HomeMy WebLinkAboutMiscellaneous - 188 CHESTNUT STREET 4/30/2018 (2)o i
Location
19 9 C;Nw O N v� S�
No. �-5 3 (-::>
Aillillwilift
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Check # C n S H
Date 1C) _3
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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Building Inspector
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Ilds for f?ti .lum t3�t
BUILDING PERMIT NUMBER:
/ DATE ISSUED: �-_ d C) 3
SIGNATURE:
/� _
Building Commissioner/1for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
J. �l S,5 /ZT
J
1.2 Assessors Map and Parcel Number:
Zap um Parcel Number
0
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Re red Provided
1.7 Water Supply M.G.LC.40. 54)
Public 0 Private ❑
1.5. Flood Zone Information:
Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
ame (Print)
Address for Service
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1ice sed Construction Supervisor:
(-I I I Q I "/ //_ ,
Liceise8 15oiTstrticti6n Supervi r:
Address
Signature
/ -
Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Register d Home Improvement Contractor,
Not Applicable ❑
COMPAMY Name
Registration Number
Address
s —
Expiration Date
Si
Telephone
Ma
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506)
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 applicable)
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 by permit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, = I as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters re tive to work authorized byt • building permit application.
— 'e-1 / .,< 7:�:::
-Signature of Owner/&44Date
SECTION 70 oW"k/AuTHokjzb5 koiVt AECLARATION
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
l
Print Na ne t
Signae er/ ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB ,
SUE OF FLOOR T VIBERS 1ST2 ND3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
UINIENSIONS OF GIRDERS
I IEfGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL, OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
We Propose hereby to furnish material and labor in accordance with specifications below, for the sum of:
Dollars ($ -L'2 _ ).
Payment to be _made as follows:
-O 3 Q0 _
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from specifications Authorized
below involving extra costs will be executed only upon written orders, and will become an Signature
extra charge over and above the estimate. All agreements contingent upon strikes;
accidents or delays beyond our control. Owner to carry fire, tornado and other necessary"—NOTE: This proposal may be
insurance. Our workers are fully covered by Workmen's Compensation Insurance- = withdrawn by us if not accepted within days.
We hereby submit specifications and estimates for: �' '
ell
UP Construction
Home Improvement Specialists ,1�%
1115 Western Ave. DLxz, ��E..1�—
Y
ro O a 1
Haverhill, MA 01832
(978)-37-4-::'93-
PROPOSAL SUBMITTED TO
PHONE
DATE
—
'�
STREET — "
i X7
JOB NAME
� '
CITY, STATE & ZIP CODE
JOB LOCATION
ARCHITECT _ -
DATE OF PLANS
JOB PHONE
We Propose hereby to furnish material and labor in accordance with specifications below, for the sum of:
Dollars ($ -L'2 _ ).
Payment to be _made as follows:
-O 3 Q0 _
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from specifications Authorized
below involving extra costs will be executed only upon written orders, and will become an Signature
extra charge over and above the estimate. All agreements contingent upon strikes;
accidents or delays beyond our control. Owner to carry fire, tornado and other necessary"—NOTE: This proposal may be
insurance. Our workers are fully covered by Workmen's Compensation Insurance- = withdrawn by us if not accepted within days.
We hereby submit specifications and estimates for: �' '
ell
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is -that -the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A..
The debris will be disposed of in:
/A in n
(Location of
L) /Z - z AO
r/:—Zzzg
OnofmitA 5plicanWt
:
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through. the Office of the Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02911
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 emplon proviidining worker compensation for my employees working on this job.
Companv name:
Address
C ft.. Phone #
Insurance Co. Policv #
Fai4xe to secure coverage as required under Section 25A or MGL151 can lead to the imposition of criminal penalties of.a fine up to $1,500.00
andlor one years' imprisorrnent_as_welLas_cbd43enakiesjnsheiarmW-aBTDP]tVDW ORDElland_afaae_dIAIAA.QO)-ajday.a9aiostme. I
understand that a copy of this statement may be forwarded to th5A? fice of Investigations of the DIA for overage verification.
I do hereby cerKy unogr* pams and penwtbtof pW4 tW@e, information prwded above a true and coaect.
Print name Y—hT ) lel / / ') /i(//
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/licensing
[]Checkif immediate response is required El Building Dept
.p Licensing Board
E] Selectman's Office
Contact person. Phone # El Health Department
Ei Other
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,3'SACMUSi
Date.. ... ....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
a
This certifies that ................:..: %: % r..�...... .
has permission to perform
plumbing in the buildings of ... _ , ......................... .
at ......... North -Andover, Mass.
Fee...; . . .... Lic. No.... ... ..........� .......-.-........ .
PLUMBING 1NSP CTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS •7
,) Date
nn t ' /Owners Name �� L Permit #
Building Location �b�
Amount
Type of Occupancy A rl i7,g -
New Renovation , Replacement MPlans Submitted Yes n No
(Print or type) Check one:
Installing Company Name (% (_ 1 i 6• I �'1�'` /v Corp.
Address . / �' /;Z/-2�"" _ 41' - Partner
.✓ f,9 / J
KIM
Lj Firm/Co.
Certificate
Name of.Licensed Plumber. Y,t) / . e� I -Z f 6 ^—�
Insurance Coverage: Indicate the e of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
D
L
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 F� Agent
I hereby certify that all of the details and information I have
best of my knowledge and that all plumbing work and instal
compliance with all pertinent provisions of the MassachuM
11 LIC
City/Town
APPROVED (OFFICE USE ONLY
(or entered) in above application are true and accurate to the
fo under P Issued for this application will be in
'ng C _ Chapter 142 of the General Laws.
Type of Plumbing License
icense Numoer Master Journeyman ❑
�..:
nn��nnnnnnn�nnnnnnnnnnnnn
. I .. •
nn��nnnnnn�annnnnnnnnn�n�
"'•�ii�iiiiiiiiiiiiii�i�iiii
(Print or type) Check one:
Installing Company Name (% (_ 1 i 6• I �'1�'` /v Corp.
Address . / �' /;Z/-2�"" _ 41' - Partner
.✓ f,9 / J
KIM
Lj Firm/Co.
Certificate
Name of.Licensed Plumber. Y,t) / . e� I -Z f 6 ^—�
Insurance Coverage: Indicate the e of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
D
L
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 F� Agent
I hereby certify that all of the details and information I have
best of my knowledge and that all plumbing work and instal
compliance with all pertinent provisions of the MassachuM
11 LIC
City/Town
APPROVED (OFFICE USE ONLY
(or entered) in above application are true and accurate to the
fo under P Issued for this application will be in
'ng C _ Chapter 142 of the General Laws.
Type of Plumbing License
icense Numoer Master Journeyman ❑
Date ................. .... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
\61
This certifies that ......... ....... ............................
' has permission for gas installation ...:.:.. .................
in the buildings of ...:....:..:..'.
at .................... .. ....".,... , North Andover, Mass.
Fee......... Lic. No..'......... ..........:...............
GAS INSPECTOR
Check #
� 'I
MASSACHUSETTS UNIFORM APPLICATON FOR PERNffr TO DO: GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
e-�
Building Locations /O ( l� .C' ✓ .1�% L% �� l Permit #
Amount $'%
Owner's Name
New ❑ Renovation Replacement ❑ Plans Submitted ❑
A (Print or type) �%
one: Certificate Installing Company
Corp.
❑ Partner.
❑ Finn/Co.
Name of Licensed Plumber or Gas Fitter 0,q U L- LZ (:;z/ r, --i , --? A -%-/-
INSURANCE COVERAGE Chec ne:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
Liability insurance policy � Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe
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 installation rmed un jer Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts,Xate 99 Codd Chapte�Jp of the General Laws.
(OFFICE USE ONLY)
Ignature of Licensed Plu�ber Or Gas Fitter
❑ Plumber (FZ;z -o"
❑ Gas Fitter License Number
Master
❑ Journeyman
PER ta 1� 011111][131
A (Print or type) �%
one: Certificate Installing Company
Corp.
❑ Partner.
❑ Finn/Co.
Name of Licensed Plumber or Gas Fitter 0,q U L- LZ (:;z/ r, --i , --? A -%-/-
INSURANCE COVERAGE Chec ne:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
Liability insurance policy � Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe
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 installation rmed un jer Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts,Xate 99 Codd Chapte�Jp of the General Laws.
(OFFICE USE ONLY)
Ignature of Licensed Plu�ber Or Gas Fitter
❑ Plumber (FZ;z -o"
❑ Gas Fitter License Number
Master
❑ Journeyman
4
0
NoDate ...:..............................
4 MoRTH 1
3?°.,„`` TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
�SS�cHusf �
This certifies that
.............................................................................................
has permission to perform.........................................................;-.....................
wiring in the building of '
at............:........................f.........':................:............ , North Andover, Mass.
Fee... .................. Lic. No.............. ............................ ...........................
ELECTRICAL INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
THE0DMMOl WE4LTHOFIIRMQYlTW TS
DEPARTMENT OFPUBLICSAFM
BOARD OFFREPREVE MONRBGM7701 N527CMR 12.00
Office Use only
Permit No. 2,--:) l
Occupancy & Fees Checked
APPUCATTONFOR PEUff TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 11)(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street 6
Owner or Tenant
Owner's Address
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Ives [�No Q (Check Appropriate Box)
Purpose of Building Duin, v,,C_ Utility Authorization No.
Existing Service Amps Volts Overhead Underground M No. of Meters
New Service Amps` Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity `
Location and Nature of Proposed Electrical Work' U2 1�f2� f0/Z-, R_Ec 5 S F A f_t Grl T Vel DD c2co0 %bC
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
('f
Swimming Pool Above
El
Below
Generators
KVA
ground
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
To. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No of Dishwarbers (
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
OthJr'
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER
alha�,estix ikedvaWpmfofsam lotheOffm YES [:�J NO j
11 1 btnt:
1
INK Al[�J BOND OTFIER
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n
artWq"knt YES [E - NO D
Ifj ubmedvdWYE!,pleaserdicethetypec€wyw4pbyctm"gthe
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ough _ "-� +{ ,�,a� wak $
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OWNE�t'SMSURANCEWANFR;IamawatethattheLiomseclotltemraneco► et�rilssubstatrt ltegtrir>al�aslac}medbyly GerrralLaws
andAniysig�seonihispem-fkappliciatwai�mftm*mulalt.
(Please check one) Owner a Agent 1:1
4 Telephone No. PERMIT FEE $�� `
Location
• No.
Date �/
,40RTq
TOWN OF NORTH ANDOVER
f �
b 9
Certificate Occupancy
$
of
s�CNUs
Building/Frame Permit Fee
$
Foundation Permit Fee
$
z
Other Permit Fee
$ /
TOTAL
$
d
Check # '• �.�.
Building Inspector
` a TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: /� DATE ISSUED:
SIGNATURE:
Building Conimissioner/InspectorjoildingsDate
SECTION 1- SITE INFORMATION
1.1 Property Address:
%/U (4 TS;
1.2 Assessors Map and Parcel Number:
6 6 (7—
Map Nuniber Parcel Number
1.3 Zoning Information:
Zoning DiAtica Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G L.C.40. 54) 1.5. Flood Zone Information:
PuUr}ic 0 Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
CARY JAUC_ GCJ:-S L4E.v
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
t
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 -Licensed Construction Supervisor:
GUAYo6�- ?(zew-vu
Licensed Construction Supervisor:
i // �v Pt/12 �� • / L�;�S
Address
/I ):i, , A�* LPA`7 -19 33
Signature I Tele-pirone
Not Applicable ❑
C' S 7 5 s o
License Number
``
Expiration Date
3.2 Registered Home Im//p��rovement Contractor
Not Applicable ❑
p�
Company Name
n
0)6,7
Registration Number
—
!
0 /0
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 applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ition ❑
Add
Accessory Bldg. ❑ Demolition ❑ Other l Specify K 1 i'C (4 F— i►„/
Brief Description of Proposed Work:
2LmO vC L X(S7) U6- (�k C (2 -'J j dile � v0
PPC a/V c C's 4 /U o REP cf-)-c C 7-o- A 4L—
C-s0 9,. o ue z Ow (ucl- L)c,(4-T--kAj6- A kA3 i2ccesseo
(-(-Fk k N &
SECTION 6 - F.STTMATF,D CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit a licant
00TOAI, USE ONLY
1. Building
-ell, o Uo
(a) Building Permit Fee
Multiplier
2 Electrical
/
/ &C)D '
(b) Estimated Total Cost of
Construction
3 Plumbing
S O C' --
Building Permit fee (a) x (b)
'
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
/ o J
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNUT
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 applications)
P01)
Signature of (honer Date
0 �
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
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS iST 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS 77
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 075350
Birthdate: 11/22/1955
Expires: 11/22/2002 Tr. no: 75350
-
Restricted To: 00
WAYNE A TRECARTIN
cz--,
111 POPLAR
ST
TEWKSBURY, MA 01876 Administrator
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name
Location: l t 1 Po e ipp'- S i
Phone #y �� .s 7 ¢ s
I am a homeowner performing aQ work myself.
0 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: Ce_ -Cf -my t Co I) S "%2 -LA CT( OA l CO
Address 1 1 1 00 P CPA2� -S 1
nihr r-wVtV'3 MA ` IA Phone
Corn pany,.name:
Address
City . Phona.
Failure tb secure coverage as regiiin l`iirMer'Set tion 25A o� MG t 52 can lead to Etre in►position of criininel enalti es of. fine up to OU
and/or one years' iMprisonrment_2s Wa-.as_CMi-penaMesin2aelorm�.aSJMPI- _ OF. RDER..2nd_.aJine-of-t$IIIO.DW-asJay-agWnstme I
understand that a copy of this statement maybe fotwarded to the Office of Investigations of the DIA for coverage vetification.
I do hereby certify un er the pains and penaltieso penury that the information provided above is bve and correct.
Signature: Date �% d %
Print name
A� C�/-Jie-n A-1 Phone # � s� 5 7 ci_o `r 3 3
NL-
official use only do not write in this area to be completed by city or town official'
City or Town Permit/Ucensina _—
El Building Dept
❑Check if immediate response is required 0 Licensing Board
E] Selectman's Office
Contact person: Phone #: E] Health Department
Other
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Town of North Andover 14ORTH
0,
Building Department o - c
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax. (978) 688-9542L me
�rSp 7TED ,.PC'C�
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and. a condition of
Building permit'# the debris resulting from the work shall .be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c1 I, sI50a.
The debris will be disposed of in /at:
`0Wca-C.Az wP5;wvop SSyA/
S���► �)H
Facility location
744
Signatu e of Applicant
7-/ U/
Date
` NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
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Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that '
has rpiermission to perform ....... :........................................................................
wiringin the building of .......... ......... .................................................................
at................................................... ............ I.." ............ , North Andover, Mass.
Fee ...... !.............. Lic. No............
Check #
...............................................................
ELECTRICALINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
C'ommonwaaIg of Mamcliujeftj Official Use Only
cc�� cc7] Permit No.
�UsParltnstii' o�..Jfirs �srvicsd
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS FRev. 11/99) . leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (hIEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE :ILL /YFORiVATION) Date:
City or Town of. To the Inspector of Wires:
By this application the undersigned gives notice of tis or her intention to perform the electrical work described below.
Location (Street & `'u
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ Noe- (Check Appropriate Box)
Purpose of Building r-- Utility Authorization No.
Existing Service Amlis / %lofts Overhead ❑ Undgrd ❑ No. of i%Ieters .
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters:
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: �
Completion ordie ioUonince table maybe ueiveti by ttir tatnretnr nr ivirre
No. of Recessed Fixtures
No. of Ceil.-Susp. (Padd)c) Fats
No. of To-a
Transformers KVA
No. of Lighting Outlets
No. of ifot Tubs
Generators KVA
No. of Lighting Fixtures
No. of Receptacle Outlets
A oven-
Siviniming Pool rnd. Elrnd. C]Batte
No. of Oil Burners
o. o Lighting
6 ig ung
Units
FIRE ALARINIS No. of Zones
No. of Switches
No. of Gas Burners
t 0. o Detection an
Initiatin Devices
No. of Ranges
No. of Air Coud. Tons
No. of Alerting Devices
No. of Waste Disposers
eat unnp
Totals:
unn, er
— -
_ns __
p
_
g o. o c - ontainne
Detection/Alerting DeAces
No. of Disltivasiners
Space/Area Heating KW
Local ❑ Municipal❑Other
Connection
No. of Dryers
Heating Appliances KNV
ecuritySystems:
No. of Devices or Equivalent
No. of Water W
KBeaters
o. o t o. of
Signs Ballasts
Data Wiring:
No. o[Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total lip
a ecommumcations Wiring:
iYo. 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 permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such c��%
is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ND ❑ O'rHER ❑ (Specify:) I — Ij) _.W
(Expiration Date)
Estimated Value of Electrical Work:' (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the! ants and penalties aofper'trry, that t/re information oft this application is trite and complete.
FIRI%I NAME: I STI t -A CO ' LIC. NO.: A /29-11 7---
Licensee:S7Z_—%.&Aj a Signature LIC. NO.:
(lf applicable, enter " �Y. ry{�C inf�c l�',cense q�yy 'ne. n /_ Bus. Tel. No.•
Address: �o U e �CJX `/ `f �/TCJQQ�S% t -'C� Alt. Tel. No.
OWNER'S INSUI2A`iCE WAIVER: I am aware that the Licein a does trot have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check onc) ❑ owner ❑ owner's agent.
Owner/Avent PIsRt1IIT TEE:
Signature 1'c(cphone l\b.