HomeMy WebLinkAboutMiscellaneous - 181 JOHNNY CAKE STREET 4/30/2018 (2)Location /j/—� —=-�
v �-
IN No. ��/ Date y
MO*Th TOWN OF NORTH ANDOVER
3?O:
.,,go, 1.�0
O
A
i
+ ; ; Certificate of Occupancy $
Building/Frame Permit Fee $
/ su,wsE
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspe
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE. OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUKDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/I r of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address: /
1.2 Assessors Map and Parcel Number:
lo 7 4
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
ReqWred Provide red Provided
R red Provided
1.7 water Supply N.G.L.C.40. 54) 1.5. blood Zone Information:
Pubes ❑ private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSI3IP/AUTHORIZED AGENT
Historic District: Yes _ No _
2.1 Owner of Record
Name (Print) r Address for Service:
.A
!gnature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SEC,TION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Su sor:
Licensed Construction Supervisor:
[ 1 e��i„ � `�� n�
Address J `fJ /`G
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (M G.L C 152 & 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all
a Ucable
New Construction ❑
Existing Building ❑
Repair(s) ❑Alterations(s)
[IAddition
❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief �Description of Proposed Work: ' t 7 "-'Zoe-07 A'0�
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OI±<FICIAJL USE t3NLY
1. Building
L-/ -0 b 0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
;/
Building Permit fee (e) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner / Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
//
7�1 S�
Prr N
Si a er/A ent f
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST2 3RD
SPAN
DINIENSIONS OF SILLS
DEVIENSIONS OF POSTS
DAIENSIONS 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
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BURDING PERMIT NUMBER DATE ISSUED:
SIGNATURE:
Building Commissioner/1r of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Numbs
1.3 Zoning Information:
Zonis District Proposed Use
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
R red Provided
1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
,dx � A& T ycm4;o Oct
Name (Print) Address for Service:
•r
Signature Telephone
i
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Su sor:
I ,7�Ie/)elA��/
Licensed Construction Supervisor.
Address
741 —?A3
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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M
NORTH ANDOVER BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
Tel: 978-688-9545
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed bf in a properly licensed solid waste disposal facility as defined by MGL
11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
Fire Department Sign off:
Dumpster Permit
(Locatidn of Facility)
Signature of Permit Applicant
Date
�N The Commonwealth of Massachusetts
Department of Industrial Accidents
' Office of Investigations
up,
�' •'` 600 Washington Street
Boston, MA 02111
o
r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: 107" (j 44V
e,,7 Phone #: Zj'�,
Are you an employer? Check the appropriate box:
. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. I
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. 21 Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 l.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #11 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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. Below is the policy and job site
information.
Insurance Company Name:" s-�a epi / Z,4. UIA-�p
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: U/ 14tka_ g/j/jam_ City/State/Zip: tl ;
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:
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 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 (LLA) 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 pen-nit/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 Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
August 9, 2016
THEN DRfFOLOQ�dD[E Df�JG�RAG ROUP
v
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner, or Inspector of Buildings
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Board of Health or Board of Selectmen
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Fire Department or Arson Squad
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
RE: Our File No.:
P1613579
Insured:
KIMBERLY INCAMPO
Address:
181 JOHNNY CAKE STREET, NORTH ANDOVER, MA
Policy No.:
H1666002A
Loss Date:
08/05/2016
Loss Type:
Building or Other Structure Damage
A claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be
applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct
it to my attention and include a reference to the captioned insured, location, policy number, loss
date and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any
type against this property, and the claim will be paid in our customary manner.
Sincerely,
William Lamb
Manager, Property Claims
1-800-688-1825 x1137
NORFOLK & DEDHAM MUTUAL FIRE INSURANCECO.we
222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109
DORCHESTER MUTUAL INSURANCE CO.Telephone: (800) 688-1825
FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818
9461
Date... .......:y�.:... /1,.
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
This certifies that En .l!�,�% �L�T
.......................... .............. ...........
has permission to perform .........9k�uN.�T
. ...........n ................... ........................
wiring in the building of G /I v
.........................................................................
at l��ONNIJ �,rj(C� �1/ „ , ,North Andover, Mass.
..............................................
1'
Fee ... `-Zr......... Lic. No. �0.� ��'[........................................
q� ELECTRICAL INSP CMR
Check # CD J
e
�N Commonwealth of Massachusetts
UM IV Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
Lev. 1/07] (jravP hl�,.Ll
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC); 527 CMR 12.00
(PLEASE PRINTIIV INK OR TYPE ALL INFORMATION} Date:
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 the electrical work described below.
Location (Street & N ber) /7A
Owner or Tenant n/,J
n /t_ A r,., � d T 1
Owner's Address S A ry-,
e ephone No.
Is this permit in conjunction with a building permit? Yes
❑ No (Check Appropriate Box)
Purpose of Building % - -—
Utility Authorization No.
Existing Service Amps / 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:
00,
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
F
Waste Disposers
Dishwashers
Dryers
Water
Heaters KW
` INo. Hydromassage Bathtubs
Completion o the ollowin table may be waived by the Inspector of Wires.
No, of CeiL-Susp. (Paddle) Fans o. of Total
formers KVA
No. of Hot Tubs Trans
Generators KVA
Swimming Pool Above In- o. o mergency ig g
d. ❑ d Batte Units
No. of on Burners FIRE ALARMS Ivo
• of Zones
No. of Gas Burners No. of Detection and
Initiating Devices
No. of Air Cond. Total
Tons No. of Alerting Devices
Space/Area Heating KW
Heating Appliances KW
h1o. of No. of`
Sins Ballasts.
❑iviuntcipa(
ConnCTjt ❑ Other
No. of )Devices or Ea
of
of Motors Total HP I Telecomm,n cations
No of Devices or
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start(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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER
❑ (Specify:)
I certify, under the pains and Wallies of perjury, that the information on this application is true and complete -
FIRM NAME: Q J
Licensee:, l'1'� LIC. NO.: G3(0
Signator
(If applicable, enter "exempt 11 in LIC. NO.: / %
,the license n m er !i e.)�
Address: C (� �. Bus. TeL No.:
*Per M.G.L c. 1 , s. 57-61, security work requires Dety Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the License does not have,the liabili Lic. No.
required by law. B m signature y q liability insurance coverage normally
By y gnature below, I hereby waive this requirement I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office Of rftvestigations
600 Washing ton street
Boston, M4 02111
www-massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
�nplicant Informafion
DL__-- V' - — -- -
Name' (Business/DTymization/Indididual):_�'"�
Ad&l -ss:
City/Sate/Zip:
G zi0
6 7 D Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a
TyE
f project (required).--__
(full and/or part-time).*
2.2 ' *1am a sole proprietor or
gneral contractor and Imployees
have hired the sub-contractors6
listed
New construction
partner_
ship and have no employees
on the attached sheet t
These sub -contractors have
7• ❑ Remodeling
worlang for me in any capacity. �•
workers comp. insurance.
8. ❑Demolition
[No workers' comp. insurance
5. ❑ We are a corporation and its
9. ❑ Building addition
required.]
3. [� I am a homeowner doing all
officers have exercised their
10 -0 Electrical repairs or additions
work
myself. [No workers' comp.
right of ex emption per MGL
C. 152, § 1(4), and we have no
11-0 Plumbing a,�
� 07 additions
insurance required.] t
employees. [No workers'
12.7Roof =a -
comp. insurance required.] 13•❑ Other
'Amy »pplicnz t thst chi bol #1 mlv! ece^• he
or. ov^r.^ ^- a ori
'homeowners who submit ibis affidavit indtcatin the�� 27e da' 11 .. _ � � • Comt.....c=^.^. Y -::".J
2Contmctors k « g i doing a" wart and th® hire outside contractor. aintt submit a new affidavit
that --heck his box must attached an additional
sheet showing the name of the sub-conummon and
indi sting such.
their workez'
1 am an employer that is providingworkers' compensation insurance Y employees.or m_�. YV --y uuurmauon.
information. f Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration pnae sho City/State/Zip:
Failure to se^ure coverage as required under Section 25A of MGL C.
152(ran (showing
to the imp the Policy number and expiration date).
' imposition of
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of f a STOP WO criminaI�gZ Penalties
am of a
Of up to $250.00 a day against the violator. Be advised that a copy of this stat„ -went maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby cera under the pains and penalties of perjury dizz the in or
f oration. provided above is true and correct
Sit_ ature: Z61
-/
Phone #:
Official use only. Do not write in this area, to be completed
by citj or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health Z. Buiiainb Department 3. Citv/Town Clerk 4. Electrics! inspector 5. plumbirzR
6. Other b inspector
Contact Person:
Phone ;':
Date ...... ..... ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... �4) ........ 7 ...................................
/Ull 121&4*,
has permission to perform .......... t ... ....... ................ ..... ................
7
wiring in the building of ............ ....................................
at .......... h Andover,
4EFee.3............................
Check 4 la�-- ELINSPECTOR
7419
J
E
CDF'1+'6a"iI�dIPllec��th, a F Af Sit��f���tta• I ------ Clificill Us,.rJ11
Ferran No. _-�-7v/F—
Detrca oFire erlr6cs;
Occupancy and Fee Checked _
l... BOAPED OF FIRE PREVENTION REGULP,TIONS [Rev. i-1/991 11eave blank)
APPLICATION FOR PERNT TO PERFORM ELECTRICAL WORK
All wort: to be perfonnecl in accordance with the Massachusetts E ectrical Code. (MEC), 527 CM 12.00
(I'LEASL.fPIA1T IN AfKOF' _IPE ALL INFOR1IIATIOId) Date: 7
:pry07- Town af: L e%� To the Irrspecior o/' Gi'ires:
By this ;application the Undersigned z. es Mice ofjhis or her intgntion to perform the electrical work described below.
Location (Street Sc Nu ber)
Owner or Tenant 7�.r_
Owner's Address
Telephone No.
Is this permit in conjunction with a 4uilding permit? Yes EZ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / 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:
No. of Recessed Fixtures
No. of Lighting Outlets /
No. of Lighting Fixtures 3
No. of Receptacle Outlets
No. of Switches
the
No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑In-
grnd. gra
No. of Oil Burners
No. of Gas Burners
ving table may be waived by the be the Inspector of lFiresof lFires. 0
No. of Total
Transformers Transformers KVA
Generators KVA
❑-1V0---0T mergency Lighting
Battery Units
FIRE ALARMS No. of Zones
No. of Detection and
ti..:r;�♦:..m no
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number
Tons
I
KW
I
No. of Self -Contained
IDetection/AlertingDevices
Totals:
No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No. of Dryers Heating Appliances KW Security Systems:
No. of Devices or Equivalent
No. of Water KW No. of No. of Data Wiring:
Heaters Signs Ballasts No. of Devices or Eouivalent
No. Hydromassage Bathtubs I No. of Motors Total HP i cEcc,crutueu111tuuuttz, VV 11-1119.
No. of Devices or Eouivalent
OTHER:
Allach additional detail i/desirecl, or as required by the Inspector of 147ires.
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 cove ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ' rBOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
lrrC7li TC Mart: I1iSpeCtiGnS to be rCgilCSiCu iri aCCGivanCe "vvttii 1viEC l�iilc i�, olid u�iCli CGiiipleliuit.
I Certify, under the pants and I)euallies of neriury, that the information on this application is trite and complete.
FIRM NAME: 6�)WA rt b t�r9uv�i� LIC. NO.:_&&�g , 4
Licensee: Signaturo,96&10u"�� ,/ I,iC. NO.:/'%gid
(ll*applicable, enter in the license number line.) Bus. Tel. No.: 0-3 "y 6 — /S
Address: Alt. Tel. rJo.:SaB-
OWNER'S INSURANCE WAIVER: i am awarf 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. PERIMIIT FEE: S
DffAXIZV!'OFPENXSAF y Pemdt Na �, AS G
BGIARDOFFfiEPREVFNIWRFJ=A7f�0I M7ag,a,� ,
Oeeupmtey Fea Checked ••••
QPUCA71ONFOR PER UTO PERFORMELEcnuCAL WORK
ALL WORK TO DE PERFORMED IN ACCORDANCE WrrH THE MASSACHUSM MSCMI AL. Cone, 527 cMlt 12:00
' (PLEASE PRINT IN INK OR TYPE ALL II`IFORMA770N)
Date
Town of North Andover
To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street dr Number) f 0� n h C CIVQ /N
Owner or Tenant
V . . f"ij 6
T,1 Cr„n4o
<1
7
Owner's Address
Score
iJ
is this permit in conjunction with a building permit: Yes[:rNo
(Check Appropriate Box)
Purpose of Building
R e g ,- dC1( 0
Utility Authorization No.
Existing Service
Arapa�/
Volts
Overhead
Underground No. of Meters
New Service
Ampa.../
� Volts
Overhead
Underground No. of Meters
Number of Feeders and
Ampacity
Location and Nature of
Proposed Electrical Work
le,
Na of Uabdtta Oudo
Nm d Hot Tubi
No. d tiarebrtttsrs total
Na of Uandty Rims
SwhMmins Pad Above M
Bad,
KVA
Billow
KVA
Na or Receptacle OutWa
Na Of OU Bttenera
Na of Btneryenry U$Mna Battery Unite
Na or switch outtau .
oZ
No. of ds Bmtters
No. of Rmige t
I
Na of Air Cod.
Tot
FIRE ALARMS
l� ~ Na of Disposde
Na d Hat
Toes��.
ToW
Total
No. ar zate.
No. d Deft" std
�-/Pump
No. of Dishwashers
Space Ara Heo ft
Tone
KW
KW
iaidadaa Darks
N& Of SOuaft Devica@
Na of SON Congeirw
Na of Dryers
Hoeft Devices
KW
Dalecti OA3ooaUl Davka
Na. of Wrier Heston
KW
cmawclpai Other
Connecdc'm
Na d
Na d
Na Hydw Musses Tabs
S
Na or Mown
Betlab
TOW IIl•
OTHER.
htuanaeCa� Piuuaaceihert�c}ieretafMroachensGlQmiLarte
' lhareacwerYlirhiyh�FbicyixkAV Cw#* orbsubrmWye¢riWtrE yg� � �
1 Ihnes�rrtibdvafd aywhttiecihadedYEi4,Pi�admlefre d
dreddggtre bac type ���
d 0
WakIDSM /G )e/,5"k MaeWunkr Rega�d
4 MNANE Pa�dPa�Y . /0 Me /=leC
I
ioerree_ 6?08-re,
r3Wn*dVAzd
Rid
vr�
lo Ao�r �1 •�
(-- AtTeLNa
�WI�R'S IIVSURAI�BWAIVQt,Iamawaedirtthel�omre�i�����rl
--/xddWffW*P*=Gnd6PM!1*4"—
cedaaVanesli� a9�tara�bj'h'g�dxslbC,Qekllatw
(Please check one) Owner Agm
Telephone No,
WFUM or UM°ERMt1' FEE /I -
Date .........
44 TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATIO
9
1
This certifies that 1,7,7 ?.51 ..Pc: n . �. r. �.....................
has permission for gas installation1..............
in the buildings of <...........................
at JP .4 lei
1;1/ 9. .:'� .... , North Andover, Mass.
Fee. Lic. No..2 -2 u i... ..... q— .. .
GASINSPECTOR
Check # 5 !�
55A.0
�IASSACUSETTS L:NTIFORNI A UCATON FOR PEPUNUT TO DO GAS FIT'T'ING \
(Type or print)
FORTH ANDOVER, MASSACHUSETTS
Building Locations
A Y\1CX\N (AK)() )ef Owner's Name
New ly Renovation 11 Replacement
Date q " �ZO L
Permit it J c> _
Amount
S 37
Plans Submitted
(Print or type)
Name
Address
Name of Licensed Plumber or Gas Fitter
C one: Certificate Installing Company
Corp.
VV P er.
Fir VC0
LNStiRANCE COVERAGE- Check one
I have a current liability Insurance policy or it's substantial equivalent. Yes Noo
If you have checked yes, please in ' ate the type coverage by checking the appropriate box.
Liability insurance policy13' Other type of indemnity 13 Bond 13
Ow ner'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
t nereoy certify tnat aff of the uetans ana information f nave suomittea (or entered) in above application are true and accurate to the
best of my knowledge and that ,ill plumbing %vork and installations performed under Permit Issued for this application will be in
' rnpliance with all pertinent proviJons of the Massachusets State Gas Code and Chapter 142 of the General L, awl.
�_ — =—may
By:
Ti tic
Cit,,;Tcwn
z�PPRO ED (.FFTCE f;sE ;hi.Y,
Signature of Licensed Plumber Or Gas Fitter
Plumber 2 Lt,2
Gas FittericC ense Number
faster
Juurnerman
BASE, ENT
!2ND. FLOOR
FLU- MEAMIX-1A,
7TH. FLOOR
(Print or type)
Name
Address
Name of Licensed Plumber or Gas Fitter
C one: Certificate Installing Company
Corp.
VV P er.
Fir VC0
LNStiRANCE COVERAGE- Check one
I have a current liability Insurance policy or it's substantial equivalent. Yes Noo
If you have checked yes, please in ' ate the type coverage by checking the appropriate box.
Liability insurance policy13' Other type of indemnity 13 Bond 13
Ow ner'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
t nereoy certify tnat aff of the uetans ana information f nave suomittea (or entered) in above application are true and accurate to the
best of my knowledge and that ,ill plumbing %vork and installations performed under Permit Issued for this application will be in
' rnpliance with all pertinent proviJons of the Massachusets State Gas Code and Chapter 142 of the General L, awl.
�_ — =—may
By:
Ti tic
Cit,,;Tcwn
z�PPRO ED (.FFTCE f;sE ;hi.Y,
Signature of Licensed Plumber Or Gas Fitter
Plumber 2 Lt,2
Gas FittericC ense Number
faster
Juurnerman
6136
Date. A!- /,�q -
.........................
�3?p���•to"�'+e+ppL
TOWN OF NORTH ANDOVER
to
Ax PERMIT FOR WIRING
This certifies that ...... ........... a ...............................
has permission to perform__ ..... I ........................ ..
...............................................
wiring in the building of ...-J'. ............................................
at -Aly ......... ..... ... . ..... . NorthAndover, Mass.
L'ic. Nofi....
-iLECrRICA4iiN*S' P**E" M** , ;;-�, . .......
Check # / �1 C/
i
/ Date. /O—//-. C S'
NORTPI
° TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that �Q C .....�. �.'�'�... `. IVA 19
has permission for gas installation . `�.`".`. �'.`.. ........... .
in the buildings of ...A PZ) ....................... .
,. at AB f.. T,s �? � v �' � C!{ V`� ...... , North Andover Mass.
Fee. =�-Lic. No..
GASINSPECTbR
Check
6'-7U
e
MASSACHUSETTS UNIFORM APPIdCATON FOR PERNIlT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building LocationsI �) 1► ����I �'�c�- Permit #
Amount $
Owner's Name
New Renovation Replacement Plans Submitted
(Print or
Name—
Name of Licensed Plumber or Gas Fitter
one: e one: Certificate Installing Company
Cff
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE • Check one:
I have a current liability Insurance po ' or it's substantial equivalent. Yes No
If you have checked Yes, please i tate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 0 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 1 Agent 13
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 St to Gas Cpde and Chapter 142 of the General Laws
ZEA, A
By:
Title
City/Town
PROVED (OFFICE USE ONLY)
Signature of Licensed Plu be Or Gas Fitter
Plumberu'
Gas Fitter License Number
171
ter
Journeyman
iB A SEM ENT
110
PIN 46 ffamllm�
(Print or
Name—
Name of Licensed Plumber or Gas Fitter
one: e one: Certificate Installing Company
Cff
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE • Check one:
I have a current liability Insurance po ' or it's substantial equivalent. Yes No
If you have checked Yes, please i tate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 0 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 1 Agent 13
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 St to Gas Cpde and Chapter 142 of the General Laws
ZEA, A
By:
Title
City/Town
PROVED (OFFICE USE ONLY)
Signature of Licensed Plu be Or Gas Fitter
Plumberu'
Gas Fitter License Number
171
ter
Journeyman
Date. Z
f
r
TOWN OF NORTH ANDOVER
.o
PERMIT FOR PLUMBING
s o� ,>• a
�1�,SACMUS�� [CP This certifies that .. AC /S .. t
has permission to perform ... R.`. .. .. f ............... .
plumbing in the buiId.ngs of dd................ .
r �V titi y l.. �r`e ,North ndover,
�► at ...... �............ Mass.
Fee..? ....Lic. Nor 7 V.%a.
PLUMBING SPECTOR
Check # N S
6647
per'MA 911
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
1
of Occuoancv
New 13 Renovation 0Replacement 11 Plans Submitted Yes
FIXTURES
Date
Permit #
Amount
No ❑
(Print or type)
Installing Company Name
Address
y
C Business Telephone
0
V
Name of Licensed Plumber.
Insurance Coverage: Indict
Liability insurance policy _
-ance coverage by check
Other type of indemnity
Check one: Certificate
1-3 Corp.
ElPartner.
5 irm/Co.
box:
Bond D
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 Owner ❑ Agent 0
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 MassachusFtts State Plumbing Code and Chapter 142 of -the G er ws.
BY: 71g—n-aM Of i ns er
Title
Type of Plumbing License
�3L� \ "21City/Town License cent u Master Journeyman
APPROVED (OFFICE USE ONLY 11 J3`�
;l / 1, y I Yr f 1I 1 r l%
APPUCATIONFOR PERMITTO PERFORMEL
ALL WORK TO BE PERFORMED IN ACCORDANCE WrrH THE MASSACHUSSrS eLWMXAL
(PLEASE PRINT IN INK OR TYPE ALL 2ffORMATION)
Town of NoM Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant Pqa Cy U
Owner's Address S�tv�e
Pemdt Na CO /i3
OecupoaFes Checked
[CAL WORK
CMR 12:00
Date
To the Inspector of Wires:
is this permit in conjunction with a building permit: Yes [aft (Check Appropriate Box)
Purpose of Building l� 2 s � dc, .(
Utility Authorization No.
Existing Service Ampa�/ Volts Ovedwad Underground No. of Meters
New Service Amps Volta Overhead Underground No. of Metes
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work /lY,lr
No. of Liandna Ostia
"oZ
No. of Hat Tobe
No. of Tnaesonnsn
Totd
No. of Liahtina Fixtotee
Swims ins Pool AboveKVA
Below
cimraaloee
mmond
rl
KVA
No. of Rwxpmb Outlets
Nw or on Butum
No. of Emergency Uandng Beery Units
No. of Switch Oudeu
No. of or Haman
FIRE ALARMS No. Of Zones
No. of Ronaae l
No. of Air cold. TOW
TOM
No. d Dewdon and
No. of Disposals
No. of Had Totd ToW
PUM
Ton
KW
Initiating Devka
No, of Soundby DeAm
No. of Dishwashwe
Space Ata Hestina KW
/
Na of Self Contabted
Lord Municipal
C] Combctiom
a
No. of Dryer
Hoeft Devices KW
No. of Wats Hewn KW
No. d No, of
S1,102
Ballads
No. Hydra Musep Tabs
W of Mows
TOW HP
hates= ININ tbbere�arnerirdMadatathQdmiLaws
trCMe1Wcr*S&ftWWdft
1�
Ih�nesubmlred�+aldpoddstrreblte� 7fF
ap°udeded7fBS,Pkaidcreftelypedaotert�by
am o ��
WodrbStattO U g}t�id EstimeledValzafF?atdcelWodt S
urid3 i�rrtfabd �
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l isee �reai�rc, P"14 ..
ri�err�
�1C�ailisT>'iNa o 1 2 nGJal Q h�2 , L�,�n. /� ti Lot 4
Gid -ash_ 6 �s
OWT�WSMRANCEWAM-lamawa iateLaQW lheiaeatceoove� ty AkTdNa
ardthatrp+s+�eaatanlhbpesniapplc�tvi�esthisregvietat °����4�dbyMre®dzsbGma�llauts
(Please check one) Owner Apo E3�
Telephone No, tm �, FEE t-�Q''
i
75 �
N2 /
Date ....... 7*"**"*'*"*
o,- TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
1544 '
This certifies that ......... ..,� l J f r ...........'
........................................................
h permission to perform ...... ,�' (`. r
�/ .` ........ ............................................
wiring in the building of �
at4............
��.......�, r%(., _ ......
�..r.l.�,North )k.ndo4er;�Mass-.
Fee .......J.J... Lic. No............ ........................... ........v....
P-LECTRICAL INSPECMR
Check N
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 3 U
Occupancy and Fee Checked
[Rev. 11/99] leave bla k
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 2.00
(PLEASE PRINT IN INK OR TYP LL 'FO tiIATION) 'Date:
City or Town of: To the Inspecto of Wi s:
By this application the undersigned�g�ves notes ➢ his or her inj ttion t9 perfoLw tie electrical work described below.
Location (Street & Number) AA11 I F �.
Owner or Tenant ° Telephone No. !
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No E!r' (Check Appropriate Boz)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed ElectricaWork: 1�rYi v-
.1 rw
No. of Meters
No. of Meters
Cmmnletinn nfthn fnllnwirro tnhlo mmr ha univo l h„ tho Isere tn.. !tt/:..,,..
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In- ❑
rnd. grnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and'
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
b
No. of Waste Disposers
1i -Totals:
Heat Pump
Number
.... .
Tons
KW
........................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Arca Heating KW
Local ❑ Municipal ❑Other
Connection
No. of Drvers
Heating Appliances KW
ecuritySystems:
No. of Devices or E uivalent
o. o ater KW
Heaters
No. o No. o
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.
INSURANCE COVERAGE: Unless waived by the owner, no pennit 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 ❑ BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: Iriv. (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion.
1 certify, under h#aIns and penalties of perjuty, that the information on this application is true and complete,
FIRM NAME: ADT Security Services 111 Morse Street, No •o , MA 062 LIC. NO.: 1533C
Licensee: John S. Bassett Signatu IC. NO.: 1533C
(lfapplicable, enter "exempt "in the license number line) D� Bus. Tel. No.: 781-278-1131
Address: Alt. Tel. No.: 781-278-1725
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. JPEk'VII T FEE: $ • tow