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Home My WebLink AboutMiscellaneous - 181 CORTLAND DRIVE 4/30/2018I µ• eTH 1 a 8S4CH°SES CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 669-2011 Date: October 13, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON 181 Cortland Drive, North Andover, MA 01845 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: Meetinghouse Commons Building Inspector Fee: 100.00 Receipt: 1416 (A m m m m m m CD m m CO) CM) CD 0 Z COD a r O .0. a? c 0 o C.) 0 CD CL cr =r CD CD 0 0 w w a . CD CO) CD CL a) CO) CD B7 CO) CD CD z CD CD .00 4) cn V n 0 z I �-i cn wg= O S. W 3 Cy. y m E -L o SO CO2 O CL m C-) m Z =r CD -400 C)910D CD CD o to IM: 0 z Cc) O co 0= -coo (A pa CD :1 Cro 0 0 CL 0d CA cr CR S. 0 CCP CA C<D to a coo IE C4)Q:v o CO) cio -,mom-: CD 0 rF 0 =r CD 0 "0 L0 CD. CD 6 %v CD 0 o CD: Im CL -S: 12 0 0 CD: �Acn cn o � Q C/) M -4 ir M p 0 .00 0 rp ir O zry cp �i 0 0 tz 01 If CAMTM GO =mom& 0 SlIkk NO 0 � Q z -4 ir M p SlIkk NO 0 0 -4 ir M p V4 GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame; Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filter/coverand outlet connection; FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls'. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations YS" air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. `F Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). r Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior, (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. '/ of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36— high, Baluster max space 5" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall_ post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure. APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION Building Permit # 6 6 q ADDRESS/LOCATION OF PROPERTY: /8/ 60 rfIg 4 fyiv Map ! C Parcel 3 Lot Number SUBDIVISION MiffilA, r - m dh.S U DATE REQUESTED FILED/READY FOR INSPECTION '0/7/16 ' CLOSING DATE ON PROPERTY: 10/1 q 110 FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENiw' DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. Permit Issued to: �4 l +4OUe (zvmmons LL Address t' 5 CadeP F)-� . M, ADCC. AA ROUTING r�l?fro CONSERVATION PLANNING N I A `C"� 0 DPW - WATER METER SEWER/WATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYIINSPECTION REQUEST DPW )�nAo � Signature File: AppNcation for OC form revised Jan 2007 x 1 Date ...6? .. . . ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...........k ...... �)ov ............................... has permission to perform....... 4x.uJ ..... kok).S.F ..................................... wiring in the building of.. . ...............1-..( . ... ..................... at ........ A.......... �A ......... North Andover, Mass. .,.q 4� ............ .......... ELEcmcAL INSPiCTO Check 9379 R commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ qA `7G�* Occupancy and Fee Checked Lev. 1/07j APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C R 12.00 (PLEASE PMT rAW OR TYPE ALL INFOJUMTJOA9 Date: City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her intention t erfomi the To the el� c work Wires: below. Location (Street & Number) Owner or Tenant Owner's Address Telephone Is this permit in conjunction with a building permit?` Purpose of Building Yes fil NO Li (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 04�0 Amps 1 / Volts Overhead ❑ Undgrd5�r No. of Meters 02 Number of Feeders and Ampacity jr �Q/ , , . _ �,,,,.., _ I , —�� Location and Nature of Proposed No. of Recessed Luminaires of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW INo. Hydromassage Bathtubs i _ trical Work: Completion o the ollowin No. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above Ig_ d. ❑grud.J❑ No. of oil Burners No. of Gas Burners No. of Air Cond. Total eat Pump Number Tons ns KW Totals: --. .._ .._.__... ..._._......�.. Space/Area Heating KW Heating Appliances KW No. of No. of _Signs Ballasts . No. of Motors Total HP table maybe waived by the Inspector o{Win l:T0. of Total Transformers KVA Generators KVA o. o mIII rIII ig g Battery Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Alerting Devices o. of elf -Contained Detection/Alerting Devices Local ❑ Municipal Connection ❑ Other Security Systems: * No. of Devices or Equivalent )ata Wiring. No. of Devices or Equivalent [ elecommumcanons 1i NO. of Devieeic nr Tl..:voto-4. Estimated Value of Electrical Work: �– Attach additional detail if desired, or as required by the Inspector of Wires. Work to Stark (When required by municipal policy.) 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 c v rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER I certify, under the ains and enalties o ❑ (Specify-) p fPmlury, th the information on this application is true and complete. FIRM NAME: �,� LIC. NO.: Licensee: ir;i7 Signature c (If applicable, nter "exempt " in the license number line.) LIC. NO.: C Address: t.< <� ty 1 Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work reqly uires D P Alt. Tel. No.. OWNER'S INSURANCE WAIVER: I am aware thatl eI Licensee does not Safehave the 1liabilityLic. Noco . required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner 0 verawner's a-ent. Owner/Agent Signature Telephone No. PERMIT FEE: $�, N 11 r E The Commonwealth of Massachusetts Department of Industrial Accidents Office of .investigations 600 Washington Street Boston, AM 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl, Name (Business/Organization/Individual): (v, Ciiy/State/Zip: ��//! Phone #:�7,r 9 ;/fes � Ar ,U,Wlain employer? Check the appro 'ate 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 I ship and have no employees These sub -contractors have working for me in any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] office h ! 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t rs ave exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees_ [No workers' comp. insurance required.] `.any applicant that checks boy. #1 dust also fill out the section below: shon!ia * +; q wori' t Type of project (required): 6. ew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' omp. policy information. I an employer that is providing workers' compensa information. tion insurance for my employees Below is the policy and job site � Insurance Company Policy # or Self -ins. Lic. #: /% 13 Expiration Date: v Job Site Address: % , ... City)State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci pains and penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance.. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current ' policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the i applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesiigaiions 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 vmr"7.rnass.gov/din Date. ,OR'r" ' TOWN OF NORTHAND ER PERMIT FOR PL BING -••SACMUSt� /j,, / �/ This certifies that .. i%!(./ .../ ...... .................. has permission to perform ......1?1azt/ .... 14,0"_aa.......... plumbing in the buildings of ........ �'2i1.A.: at ...../9Z .... AV,-.{�G°?. ... ......... , N rth Andover, Mass. Fee�r �Pu... Lic. No..../ 57........ ....... . PLUMBING INSPECTOR Check #�� ✓ 86u� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location % ' /0�) V Owner 4'M New 0 , . Renovation ❑ Replacement ❑ +a & 1W 17 Date / f) Permit # Amount Plans Submitted Yes ❑ No (Print or type) Installing Company Address Name of Licensed plumber: Insurance Coverage: Indicate Liability insurance policy Check one: Certificate ❑ Corp. G ❑ Partner. ❑ Firm/Co. �C of insurance coverage by chmkang the appropriate box Other type of indemnity ❑ Bond rl 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 Signatm Owner ❑ Agent ❑ 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 Massachusetts State P b' Cod 142 of the General Laws. By. �� 7S7nAmr n n Title Type of Plumbing License City/Town / ,,Z/5 7 rcense umoer Master ' �jss�" Joumeyman ❑ APPROVED to�ieE USE ONLY ee __ r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location % ' /0�) V Owner 4'M New 0 , . Renovation ❑ Replacement ❑ +a & 1W 17 Date / f) Permit # Amount Plans Submitted Yes ❑ No (Print or type) Installing Company Address Name of Licensed plumber: Insurance Coverage: Indicate Liability insurance policy Check one: Certificate ❑ Corp. G ❑ Partner. ❑ Firm/Co. �C of insurance coverage by chmkang the appropriate box Other type of indemnity ❑ Bond rl 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 Signatm Owner ❑ Agent ❑ 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 Massachusetts State P b' Cod 142 of the General Laws. By. �� 7S7nAmr n n Title Type of Plumbing License City/Town / ,,Z/5 7 rcense umoer Master ' �jss�" Joumeyman ❑ APPROVED to�ieE USE ONLY ee __ I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 K'ashing ton Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DDlivant infnrmai;nn Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate boa: 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and 'ts required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 1 Officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] ?. "ny applicant that checks box *1 must also fiU out fhe section beim, ^`'"Wb etr wort;' Compensation Policy iniorra tion. Homeovrnes who subsit this affidavit indicating they are doing all work and then hire outside contractors m 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' compensation insurance for my employees Belom, is the policy and job site information. 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 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 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 andpenalties ofperjury that the information provided above is true and correct Signature: Date.: Phone #: [[6. ficial use only. Do not write in this area, to be completed by city or town official ty or Town: Permit/License # uing Authority (circle one): Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Piumbing Inspector 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 incu_rAnce requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 - v vm,.mass._gov/dia M • Date ... `.) !. / �i f 0 .. . NpRTFi TOWN OF NORTH ANDOVE F PERMIT FOR GAS INSTAL ION This certifies that ... M.- 14/. (�..... &A ........... has permission for gas installation ... /)/` PJ el .. ��?��.5 ........ i, ! , k in the buildings of .... ,.4 !'y? .Q <.��d. ................. at ...6( ...... . V ......... Noy h Andover, Mass. Feel,/ O.q... Lic. No.. /, .�� .% ..... �!� ...... ........... . GA�INSPECTOR Check # 72+d MASSACHUSETTS UNNORMAPPLICATON FORPERMITTO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations �� / I/j�lQ-,kjnC Owner's Name New enovation ❑ Replacement ❑ Plans Submitted Date / U Permit # Amount $ J w U o w a C v m x cZ °o z Gx w a w c a H. H z H w C7 w> w a Q o w o H r4 w x O 3 C U a U o° a > o w O SUB -BASEMENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 83'H. •FLOOR EL (Print or type) Address Name of Licensed Plumber or Gas Fitter {JjL� Check one: Certificate Installing Company I �; ❑ Corp. �� P ❑ Partner. / S ❑ Finn/Co. INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 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 Massachusetts State Gas Code and Chapt f2y,(& General Laws. (Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter. ❑ Plu r as Fitter License um er Master ❑ Journeyman 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 nnliennt Tnfnrrna"__ 1 Name (Business/Organization/Individual): Address: City/State/Zip: 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. ❑ I am a sole proprietor or partner- listed on the attached cbPPf t ship and have no employees working for me in any capacity. [No workers' comp. insurance 5 required.) ❑ 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.) `.2'f' applicant that ehecL' box #1 must also fill out the section be. w sh^wi ^ thar 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 Homeowners who submit this affidavit indicating they are doing all work and Hien hire ers conm= on policy information. outside contractors must submit new affidavit indicating such. $Contactors that check this box must attached an additional sheet showing the_ name of the sub -contractors and their workers, comp. policy information. I am an employer that is providing workers' compensation insurance information. for my employees. Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement 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 Signature: Date: Phone #: F fficial use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): I. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information an d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house ., or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be .:,tuned 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street: Boston, MA 02111 Tel. # 617-727-4900 ext 4,-06 or 1-877-MAS.SAFE Fax # 617-72.7-7749 Revised 5-26-05 vi-Aru7.mass._ bov/dia Date ..... :... ..3.: OF TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that < has permission to perform/ �r �'� 5-xxU ............................................................................. wiring in the building of L ��Qa1at .....`.I.......... . ' .............. orth Andover, Mass. " iee......... Lic. No. /�/S"/.............. L�l./l1 LF. CTRICAL INSPECTOR d } Check # —Lu—, -3k r/ 8373 Commonwealth of Massachusetts NEW Department of Fire Services \VJ BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 0 3 73 Occupancy and Fee Checked Lev. 1/07] t1PauP l,lanlrl APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (PEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: q Z, -L or City or Town of: NORTH ANDOVER To the Insp— e for of Wires: By this application the undersigned gives notice of his or her intention to pe orm .the el cal work described below. Location (Street & Number)tek C0vCT A, `, Owner or Tenant Owner's Address C N' Telephone No. &Fr7 -" Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Boz) Purpose of Building ' LCL Utility Authorization No. S-3 -7 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Ldc% Amps LIn volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: SCkyt cz Com letion o th ll bl No. of Recessed Luminaires e o owtn No. of Ceil: Susp. (Paddle) Fans to r .,,may ue watvea oy the ins ector q1 wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above❑ n- ❑ o. o Emergency Lighting rnd. rnd. BatterUnits 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. TonTots No. of Alerting Devices No. of Waste Disposers Heat Pump Number .Tons No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances I Security Systems:* No. of Water No. of No. of No. of Devices or Equivalent Heaters ICS' Signs Ballasts Data Wiring: No. of Dvices 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 o Elec 'cal Work: 7,0o. (When required by municipal policy.) Work to Start: 7, -LA Ot 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 Iicensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such e a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE co[BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: ,p , f hln l A r .L�-GC� Z•( (C.4 C _-S(=�t1d —S LIC. NO.L�L,� Licensee: �LW4+48;(� Signature LIC. NO.: (,:7,72, (If applicable ent "exempt " in the lc e number line) Tel. No.: YC/ v�a57%�s' Address: 66 ; uTel. No.: ) (�it� *� *Per M.G.L c. 147, s. 57-61, seclarity work requires Department of Public Safety "S" License: Lie. 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: $4�4w