storm Windows & Doors • Vinyl Siding, Trim & Shutters • Glass & Screen Patio Rooms • Entry & Patio Doors WHOLESALE & RETAIL PATIO ROOM CONTRACT CHAMPION TO MEASURE, MANUFACTURE, FURNISH AND INSTALL THE FOLLOWING CUSTOM MADE PRODUCTS FOR THE AMOUNT STIPULATED BELOW: O Champion To Build A Patio Room With Outside Dimensions Of Approximately A X B: X C: O Champion To Build A Screen Room From 2' Components With outside Dimensions Of approximately a X B: X C: PECK OR SLAB /%(� YES NO Y N❑ Room Deck Approximatetyl� ' • X Material �/ w Z ❑ 13 Under Customers Existing Roof _, Open Deck Approximately�X/ Material ❑ a on Customers Existing Concrete slab ��,`/ ❑ O On Customers Existing Deck h Steps: Wood O Concrete O Approx. Number Risers 10 n Gosed ❑ Tee O Tear Out Existing: Slab ❑ Deck)( O O Railing Approximately Material O ❑ Footers For Existing Slab ❑ O Skirting Approximately Material ❑ O Tear Out Existing: Walls O Screens ❑ Roof O Rails ❑ O ❑ Pour New Open Concrete Slab Without Footers Approximately X O 0 3fV Tongue & Groove Sub Floor O ❑ Pour New Concrete Slab With Footers Approximately X AAD Champion Patio Room wall systems consist of a series of sliding aluminum windows on top of an approximately 16' tall knee walls andlor full view sliding doors (see layout). Windows and doors include dual locking system, anodized aluminum threshold, synchloc k interlocks, stainless steel wheels and sliding screens. Champion to determine exact size of units at final field measure. Al glass is tempered safety glass, and all walls include build -out and leveling system as necessary. NO HOUSE O Super Frame, Wing & Trim Color: White O Tan O Bronze 0 O O 3116' Triple Strength Non -Insulated Glass O Double Pane Insulated lass O Low -E Insulated GW9L Solar -Green Insulated Glass O 1 t� ❑ Fixed Glass Knee Walls Lavation: A O B O C O /S �L f O O Knee Wal w/Aluminum Skin (R-19): White O Tan O Bronze O C O Knee Wall w/Vinyl Skin (R-19): Whit�Tan O A O O Build Up O Build Down ❑ Location: A B O C O ❑ ❑ Fixed Transom Glass Location: A ❑ B ❑ C O 0 O Lacking Sams LAYOUT SKETCH OK O Cap Exstimg Posts X = ACTIVE 0 = FIXED O O Key Lock = FULL VIEW O O Sliding Screen Room System (No Glass) = KNEEWALL S 111111QOF expanded poly -styrene insulated foam (R-19) with an embossed laminated aluminum skin and tthermallyChampion's superfoam roof system is a nominal 4'(R-19) or 6' thermally broken I -Beams VKS NO YES NO O Gutter & Down To Grade + �` CWra►rlst- f� , ❑ O Studio Roof System Color. White Tan ❑ 4'CI 6' ❑ Spout h 1iOn' O Gable Roof System Color. White Tan ❑ 4; 6' O Shingles (To Match As Close As P bite) O O Gable Gloss Wing Glass O Number 01 Pieces:� O Skylights: Vented O Non VentedQuantity:� M� ' ❑ O Gable Tie-in ncludes Shingles On Saddle Only And Vdffical inyl F inside Of Saddle) DOORS YES NO 6 O O Storm: Outswing Color Style Left Hinge ❑ Right Hinge ❑ OSU O ❑ Entry: Inswing ❑ Outswing O Color Style Left Hinge ❑ Right Hinge ❑ OSLI 45 OTHER YES NO YES NO ° ❑ O Heat/Cool Unit O ❑ Carpet — X _ Color Cut To Fd Loose Laid ❑ ❑ Blinds: Color ______^ SfyleHeiht Location: AD B O C O 13 Electrical Package (Including4Tau-�;;-5Wag Switch(es) & Q Hook Ups Of Customer Provided Ceiling Fan With Wire Mold)COMMJ Interior Rokif Slooes To "ImI ft. Aftaclies To House: Wall ❑ Gutter Board ❑ Fascia aht ft 0. ' 00, ! grAlMWWD •- � D1�•DS'Ki RiSG�►•� AND s'tAN� 710C1�: Im ST%►'l�st�� 00� COQIWN low •&�J ivatslwewm�e (M Q%gars ������� # - -A-I� aft M� do& X01 k got= Boom md MONO"or pemoos �� •aooi'°lwd aN■� � .i��eems� ww,i000" adoo• .. aelo�dromeo�aios��aree�apiwr�enoP�O°o � i�:11a4 sod atiea�4�ormom • T�eatf�■t • Lrrrrs"�rr • • 8als Yot iMa was" • �rli■ta•dpdmft MOW'sW md Ire - • ����� �saNddo 8.oftsiOoel UdbWr- '�mom !'�iiartCom — a!s !ad's for s� (Mfg law A/�ior�S�oaSloj�ot gnaw owmetowkwasw I U'7A1 i, pop 0 vwwmmw AFFiDAOT . too a DOW • df #A . - - - - ... �� �animzoOE o�✓�aeoda�uaelld i j Board of Buildlug Regulations and standards — s ROME IMPROVEMENT CONTRACTOR Registration:. 127172 Expirabow 9115/2004 sSu ement Card . �. : type: PPI CHAMPION WINDOW ATJO 32` jlfw , �Mft { 35 DUNHAM RD., • BILLi:RICA, MA 01821 Administrator t MOM CERTIFICATE OF LIABILITY INSURANCE 01/22/2003 PRODUCER (513)421-6515 FAX (513)421-0130 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Walter P. Dolle Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON T*E CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 201 E. Fifth Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 1000 INSURERS AFFORDING COVERAGE Cincinnati, OH 45202 INSURED C is pion Wind= Co. or Boston norZn, LLL INSURER L11MF%] MYl-YY. i95 ......r---, 35 Dunham Road INSURER Firm's Fundq Billerica, MIA 01821 INSuRERo. St Paul Fire & Marine m)RERC Chubb & Son Ins. Co. INSURER I - COVERAGES 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ATE MAY BE ISSUED OR "AV 0==re1U TWO thMNIPANCF AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS, OF SUCH POLICIES. AGGREGATE L$IIITS ZKOMMAY =NA- LTRTYPE OF INSURANCE POLICY NUMSER -541-434193-012 12/01/2002 12/01/2003 LIMITS `EAcH OCCURRENCE s 1,000,00 Gr�ERAL riAelLRir . ' 00 FIRE DAMAGE (Any ane faro) _ S 250, X COMMERCIAL (NERAL UA8ILITY f 5,00 CLAMSMADE Q OCCUR MED EXP (Airy Otte pelsoll) PERSONAL& ADV INJURY S 1,000,00 A GENERALAGGREGATE - S 2 , 000 00 PRODUCTS. 00%~ AGCi S 2 Off, OO GE 'L AGGREGATE LIMIT APPLIES PER: POLICY PFtO-LOC AUTOEtroB+LE LIABILITY 541-434162-012 12/01/2002 12/01/2003 COMSI NED SINGLE LIMIT . f (�> 11000,00 X ANY AUTO ALL OWNED AUTOS WPLeY INrsonJU)RY S (Pbt p A SCHEDULEDAUTOS X HIRED AUTOS SO $ NON4"ED AUTOS DAMAGE $ F] (Pette � bdalm' AUTO ONLY -EAACCIDENT S GARAGE LIABILITY EA ACC S AOTHER NY AUTO THAN AGG $ XYZ96979653 12/01/2002 12/01/2003 EAcH OccuRRENCE S 5,000,00 AGGREGATE f S'000,00 EXCESS LIABILITY X � CLAIMSMADE s OCCUR B S S DEDUCTIBLE • RETENTION S v aPLaRSAtLON AND2m EMPLOYERR� umurr •' 12/01/2003 TDRr uMETs L3R E.L. EACH ACCIDENT S 1, COO, OQ E.L. DISEASE - EA EMPLOYEE S 1,000,00 f �" E.L. DISEASE - POUCY LWH f 1 000 00 �== 9615100 12/01/2002 12/01/2003 510.000,E Limit ER cess Liability B DT:SGKIFTWIfururclutIn row. -.., - HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OESCRLBEO pOUCW .S 8E CANCELLED BEFORE THE EXPiRATM LATE THEREOF. THE ISSULNG COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRLTTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR uABII.RY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPR6Se0ATNE7 TO WM MI IT MAY CONCERN I•"•�•,•,•••"•••.`r"`"`" ._ iAA —C Cl) m M m m 5 m y 'O C � C0CD n n Z H CD O 'O CL r n� c 21. =C cm S. CO) >to -0 � o � C .0 CD CD o cr WC W CD CCD o CSD ww � C CD yCD� Q C CO) �• o co CD a v CO) O '0 Z CD n �« CD o 0 CD O —• ce cr H �O c m -0 y E 0 m n CM Cl) no 3 m Z CO�-C C 0, .O►� �:m C T =r CLCD m CA O m m a O C VC um O C ••► O C y n W �oCD � Au ' i� a CS. to o � Om CO) Cd1 m ►--� c n m N •� cn o -CL c^o d o Q H C to E CD y ® o. CA CD z �oZ CD wow C CD � m CO2 a) 954 r: bCL CD apCD o tw cn� o rD (D rt o .� d 9 4 w cp rt r oGv Ci7 � w l"' w as O w � � cn cnITI (D O A x ro 9 o p M c C 0 � M rA rAV 1 0J