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HomeMy WebLinkAboutMiscellaneous - 183 CARTER FIELD ROAD 4/30/2018,.sP'a� �i�' �...y'_. 1� �,'. 6 � � ,.a.S ,a�' `= y- 6 ..r'.-m.�.`e11 ��_ 1 ; ✓ _ 2012 Massachusetts EIectricaI Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with theprovisions of M.G.L. c.143, §. 3L, the ✓ permit application form to provide notice of installation of wiring shall be uniform throughoutthe Commonwealth, and applications shall be filed on the prescribed form. Atter a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shallbe limited as to the time of ongoing construction activity, and maybe.deemed_bythesnspector_of_Wires abandoned_and.invalidaf-he—.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the. permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 ofthe Acts of2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote-job;growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certair•permits'and licenses concerning the use or development of real property. With limited exceptions, the Act automatically dxtends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 20008.aand extendingthrough August 15, 2012. Rule 8 — Permit/Date Closed: 2 l 7' * Note: Reapply for new permit f ❑ Permit Extension Act — Permit/Date Closed: � J Date.. 7 .Z...Q�.... �.Z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... �� 7�.{� `.... f . / /v,.l�'/. ........................ has permission to perform ........Y."�pp; :�"D } ............ . .............................. r' .Lcl� wiring m the building of��......./...........................�.......................................... at ... 8 x,...... !/L..�.�..�...1..:....E2`1.�............... ... . North Andover, Mass. ... Lic. No. .......... :..................... j ELECTRICAL INS CTOR Check # 10852 Commonwealth of Massachusettts a Department of Fire Servlces BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 16 ZkM Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL INFORMATIOA9 Date: ,*I-a's , d-ol a' City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice o his or her intention to perform the electrical work described below. Location (Street & Number)_ /f 3 ae- h -e art Rd Owner or Tenant Telephone No. (e7 /�' a 09-0/" Owner's Address L. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building_ P1p1 Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters j Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: hyi re n/Zwo A &oJp 6 rdebt Com tion o the ollowin table m be waived b the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- ❑ o. o mergency ig mg rnd. rnd. Batter Units No. of Receptacle Outlets No. of 011 Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingTotaDevices No. of Ranges No. of Air Cond. Tons l No, of Alerting Devices No. of Waste Disposers Heat Pump Number .Tons �.._ KW,... No. ofSelf-Contained Totals: Detection/Ale in Devices No, of Dishwashers Space/Area Heating KW Local Municipal ❑Connection ❑Other No. of Dryers Heating Appliances KW Security stems". No. of Water No. of Devices or E uivalent Heaters KW No. of No. of Data Wiring: Si s Ballasts No. of Devices or Equivalent r No. Hydromassage Bathtubs No. of Motors / Total HP Telecommunications Wiring: No. of Devices or Eq uiv[lent OTHER: trs Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value ofElectrical Work: ��� (When required by municipal policy.) Work to Start: M1%J �- 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 andpenalties ofperjury, thn_t the information on this application is true and coni0ete: FIRMNAME: LIC. NO.: Licensee; S� (.�n Signature LK LTC. NO.:S� rl (Ifapplicable, ente "exem�pt" in the cense n rmber I' e.) Bus. Tel. Noa9�F° Address: _ � l�Dlo /0 r " l�19/3 Alt. Tel. No.- *PerM.G.L c. 147, s. 57-61, security work requires epartment 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: $ / - _ ELE+ (CTk�.X��'.A�-.L�PE� �RM-�y �T/NOp,�Y Inspt-or'co7ane�utecPasse$ s:S�'ailed� C 1e-5nspection Xequiuedf ($0.00) C ' tr. e a •. 9. ' (Xnspectoxs'signature -•xao •nliiaTs) Date Passed --j) paned --•j Le 3ms�ectiox�xequixec ($50.00) j InSpectars' coTnlnex�.ts: (Cnspectors' uignatare - no Wtials) Pate r s, UNDER GROUND-W'BRXCTXOZy: Passed- I+ailed- j ] ate-inspeciior�xequixec (�50.U0) j a Inspectors' Comm.exits. (inspectors' Siguaiure--n.o fuitfals) Date 4. I DATE CAIMM, D N.&WONAL GRID, Passed—[ x YOM—[ inspectors' commeph: Cpiasp ectors, slgaz Luxe •• io nspection required ($50.00) •• j Date 'assed--• C Ipaned- j atenspeciionxequixed ($50.OD) - [ - aspectors' coznraents: asp ectora, Signature -)10 xuitials) Date © G OR TAGS AIS TO DE TIMLED Ql- T AND LEFT OX RITE IF TM .AREA. TO BE MTECTED ISNOT ACCESSIBLE AND .ARE INSPECTIONO)TS50.00 Y9 TO DE CHARGED. - - The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �j' /I ��i Please Print Legibly Name (Business/Organization/Individual): �r tT ° �G� U hVVT%-e Address: p d ( nk o �uf:2f✓��- cp"/3 City/State/Zip: Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 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.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. EJ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.0 Other POVI ktfal *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 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 requiredunder 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. Phone #: 7 �✓ (� D—' 3 ��'� 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 #: 1 f 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 employeiis 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 fox 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 bum 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 ort 406 or 1-877rMASSAFF Revised 5-26-05 Fax # 617-727-7749 www.mass,goV1dia Location �v� i$,3 CA91i le F, v14 PCP No. r7 a Date :c N°RTM TOWN OF NORTH ANDOVER a - x Certificate of Occupancy $ �SswcHust` Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ qC, yp Check # Cl r 17 4 21 Building Inspector TTS 4 w Q O cr' 0 0 Z 0 W (n Z W U J U z 0 z O w U) Qft� LJ I w 2 H H U (n - LL U) Q z Zw aQ z Of c� 0 w } J Z wd - Q V) ZO O O F-� =O W O Zww�>- O¢ �7 H 0 < = U .. 0 0 p D r < Z NO o o m z Z_jZ O 1= II w a z 1'- �� (n L J J W QW = � Z= �w =0 J p Z � Z O :: d ~ ~ W nn �p ogv, Jn 0 L QL O Z�Uo HO 1-Q 12w >- (nom D � 0 LL- O w Ll co O O- o Z O N z O > ~ U af J d > mW L zw (nt H_ W0 OLL-> US W O mwZ 0 N — t J wN >-� w O w wQw m 00 w� LL) N m WIZ N Cf) 'IIIIIIII TTS 4 w Q O cr' 0 0 Z 0 W (n Z W U J u� n O N �d'r7 Q r J CARTER FIELD ROAD H Q m Z O (n Z w O Lo U 5 (n w w w 0 0 z +L w H CD W Co JayauoJJ'o wol4:ot bo/8o/9 6MP'lgo6oL L\00601l'(ovo\s?o-�ojd\:d U 0 o V) Zw aQ z m^ 00to MZ a rn F-� o vii N O O r _ �7 H y 06 °I p W H o o m z L J J W W �0x00= p Z O I nn �p mmMCL MIS • H O �L ZQU or W �U O 12w 0, w Ll co O _j U) J o Z O N o CL F -i z > mW L Q > % W 00 rr V)w w a w O w w Z 0 Ld> w CSOd Y> UO m 'IIIIIIII LL Q W U Z !Q! Q < U a`no � N r w w � � 111 1111 Q z O Z q�IlN IMI. c ° o U �..a U � W '�IIIIII o+ II m ZU u� n O N �d'r7 Q r J CARTER FIELD ROAD H Q m Z O (n Z w O Lo U 5 (n w w w 0 0 z +L w H CD W Co JayauoJJ'o wol4:ot bo/8o/9 6MP'lgo6oL L\00601l'(ovo\s?o-�ojd\:d 8992 Date. 15.7.F— - t I... TOWN OF NORTH ANDOVER j? •`_ °� . . PERMIT FOR PLUMBING o ,SSACMUS� "+ This certifies that ................ has permission to perform �N ............. `` plumbing in the buildings of .n.-C?�-.� !;,A .. .r " V 5 c e G- at. .......(.. North A do er, Mass. Fee . .(A . Lic. No.. � 5 . ......, �' .0 )�. . PLUMBING INSPECT Check #� I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town-o-r MJover , MA. Date: Permit# Building Location:/e, Carl er 1 C 1 J ld Owners Name• (0 +�E� kf- / Va C� Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No ❑ PIYTI 1QFC IVaUKANUr t;UVtKAGt: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ f you have checked Yes, please indicate the type of coverage by checking the appropriate box below. t k liability insurance policy Other type of indemnity ❑ Bond ❑ )WNER'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 ii nature of Owner or Owners A ent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. OF iy Type of License: ltle .Plumber Signature of Licensed Plumber ;ity/Town ❑ Master !� \PPROVED (OFFICE LISF ANI Yl J�Journeyman License Number: f� T f I DEDICATED rr Z SYSTEMS w o LU W Y Z Uj >z N it z 'a x �, Q W a Uj W 0 Z e °` 0 aW Q Co#Aoc 0 oc O Q W a Q y a Z cc oe a: Y Z rn Zn U o. a 2 vi Q 3 ii (� 3 O C �1 Q ]G Z 0 W D 0 W = Z Q LL iA j Q Y z Z a. = W W Oil 0 0 iA W W F Q m m D C O = Y > > O 0 0H� Z OC Q Q Q to Q a SUB BSMT. BASEMENT 1"' FLOOR 2ND FLOOR 3RD FLOOR CH FLOOR ST" FLOOR 6T" FLOOR 7T" FLOOR 3T" FLOOR iJ P Check One Only Certificate # InstallingCompany Name, a 1+e' `Tf'P u 4ddress• � y�yF City/Town• �� Flr S State•/ "1 � 1 C] Corporation q��/ % % S ¢� 3usiness Tel: 6 O El Partnership Fax: Finn/Company / Vame Licensed SI,.Gt of Plumber: w L. IVaUKANUr t;UVtKAGt: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ f you have checked Yes, please indicate the type of coverage by checking the appropriate box below. t k liability insurance policy Other type of indemnity ❑ Bond ❑ )WNER'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 ii nature of Owner or Owners A ent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. OF iy Type of License: ltle .Plumber Signature of Licensed Plumber ;ity/Town ❑ Master !� \PPROVED (OFFICE LISF ANI Yl J�Journeyman License Number: f� T f I �OMONWEAL`TH OF MASSACHUSEi'TS �. 3 .;; I URNEWAM4 PLUMBED i LICENSED ASA ISSUES THE ABOVE. LICENSE TO: SH AW N � WHITE i. OX 1186 01949-3186 p0 B MA MIDDLETON 788605; 25491 05/01/12 --~ G The Commonwealth of Massachusetts I a g I, j� Department oflndustr°ialAccirlents :�,�• Office of Investigations , k ;` ;r' i` 600 Washington Street Boston, MA 02111 www.mass gov/dica Mrorkers' Compensation Insurance Affidavit: builders/Contractors/Fllectricia>nts/P numbers Applicant Information . Please Prinf Legibly i Name (Business/Organization/Individual): Address: /� I s lark r Y� r ot�2 .7City/State/Zip: I/ate Jc��'S � f Phone /#: R 7k' 7 7-7 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I ami employer with 4. ❑ I am a general contractor and I 6. ❑- New construction employees (full and/or part-time).* 2. KI amt a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. [NO workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their I0.❑Electrical repairs or additions 3. ❑ I atn a homeowner doing all work right of exemption per MGL - 11.❑ Plumbing repairs or additions inyself. [No workers' comp, 0.1.52, § 1(4), and we have no 12.[] Roofrepairs " insurance required.] T employees. [No workers' 13,E] Other comp. insurance required.] Tfmy pppncant mat enecxs box it must also.tia out the sectior; below showingtheir workers' compensation policy information. t Homeowners who submit this affidavit indicating they ace doingall work and thea hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors said their workers' comp. policy information. X 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 Section 25A of MGL c. 152 can Iead 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance'coverage verification. X do hereby certrfy u the pains clp aItie fperjury that the information provided above is true and cor`,rect.' Sinature: i nate. � uv�C Official use only. Do not write in.this area, to be completed by city or town offrcr'al. 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 Instruefions 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 ofthe foregoing engaged in a joint enterprise, and including the legal representatives of 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,.deerned to bean employer." .MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance' requirements of this chapter have 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 cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation 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 ifyou are required to obtain a workers' compensation policy, please call the Department at the number listedbelbw. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Oficials Pleasebe sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe 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 pennit/lieensenumber which will be used as a reference number. M 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 n 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 CQmMonwealth Of Massachusetts Dgpartinmt of Industrial AGGide.nts Oflace Of Investigations 60.0 WashfiWon Street Boston, IIIA 02111 Tel. # 617-727-4900 W406 or 1-977 MASSAFE Revised 5-26-05 Fax #t: 617-727-7749. www.mass.gov/dia Date.. �.-. b .. 1.1...... . ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .ty a This certifies that ..5.V\! !"t...�:L'.!.`.. �- .............. has permission for gas installation ?"`! C(L- ..!`}!.'r� :. in the buildings of at �. .. R f <<..�°`�.. , North Andover, Mass. Fee.::�94-L . Lic. No—A-1510.4 .....�.�. .. GAS INSPECTOR Check # h-, G FIXTURES tY W W MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: df tk AtAVC'� , MA. Date: Permit# Building Location:/ 9-3 6a f 1 r FCS IJ Owners Name: (fol eco, A >r I V Q e e Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: P5, Plans Submitted: Yes ❑ No ❑ FIXTURES tY W W Y F Cd H W D Im OUJ U O 0 ca = t— F Z I.- O W t9 J �. Z V1 p W Q' N W U z W>Lu w w CD O O Q rn Oa a = X I > V W Z O Zh— 5 W j .1 11— M 9 1.-O Z W m> J 0 U" N= W W Z W W W H O Q O ¢Z -O Z Q SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR //_ f Check One Only Certificate # Installing Company Name: Qcc�(l u��l t•�� �' % P "5 1 �D µ (VF Address: -/O �'J� CityITown:�Rvtri/F%S State•/�� El Corporation Business Tel: %/-,Ff 777 ff ? S ❑ Partnership Fax: Name Licensed Plumber/Gas �� ,� � � (' ❑Firm/Company of Fitter: W G1 r INSURANCE COVERAGE: I have a current liability 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 of coverage by checking the appropriate box below. A liability insurance policy 9 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement Check One Only Signature of Owner or Owner's Agent Owner 1:1 Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: 9 Plumber Title El Gas Fitter ❑ Master Signature of Licensed Plumber/Gas Fitter Cityfrown PlJoum�Jr eyman License Number: '1" APPROVED OFFICE USE ONLY ❑ LP Installer Date..Z,..-II�?W ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING /I1�2 This certifies that ....'k - --L . . ......... ........................ I ................. .. ....... ... . ....... es has permission to perform... ................................ wiring in the building of ...... .... .. ....................... .. ............ at ....... —. ....... ,North Andover, Mass. Fee. ..... Lic. No. .4!5 At!?RICJ Chec'k # 7877 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ,7f - 7 Occupancy and Fee Checked 6�5, [Rev. 1/07] leave blank 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: / Z �� 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 & Number) I <i 3 tom} ✓(. —(01^ -FI -rr� n (' Owner or Tenant. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building 51 (,V�_ 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: i^mm�lOfjon nfrba � 77.....;. - r l l ... ,. 5 ,.. :.. 7 z...t._ a_____.__. _�rn�___ No. of Recessed Luminaires 20 -- -----of No. of Ceil: Susp. (Paddle) Fans No. Total u anc li of F v rr truly. Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Swimming Pool Above 11 In- ❑ rnd. rnd. o. o mergency ig ng Battu Units No. of Receptacle Outlets 3 C> No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection an Initiatin Devices No. of Ranges No. of Air Cond. TonTots No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number ­ Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or E uivalent 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 ifdesired, or as required by the Inspector of Wires. Estimated Value o Electrical Work: � j,, 00 ( When required by municipal policy.) Work to Start: 1 k • 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 cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND [IOTHER El(Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: �� �t.4-L_t�v(S LIC. NO.:/1-1 pc,sa_J� Licensee: /✓, V -R 41�,7 fr M�`�,yd Signature LIC. NO.:�/--,Z7 &D 5— (If applicab en,t.ggr "exem t" in the lic nse number line. us. Tel. No. �J 3 3-a Z-Ztdl j! Address: 1-'��5� S�✓t t _S��v Alt. Tel. No.: +7k ? *Per M.G.L c. 147, s. 57-61, qecurity work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $'-Cre� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.n:ass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual):.o n �= fink C4 -e_ S6G ��'��2>�tl��' I ^ City/State/Zip: Phone #:. �] 7 ;�r `� 7 S -r) S Are y an employer? Check the appropriate box: 1. 1 am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or p -time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 2 6. ❑ New construction 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for me .in any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9, Q Building addition required.] officers have exercised their 10 -0 Electrical repairs or additions 3. Q I am a homeowner doing all work right of exemption per MGL 1 l .Q Plumbing repairs or additions myself. [No-worke'rs' comp. c. 1.52, § t (4), and we have no 12.Q Roof repairs insurance required.) t .employees. [No workers' 13.❑ Other comp. insurance required.) -Any applicant that checks bozr # I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contiactors that check this box mustattsehed an additional sheetshowing the name of the sub -contractors and their workers' comp. policy information. I ant an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: �L@ -- —KAI J OV -&—A- i 15 JA- .41C -C-_ CO . 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 ceriq under the pains andpenalties ofperjury that the information provided above is true and correct Zlt Sulo Phone #: Ofj'icial 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): 11 L&.40ther Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector ntact 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 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 -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 lnvestigations 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/clia 6-f-a'l Date.................................. TOWN OF NORTH ANDOVER ,PERMIT FOR WIRING This certifies that ... e ... .......... ......... . ... ....... ............................. has permission to perform ...... ............................................... wiring in the building of ....... ...... ................. at ....... ...... "'.e ............................. . North Andover, Mass. Ae Fee..96 ........... Lic. ..... ..... ....... Check # _/0 7oS INSPECTOR _0 5274 TRE COAMOATHEfLMOFAUSS4CHU,S'EITS Office Use only DEPARTAIEWOFPUNICSAFETY� f Permit No. BOARDOFFIREP ONREGUTATIONS527CNIRl2:(b 'D y Occupancy & Fees Checked APPLICATION FOR PERMI�l/TTO PERFORM ELECTRICAL Woiq ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORI 4ATIO Jh) Date (i Town of North Andover The undersigned applies for a permit to perform Location (Street & Number) Owner or Tenant Owner's Address work described below. To the Inspector of Wires: Is this permit in conjunction with abuilding permit: Yes ©rNo (Check Appropriate Box) Purpose of Building K:L ab 5 t Z(� C ,,, VX-(__ Utility Authorization No. �f Existing Service Amps / Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 74-4-" 0M E No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Air Cond. Total FIRE ALARMS No. of Zones No. of Ranges No. of Heat Tons Total Total No. of Detection and ,f). of Disposals 1 4 Pumps Space Area Heating Tons KW KW Initiating Devices Nq, of Sounding Devices No. of Dishwashers ! Na oESelf Contained Heating Devices KW Detection/Sounding Devices Local Municipal Othe No. of Dryers No. of No. of Connections No. of Water Heaters KW Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• k mnoeCovaage Pt=antto&wgtutemff&ofMass nlSe Gffoa1Laws 1 IhaveaomentLiabihtyhwuancePblicyiwkdngCompL Covetageoritssuh�v�tialegrmlat YES NO I submitodvaWp> of of same to de Office. YESLfr Fyouhave cbedcodYES, pleaseir�ttleMmofooverageby g IN>'trJRANCEff' OTH BOND ER F-1 (Please Spa*) EVirationDate WorktoStart SignedundeM esofpew- FIRMNAME in t_ AA -A --C , Qyu-i- 6u- EsfimatedValueofElechicalWodc $ Rough I Final licenseNo. IC�Lk1 LicascNO _Z7S BusulessTel No. _ AitTei No. OWNlR'SINSURANCEWAIVITOamawatetilatlbeficerwdoesnothavelbeinstrr=covetageoritssubs=alegunlentasreguaedbyMassachusctsGale Lam and that my sigrlahue on this pennit apphcafton waives this mquireanent (Please check one) Owner ® Agent e,: Telephone No. PERMIT FEE rgna ure of 77ner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: City: Phone #: Insurance. Co. Policv # Company name: Address City: Phone #: Insurance Co. _ _ _Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment -as _well_as _civiLRenalties in the form of-a_STOP WORK_ORDER..and_a fine -of -(.$1.D0..OD)_a day against -me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # ' r Official use only do not write in this area to be completed by city or town official' M% City or Town Permit/Licensing Building Dept ❑Check if immediate response is required E] Licensing Board F1 Selectman's Office Contact person: Phone #: E] Health Department ❑ Other TBE COA MONWEALTHOFMASSACHUSEm Office Use only �7 DEPAR7ARMOFP U SVEIY Permit No. BOAROOFFIREP DN1?EGUFW0NS527CM12.VO Occupancy & Fees Checked O "APPLICATIONFOR PERMIT O PERFORMELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE H THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFO t ATIO Date 'D Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform th ele rical work described below. Location (Street & Number) t �( Owner or Tenant LGA t _ t 1 % / �� �-t�.� �,� "_ Owner's Address 1 7. k Com_ (Z.';'Yl h �� InIN Is this permit in conjunction with abuilding permit: Yes [�No (Check Appropriate Box) � ab Purpose of Building K 5 f 1S C -A,1 .�_ Utility Authorization No. �f g Existing Service Amps�Volts OverheadM ED Underground New Service Amps / Volts Overhead M Underground Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets No. of Switch Outlets o. of Ranges bf Disposals of Dishwashers of Dryers of Water Heaters Hydro Massage I No. of Hot Tubs Swimming Pool Above No. of Oil Burners Below of Transformers of Emergency No. of Meters No. of Meters Total KVA KVA Battery Units No. of Air Cond. Total FIRE ALARMS Tons No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices Space Area Heating KW Np. of Sounding Devices N4,ofSelf Contained Dettction/Sounding Devices Heating Devices KW Local Municipal Connections KW No. of No. of No. of Zones M Other Coves R=Mt wdlLaws wulgl bltykmrmmPblicyurbdngCompk$5 CoVelageoritss kWI)lialecgrivalerlt YES NO valid fofsametotheOffica YES �°o L --- J ff}vuhawclteckedYES,p]easeindc&typ theeofcoVetageby CEOND OITIER FinseSpedy) EViialimDale bEtmatedValueofl7earicalWork $ ofpetjury. h>SpechonDateRequested Rough Final le LicffwNo. Signature Lic=No Bt>Sit ss Tel. No. Z �6ti AIL TelNo. if 7S_O$62__ t'SINSURANCEWANIIt; amawatethatthe Lmredoesnothavetheins=-mverageoritsmbstamdequiivalentasragnedbyMassachuseusGeneaalLam d thatmy signahueon thispem,tapplication waives this mgm' mlu t lease check one) Owner Agent ry O le Telephone No. PERimTT FEE $ /� Igna ure or Uwner or gen 0 Location ISS No. Date 'e-,, y NORTH TOWN OF NORTH ANDOVER f 1 OG � Certificate of Occupancy $ sMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # /0 i-- 17318 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLIIS�aH�A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: �L SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �- // I #% g3 e4,� g;w ` A, 46bel f, mA Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: SSR 21, W >v3 Zoning Dnstrict Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided Required. Provided Zd z ZD Z Z,6 /5-40 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ private ❑ -Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �� LL 44"- 1216 arae (Print) Address for Service : �I7 S �g7-Z63, Sign a Telephone 2. wner of Record: I Name Print Address for Service: r Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Constntction Supervisor: S - 4C 4 0 Not Applicable ❑ I'D "li Licensed Construction Supervisor: �^ License Number 1 A dress •/�' s.� l r�� 77 Expiration Date Sig re Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ _z . Con1pany Name Registration Number Address Expirat Date Signature Telephone T M X z O r v 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 hcable New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bV permit applicant QF>�ICIA;=U °(# ,, -• I. Building Z ? q rVd, (a) Building Permit Fee Multiplier 2 Electrical ' (b) Estimated Total Cost of Construction 3 Plumbing ZUL>a . Building Permit fee (e) x (b) g' 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 3 /5' &600 • Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPI IES FOR BUILDING PERMIT 11 � 1L as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all n ers relative to w thorized by this building permit application. Si na Owner Date _SEGf1ON7b OWNER/AUTHORIZED AGENT DECLARATION 1, r 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 i Print Name Siof Owner/A ent Date ire NO. OF STORIES SIZE Q BASEMENT OR SLAB Q SIZE OF FLOOR TIMBERS -c—'e &2 1 Q 2 ND 3 SPAN s -- DIMENSIONS OF SILLS Z �, DINIENSIONS OF POSTS D1INIENSIONS OF GIRDERS 11EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING Z X l MATERIAL OF CHIMNEY 6 LAG IS BUILDING ON SOLID OR FILLED LAND S 'D IS BUILDING CONNECTED TO NATURAL GAS LINE b g e6m FORM U - LOT RELEASE FORM a Si -a-1) 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******'***************** �� ,bevel APPLICANT-. LOCATION: Assessor's MapNumber67i SUBDIVISION �GAC4C �' STREET &C- 1t -r TIeJ Raj PHONE q 78-6ff7-- 7-4 35' PARCEL 'Z LOT (S) // ST. NUMBER /k-3 ************************************ OFFICIAL USE ONLY I RECOJMMENDATIONS OF TOWN AGENTS: —1 CONSERVATION ADMINI RATOR DATE APPROVED DATE REJECTED_ COMMENTS FOOD 1NSPE-CTOR-HEALTH SE COMM TH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEW,,AY/iPE FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9\97 jm DATE GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVER BUILDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the necessary Afoimation as request below. ra l -e' C4' /))-#183 (44 r � 6 7-1Z ermit App9cant Property address Map / Parcel Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the Growth Management Bylaw. I also understand providing this form does not absolve me or any, party to this permit from the requirements of obtaining other permits required prior to the issuance of the building permit. Further I understand that my interpretation of the exemption status is subject to review by the Building Department and is only officially accepted when the building permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application fora building permit for the enlargement, restoration or reconstruction of a dwelling in. existence as of the effective date of this bylaw, provided that no additional residential unit is created. The lot(s) was / were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the Zoning Bylaw. .1 J This application is for dwelling units for low and or moderate income families or individuals, where all of the conditions of 8.7.6 are met and or represents dwelling units for senior residents, where occupancy of the units is restricted to senior citizens through a properly executed and recorded deed restriction running with the land For purposes of this section "senior" shall mean persons over the age of 55. This application is part of a development project which voluntarily agreed to a minimum 40 % permanent reduction in density (buildable lots) below the density permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space or farmland. The land to bepreserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the planning board that will ensure its protection This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a one time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. k_ This application represents a lot which is ready fora building permit ( all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that year. One building permit will be issued per year per Development until such time as the development schedule accommodates issuing building permits. Applicant must submit an approved FORM U with this EXEMPTION. PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS. BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED BUILDING PERMIT 1S ALLOWED AN EXEMPTION AS CITED ABOVE. i?v D THAT S MITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE BOVE ON WHICH DOES NOT COMPLY, WIIETHER DONE TO MY KNOWLEDGE OR EFUS BY BUILDING DEPARTMENT TO ISSUE A BUILD G P . ��1/�URE DATE THIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION Town of North Andover Planning Board F This form represents the schedule for allowing the following lots to be considered as eligible forMIS q permits under the Town of North Andover Management by-law Section 8.7 of the Zoning by-law.K) to 8.7 this Development Schedule must be filed in the Registry of Deeds and be referenced on the deed of each of the lots below and be filed with the Planning Board prior to the issuance of any build] v Wt" pi )VLJ permit for construction. Name and Address of Applicant for Lots: Name of Development: A?,A LE16t4 t>FrUGLdPMEK LLC 185 H\t-okY HILL PoAD NORTH {�+,3DoUtiR M A O t�`(5 C hRT t; P, FI£LO (oFF SRAbFGRb $TkvrlT Map and Parcel of Original: M h P G 2 DoT i? Date of Application for Lot(s) Division: flU G UST 9 1 2 002 Lots Covered by this Schedule 1-11-4 The Planning Board by their: signature below, or a signarure of a duly authorized represcantative, do hereby establish for the above named development the following Development Schedule for the purpose of Section 8.7 of the Growth management By -Law. The applicant, their assignees, successors and or subsequent property owners shall conform to the following schedule that limits the eligibility of the following lots for building permits. This form must be filed in the Registry of Deeds by the property owner or representative °A and be referenced on each deed for each of the following lots. Such deed reference for the deed of each lot shall at minimum reference the book and page in which this Development Schedule is filed and contain the language; '`This lot is subject to a Development Schedule pursuant to the Town ofliorth Andover Zoning \. BV Law all owners, representatives, and future purchasers should avail themselves of said restriction by v reviewing the approved Development Schedule as filed in Book insert here and Page insert here. The fact that a lot is eligible for a building permit is subject to the limitation of the number of building permits per year pursuant to section 8.7.2d of the Zoning By -Law." ,O n the Planning Board hereby schedule the lot(s) for the above development as follows: Year Eligible I Number of Lots Building Office Use Buildin, Office Use Elib;ible Date Lot ElizibiliNotes I Completely Utilized FY 2ooy (o zoos I I PI g Board member or Authorized Representative Sigrr6rin-e of Property Owngr or A --�`A�,�/ 6,61 rve 1 Date Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: a Q/� Location: r Citv l u • —41A Lye Y'. 'MA 6 loc-gJ ' Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity F7 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance Co. Policy # Company name: Address City: Phone #: Failure to secure coverage as required under Section 25A or L 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as_well_as_civil.,penafties in a nim nfa_STOP W9RK_ORDER_and_a fine _of.($]D0.00).a�lay.against.me. I understand that a copy of this statement may be forward t he Office of Investigations of the DIA for coverage verification. I do hereby certify under the pa' nd penalties of pe u that the information provided above is true and correct. Signature Date l% Print name 6Phone # 3J Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing 0 Building Dept ❑Check if immediate response is required . Licensing Board Selectman's Office Contact person: Phone #. Health Department ❑ Other MECcheck Compliance Report Massachusetts Energy Code MECcheck Software Version 3.3 Release lb Data filename: C:\Program Files\Check\MECcheck\Lot 9 Carter Fields.cck TITLE: Lot 11, #183 Carter Field Road CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 05/25/04 DATE OF PLANS: 3/23/04 PROJECT INFORMATION: Carter Fields North Andover, MA 01845 COMPANY INFORMATION: Tara Leigh Development LLC COMPLIANCE: Passes Maximum UA = 584 Your Home = 583 0.2% Better Than Code Ceiling 1: Flat Ceiling or Scissor Truss Wall 1: Wood Frame, 16" o.c. Window 1: Vinyl Frame, Double Pane with Low -E Door 1: Solid Floor 1: All -Wood Joist/Truss, Over Unconditioned Space Furnace 1: Forced Hot Air, 90 AFUE Furnace 2: Forced Hot Air, 80 AFUE Air Conditioner 1: Electric Central Air, 11 SEER Permit Number Checked By/Date Gross Glazing Area or Cavity Cont. or Door Perimeter R -Value R -Value U -Factor UA 2088 0.0 30.0 65 3384 0.0 19.0 233 512 0.340 174 63 0.340 21 2088 0.0 19.0 90 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in MECcheck Version 3.3 Release lb and to comply with the mandatory requirements listed in the MECcheck Inspection Checklist. The heating load for this building, and the cooling Standard Design Conditions found in the Code. Tl be no greater than 125% of the desigwfoad as spec Builder/Designer. appropriate, has been determined using the applicable C equipment selected to heat or cool the building shall Sections 780CMR 1310 and J . . Date MECcheck Inspection Checklist Massachusetts Energy Code MECcheck Software Version 3.3 Release lb DATE: 05/25/04 TITLE: Lot 11, #183 Carter Field Road Bldg. Dept. Use I Ceilings: [ ] I 1. Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 continuous insulation I Comments: Above -Grade Walls: [ ] I 1. Wall 1: Wood Frame, 16" o.c., R-19.0 continuous insulation I Comments: Windows: 1. Window 1: Vinyl Frame, Double Pane with Low -E, U -factor: 0.340 For windows without labeled U -factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: Doors: 1. Door 1: Solid, U -factor: 0.340 Comments: Floors: 1. Floor 1: All -Wood Joist/Truss, Over Unconditioned Space, R-19.0 continuous insulation Comments: Heating and Cooling Equipment: 1. Furnace 1: Forced Hot Air, 90 AFUE or higher Make and Model Number 2. Furnace 2: Forced Hot Air, 80 AFUE or higher Make and Model Number 3. Air Conditioner 1: Electric Central Air, 11 SEER or higher Make and Model Number Air Leakage: Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. When installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin (0.944 L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. Vapor Retarder: [ ] Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. Materials Identification: [ ] Materials and equipment must be identified so that compliance can be determined. [ l Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. [ ] Insulation R -values, glazing U -factors, and heating and cooling equipment efficiency must be clearly marked on the building plans or specifications. Duct Insulation: [ ] Ducts shall be insulated per Table J4.4.7.1. Duct Construction: ( ] All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. [ ] The HVAC system must provide a means for balancing air and water systems. Temperature Controls: [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. Heating and Cooling Equipment Sizing: [ ] Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in Sections 780CMR 1310 and AA Circulating Hot Water Systems: [ ] Insulate circulating hot water pipes to the levels in Table 1. Swimming Pools: [ ] All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. Heating and Cooling Piping Insulation: [ ] HVAC piping conveying fluids above 120 OF or chilled fluids below 55 °F must be insulated to the I levels in Table 2. Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes. Table 2: Minimum Insulation Thickness for HVAC Pipes. Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range ( F) 2" Runouts 1" and Less 1.25" to 2" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 Insulation Thickness in Inches by Pipe Sizes Heated Water Non -Circulating Runouts Circulating Mains and Runouts Temperature ( F) Up t0 1„ Upto 1.25" 1.5" to 2.0" Over 2" 170-180 0.5 1.0 1.5 2.0 140-160 0.5 0.5 1.0 1.5 100-130 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes. Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range ( F) 2" Runouts 1" and Less 1.25" to 2" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant, 40-55 0.5 0.5 0.75 1.0 and Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD (Building Department Use Only) PPWI L-4dli - ma Cd 0 "Cl 0 am quo Z o Q. 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W. 7a 7r` OO r.� N01, J `r lh w' ,✓• r1 a r. >� 1 � _0 T � J w' ,✓• r1 a r. >� 1 _0 ..=zi 9 Is o ( Ae o O M f�7/• N � a^ Z 00 OO��o a z�Hz o- E R 1 1 0 N Z w N Q N I ^^ r , A 4 d i 4 � o � o 3 19 g Q-2 O I o- g�' Date .... y ... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Jhis certifies that ,,.<,,�., ....... ....................................... 'has permission to perform ... .............................. wiring in the building of ...... ...................... Nor , th Andover, Mass - at ..18B ....... Fee..'.-�. Lic. N(F"�' ........ ................... ELECTRICAL INSPECTOR Check # 5131 Official Use Only Permit No. '7,;(5 edni12d7Zl(/5t z?w 61�7 i%Z>lf55X4(?WLS5�I tDrq&ant�xurt a� ?uelie Sway�� Occupancy &Fee Checked C� BOARD OF FIRE PREVENTION REGULATIONS 527 CM 12:00 APPLICATION FOR PERMIT TO PERFORM LECTRICAL WORK All work to be performed in accordance with the Massachusetts ectrical Code 527 CMR 12:00 I (Please Print in ink or type all information) Date To •l. /....... cto-r of III: Iv llle IIIJFJCa.lV1 v1 ■YICJ: Town of Andover The undersigned applies for a permit to perform the electrical work Location (Street & Num1bbei Owner or Tenant�Y Owner's Address l �- co*I%- Is this permit in conjunction with a building permit Yes 8/ No a (Check Appropriate Box) Purpose of Building :ts ( ^' Utility Authorization No. 2-07 ! to Existing Service Amps Voits Overhead 0 Undgmd 0 No. of Meters New Service t V Q Ampsa10J__Lq0Vofts Overhead 0 Undgmd No. of Meters Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Work INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includin mpleted Operations Coverage or its substantial equivale YES NO s ha jlid proof of same to the YE >- NO - If you have checked YES please indicate the type o coverage by checking the appropriate box. IN URANCE BOND - OTHER a (Please Specify) n _ _ vo (Expiration Datet aS Bus. Tel No. av .✓0 O� Address � � J 1 S lu'y Alt Tel. No. OWNER'S INSURMCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ Vy (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above a In a No. of Lighting Fixtures Swimminq Pool gmd a gmd a Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units N16- of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and 8 Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices a Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW S' ns Bailases Wirin No. Hydro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includin mpleted Operations Coverage or its substantial equivale YES NO s ha jlid proof of same to the YE >- NO - If you have checked YES please indicate the type o coverage by checking the appropriate box. IN URANCE BOND - OTHER a (Please Specify) n _ _ vo (Expiration Datet aS Bus. Tel No. av .✓0 O� Address � � J 1 S lu'y Alt Tel. No. OWNER'S INSURMCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ Vy (Signature of Owner or Agent) .Name: City Phone am a homeowner performing all work myself. FI am a sole proprietor and have no one working in any capacity = I am an employer providing, workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance Co. Policy # Company name: ' Address City: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature. Print name Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact FORM WORKMAN'S COMPENSATION Date Phone # ❑ Building Dept E] Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other Town of North Andover Building Department 400 Osgood Street North Andover Ma 01845 (978) 688-9545 Fax (978) 688-9542 t%ORTH O�tt�ec ,6q�'O O gyp_ coc.ncww.cw APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION ADDRESS l 10 �2 6 fir LOT DATE REQUEST FILED `517 SUBDIVISION (�f tA r ) DATE READY FOR INSPECTION TEN (10) DAYS NOTICE PRIOR TO CLOSING DATE IS REOUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE 25.) DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT ME' L APPLICABLE CODES. SIGNATURE OFFICIAL USE ONLY ROUTING ?o as D.P.W. -WATER METER (/1S'7�DATE I d D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO THE INSPECTION REQUEST DATE. t4e Uj SIGNATURE / DPW AUTHORIZATION -4 Date. !F //. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACHUS Q".a, . . . . . . . . . . . .. . ........... This certifies that ....... has permission to perform I. ..................... plumbing in the buildings of ....... .................. at. Ik" ................................... North Andover, Mass. Fee Lic. No.. -z1a .. ............ PLUMA90SPECTOR Check # 6140 MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location/1-r ` NIFORM APPLICATION FOR PERMIT TO DO PLUMBIN DateL110 ?wners Named �Zt j /1( c Permit # Amount of Occupancy r`9 New � Renovation Replacement Plans Submitted Yes No ❑ FIXTURES (Print or type) / Check one: Certificate Installing Company Name�V��i�C'�C� /il/^�/n. ���/ia1 Co Address .1167 r. ll/. /L(� Gt.�Pi l%i t Business Telephone c� — �/ �Firm/Co. s Name of Licensed Plumber: t&A Insurance Coverage: Indicate the ty a of 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 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 instal latio rformed under Permit I sued for this application will be in compliance with all pertinent provisions of the Massachus a Plumbing Code apter 1 the General Laws. By igna ure of Mcenseaum er Type of Plumbing License Title 67 t City/Town i en a UMDer MasterJourneyman El (OFFICE USE ONLY Date ... `i ....... . ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that J has permission for gas installation , ..".,. in the buildings of ... `��''?.•�-�� ........................ �l at �' t ..... ........ ... , North Andover, Mass. Fee 6 ..... Lic. No...3 �,,, ....... . GAS INS . -CbR Check # "A811 MASSACHUSETTS UNIFORM APPUCATON (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations L!% / 41,43 Gc-)n Owner's Name New Renovation ❑ Replacement ❑ ti T TO DO GAS Date /l Permit # 40 Amount $ Plans Submitted 0 (Print or type)a �G'�'C / l V')1BIp+y /�_ % '>�Z�fn� heck one: Certificate Installing Company C❑ Name Corp Address ai tner. AA Aada Business Telephone 7 ^— ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter /` (i !/1 6TH. FLOOR (Print or type)a �G'�'C / l V')1BIp+y /�_ % '>�Z�fn� heck one: Certificate Installing Company C❑ Name Corp Address ai tner. AA Aada Business Telephone 7 ^— ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter /` (i !/1 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked yes, please in cate 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 perforneounder Permit Iss d for this application will be in compliance with all pertinent provisions of the Massachusetts State. de and Chapter o tGeneral Laws. Title City/Town OVED (OFFICE USE ONLY) y Xgnature of Licensed Plumber Or Gas Fitter Plumber Has Fitter Licertse'�umber ' Master ❑ Journeyman Date... ... ...,.......... . t o�oy` ,..o e•,�o ,� TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION ... ,9SS,ic HuSE� This certifies that ... .. �1.......' r �,. l - has permission for gas installation .....r in the bui ngs of t'rg... Lal ��-�- se M� -114V- r� atib/r/th Andover, Mass. Fee .c,�.� . �OLic. No.. %/ .. .......................... i GAS INSPECTOR Check # f2, 4877 MASSACHUSETTS UNIFORM APPLICATON FOR (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations Tara Lee Develolment Ow New Renovation ❑ Replacement $25.00 G UB -BASEMENT A S E M ENT ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. STH. FLOOR FLOOR TO DO GAS FITTING Date 10/6/04 11 Permit # #te77 Amount $ 978 687 2635 ' Plans Submitted ❑ U w .0 de gr u $ C a 1 ne to a z c 1 be 's st'b o o0Ig 10 W F E A (Print or type) Ch k one: Certificate Installing Company Name Eastern Propane Gas In Corp. Address 131 Water St., Danvers MA 01923 ❑ Partner. ❑ Business Telephone 1 800 322 6628 Firm/Co. Name of Licensed Plumber or Gas Fitter Brian Kimball INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes f No ❑ Ifyou have checked yes, please jndicate the type coverage by checking the appropriate box. Liability insurance policy FA 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 certifythat 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 Codeod Chapter 142 of the General Laws. Iftawalk ICity/Town (OFFICE USE ONLY) s[gn'atemeFLiNfiffdAlffimber Or Gas Fitter Plumber �'tI P1 n Gas Fitter License Number ❑ Master ❑ Journeyman j IZI 1,1y� w z w x a w d N U w .0 de gr u $ C a 1 ne to a z c 1 be 's st'b o o0Ig 10 W F E A (Print or type) Ch k one: Certificate Installing Company Name Eastern Propane Gas In Corp. Address 131 Water St., Danvers MA 01923 ❑ Partner. ❑ Business Telephone 1 800 322 6628 Firm/Co. Name of Licensed Plumber or Gas Fitter Brian Kimball INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes f No ❑ Ifyou have checked yes, please jndicate the type coverage by checking the appropriate box. Liability insurance policy FA 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 certifythat 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 Codeod Chapter 142 of the General Laws. Iftawalk ICity/Town (OFFICE USE ONLY) s[gn'atemeFLiNfiffdAlffimber Or Gas Fitter Plumber �'tI P1 n Gas Fitter License Number ❑ Master ❑ Journeyman j A ,q O cHus {� CEICATE OF USE & OCCUPANCY Viii N OF NORTH ANDOVER Building Permit Number Date T S CERTIFIES I THE BUILDING LOCATED ON `t D ! g7 MAY BE OCCUPIED AS l `r- � `< ` IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY, APPLY. m m m m m 141 CA F) v y .O C � CO2CD C" n Z y CLO �C'lMM� r O C. _' y nC.O "0 CD CDO CDCL o c� CO CD CD o CD w� a. 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