Loading...
HomeMy WebLinkAboutMiscellaneous - 197 VEST WAY 4/30/2018s > Date... ? �.. �. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that � i P`�'� , a d .......................................... .... has permission to perform ..,, . .... Ca S Sr wiring in the bui ing of........'....".................................................. ............................................ at / .................................... _eD Fee ..-......... Lic. No.. ......... Check # 2 ........................... ....................... North Andover, Mass. ELECTRICAL INSPECTOR Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. I -605Z- I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 NK OR TYPE ALL INFORMATION) Date: J AJ '2eI , i L, City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives no ce of his or her intention to perform the electrical work described below. Location (Street & Number) 10(-/ V G4 i AV � Owner or Tenant h— Telephone No. Owner's Address 1-7-7 \l{-- f+ ✓lrz. Is this permit in conjunction with a building permit? Yes a No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: ;w�ra�l�-moi ay�- 6 �RGc�SsCD � Completion ofthe following table may be waived by 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- ❑ rnd. grnd. o, of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number . Tons ."""'............. '" "" KW """" "".......... "' ' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Key Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: o Atiach additional detail if desired, or as required by the Inspector of WYres. 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. 14 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 [?f BOND ❑ OTHER ❑ (Specify:) I certify, under the p ins and penalties of perjury, that the infoYntation n tIf" plication is true and complete. FIRM NAME:. w 1 v �- i LIC. NO.:% Z Licensee: y� �; w: L io Signature _ �> LIC. NO.: -2 3 a9"2 (If 9"(If applicable, enter "exempt" in the license ilumber line Bus. Tel. No. • a 7i J/,f ¢491 Address: A/L1Ve4 0oN c t1Y Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departm 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' agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After 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, fine 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 shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if 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 of the Acts of 2010 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 certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, 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, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass P Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECT N: Pass 0 bl Failed Re- Inspection Required ($.) ❑ Inspectors Comments: 414 Inspectors Signature: Date: EB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com - Jhe Commonwealth of Massachusetts Department of IndustrialAccidents s ~ = X Congress Street, Suite 100 ' d Boston, MA 02114-2017 vt www mass•gov/dia d�M SJ�v -Workers, Compensation insurance Affidavit: Builders/ContxactorslElectricians/Plum ers. TO BE FILED WITH THE PERMITTINGAUTHORIJLY. olnoetaprint 1 FAVPu�Qu6,�,y iva u+, a Name (Business/ftanization/lndividual): Address: Rt `� v QY City/State/Zip:_ Are you an employer? the appropriate box: Phone 1.Q I am a employer with employees (full and/or part time)." 2. ❑ I am a sole proprietor or partnership and have no employees working for me in a acity [No workers' comp, insurance required.] My c p 3.❑ I am a homeowner doing all workmysel£ [No workers' comp. insurance required.] t 4.❑I am a homeowner and will. be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no eriployees. 5.F]I am a general contr4gto f'and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 1 4 and we have no employees: [No workers' comp. insurance required.] Type of project (required): 7. [1 Ne" " onstr66tlon g, emodeliiig 9, ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions l2, [] Plumbing repairs or additions 13T] Roof rep airs 14.n Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: i Homeowners who submit•this affdavnt indicating they are doing all work and nye of the sub -contractors and statg whether or a e outside cont acto S must submit anew pooti thoscpntiges, have h $Contractors that check this box must attached an additional sheet showing Penni ovees. If the sub -contractors have employees, they must provide their workers' comp. policy number. d •' b site I am an employer that is pr ovidingwor ""S' information. Insurance Company Name: compensation insurance for- my employees. Below is the poltey an �o Expiration Date: Policy # or Self -ins. Lic. it: . (� o "G I q �;tk_�W_ City/State/Zip ' ��• Job Site Address: Attach a copy of the yvorkexs' compensatio policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under M c. 152,es §he is o£aSviolationnal punishable STOP ORDER and fine of up to $250.00 a and/or one-year imprisonment, as well a pen day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veru I do hereby and penalties of perjury that the information provided above is ar ue urs. ��� G��• TWA - Of flcial a+P• Official use only. Do notWite in this area, to be completed by city ortown official. Permit/License # City or Town: issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Phone Contact Person: U 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 hive, 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 receivot'or trustee 6f 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 b6 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 applicai tt•whd has not produced -acceptable evidence of compliance with the insurance cover age req. aired." 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 Pleasb 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 certificates) 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I D ate��/���............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...Y..� 1 VY1►AR CfPc' n? Avl P�# , .........�.. -S has penin ion toperform .i!.�� !+G�-('�e r^`'�2 ' P.n � t- C c 1 s� ......................................................................................... wiring in the building of.........�-e 4 .................... . ......................................... v S+ orth Andover, Mass. /^� Fee.". . �~........ Lie. No. I..`.........L ...... ....................... EEC K��IN�PI�T� Check # .� I r) 7 7 f�>PA s Irzd t� Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS 0 cial Use Only PermitNo. N 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 PRINTW INK OR TYPE ALL INFORMATION) Date: 16 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) 117 V GS �- WO -1 Owner or Tenant 1 �? J t j `d k e-4 Telephone No. 178 6 $ 8 Z 14 D Owner's Address W7 7 \/CS I' Is this permit in conjunction with a building permit?Yes L Purpose of Building 5t - k �kMA, `( '�P ,5%Aof cC. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Electrical Work: PuL� r & PL&ce— tk k -(J SOc°c4 L t— 61(i t— )cC r-C,n)^-CTS fir Location and Nature of No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: 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- El rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number " Tons J.KW ..."'."". .......... No. of Self -Contained Detection/Alerting Devices No: of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritNo. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent Leo. Hydromassage Bathtubs Le No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: s Attach additional detail if desired, or as regidred by the Inspector of Wires. Estimated Value of Electrical Work:�(When required by municipal policy.) Work to Start: 10 6 14 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:) Icertify, tinder thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. 1 %b t11 J X F L2(- rc L C 4f f V c e& Is LIC. NO.: 1.5 o 0 2 Licensee: r/1 -f( S. oy,,)6 Signature LIC. NO.: 601 /1 - (If applicable, enter "exempt" in the lice a ryztmber line -Z, Bus. Tel. No.: b� 3 a 35 � 9' 5b Address: 1$ !k t L l -d L c�°"`l d -%! v � O 3Dg Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security 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. nature below, I hereby waive this requirement. I am the (check one) [Iowner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the ` permit application fotnn to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, §32, an i 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 shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if 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 of the Acts of 2010 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 certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, 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, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: } PARTIAL ROUGH INSPECTION: r Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Y Pass 0 Failed Re- Inspection Required ($.) ❑ i Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Faile Re- Inspect n Required ($.) ❑ Inspectors Comments: --17 S Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustriqlAccidiks Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): V 0 JV' (k f y Address: 1,7 ( LLS f -o,- i� d City/Stat(VK d 3 6 6 7 Phone #: 60 3 3 Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with �_ 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors �• [VrRemodeling 2. El am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. El We are a corporation and its g E] Building addition [No workers' comp. insurance required.] officers have exercised their 10. ❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] r q ] employees. [No workers' 13. ❑ Other comp. insurance required.] *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. � Insurance Company Name:. 1 p`t e d ` u k---( (YJS Ul X -'J Z CO Policy # or Self -ins. Lic. #: U 4 6 �- 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. Ido hereby cert fy under the pains and;penalties ofperjury that the information provided above is true and correct. Phone #: t b 3 2 3 5 6950 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # -6-(-I Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 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 (ifnecessary) 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 Ma ssachu setts Department of Jndusfdal Accidents Office of Investigations 600 Washington Street Boston, M. 02111 Tel, # 617-727-4900 at 406 or 1-877:MASSAFE Revised 5-26-05 Fay, # 617-727-7749 www.mass,govaa v 4 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address: Policy Number: Date/Cause of Loss: File or Claim Number: Kevin & Melanie Foley 197 Vest Way H QZ947 8/19/2012, Water/Tank Let Go 26648-J Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Jim Taylor On this date, I caused copies of this Notice to be sent to the addresses indicated above by First Class Mail,, nature bnd D ANDERSON ADZWVMENT O. I C. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 above at the -16-12— ANDERSON 16-12 a 'N2 41"4.2 Date-e"?�-o/ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SACMUS" This certifies that .. �`... _ ?' } .- �.�--�-rJ .. • • • • . • • • • • has permission to perform .,:�c«%`?-� �- 2_���/........... • . • . plumbing in the buildings of .. _ `! �. - ��............. • .. . at. �' l 2. . .. • • • .. , North Andover, Mass. n Fee- ) . .. Lic. No.. �: 3_�:. .. /`: u-z`..t�. .......... . PLUMBING#N ECTOR Check WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION•FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDO/V�ER, MASSACHUSETTS Building Location 7 �, �,/�. Date p"��j Owners Name / p r f Permit #_ �l`9yz— Amount �j 0 Type of Occupancy ` t New Renovation Replacement Plans Submitted Yes No n 11�J FIXTURES r 1' •8• 91H HJOM (Print or type) Check one: Certificate Installing Company Name j> ElCorp. Address Tb F1 partrier. Business Telephone—/q 7©Fum/C0. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 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 7 Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass c tate umbing ode and Chapt e 1 Laws By Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License tcense Num0er MasterEJ Journeyman �'j 3 6. 7Date ... .. .1121'�-�L A TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... Va'.!A `t.. �.,..... ... I ��. �. i . has permission to perform ......12.... !.�?.�. e. I ................................................ wiringin the building of V � �G! "? . �.�....... St ..0 i.j v Or8 .............................................. .. , North AndovOMS F ee. .s....�� . Lic. No...... -R?!...... . ... . �q ELECTRICAL INS ECTOR Check #' The Commonwealth of Massachusetts FOR OFFICE USE ONI* Department of Public Safety permit No. BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00lgo, - Receipt No. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work will be performed in accordance with the Massachusetts General Code. 527 CMR 12:00 I/1 / (PLEASE PRINT IN INK gR,TYPE ALL INFORMATION) Date 3% City or Town of n r\ G1 �/ G— To the Inspector of Wires: No. of Transformers Total KVA U The undersigned applies for a permit to perform the rlectrical work described below: Swimming Pool Above grnd. ❑ In-grnd. ❑ Generators KVA U Location (Street and Number) Cl 7 e y No. of Oil Burners Map: Lot: Owner or Tenant i g C, V f i rtx G 1\ FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self -Contained Detection/Sounding Devices Zone: No. of Air Cond. Total Tons Owner's Address CZ W�.+-- No. of Total Total Heat Pumps Tons KW No. of Dishwashers Space/Area Heating KW Is this permit in conjunction with a building permit? Yes ❑ Not No. of Water Heaters KW (Check Appropriate Box) Purpose of Building Utility Authorization No. Low Voltage Wiring Existing Service Amps / Volts Overhead ❑ Underground ❑ No. of Meters New,.Service Amps / Volts Overhead ❑ Underground ❑ No. of Meters Number of Feeders and Ampacity Locat%n and Nature of Proposed E ectrical Work C 1 h to ;, ;; �-+��1 @� 1 tilii f 'S ! 1S ►t•` ��� 11 � W Ig (� i1 -A f�1�1 �l( No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA U No. of Lighting Fixtures Swimming Pool Above grnd. ❑ In-grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emerg. Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self -Contained Detection/Sounding Devices No. of Ranges No. of Air Cond. Total Tons No. of Disposals No. of Total Total Heat Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers 11 Heating Devices KW No. of Water Heaters KW No. of Signs No. of Ballasts Local ❑ Muncipal Connection ❑ Other No. of Hydro Massage Tubs No. of Motors Total HP Low Voltage Wiring OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES W NO ❑ I have submitted valid proof of same to this office. YES 43 NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE $' BOND ❑ OTHER ❑ (Please Specify) FSIS.��G Estimated Value of Electrical Work $ Work to Start _ -� / / G.%' c' Z Inspection Date Requested: Rough Signed under the penalties of perjury: FIRM NA Licens( " Address Signature Final LIC. NO. LIC NO. 3 o CJ J �= (Expiration Date) Bus. Tel. No. Alt. Tel. No. of 2 9,' r 51 _ -Z 90 r OWNER'S INSURANCE WAIVER: I am aware that the Licensee 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 th' requirement. Owner ❑ Agent El (Please check one) Oq(/d 1 Telephone No. ____ PF.RMTT FEF. It (� (Signature of Owner or Agent) r- ta'1 Location L S 7 4(-;;) No. Date �s/h A TOWN OF NORTH ANDOVER Water Connection Fee ,UW 0 TOTAL No. p,�doves Good Building Inspector Div. Public Works Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHuse Foundation Permit Fee $ Permit Fee $ RE�EIV�D PAYM'er sewer Connection Fee $, Water Connection Fee ,UW 0 TOTAL No. p,�doves Good Building Inspector Div. Public Works Location / -T No. Date NORTF� TOWN OF NORTH ANDOVER Of,«1O '�, O A : Certificate of Occupancy Building/Frame Permit Fee $ $ `- ,; �' b",CH •''�� �Ss�cHuSEt Foundation Permit Fee $ Other Permit Fee $ REcENED P Sewer Connection Fee $ milnnection Fee $ TOTAL $ No• Andover Colle otor Building Inspector Div. Public Works Location 1 U No. Date PKIL TOWN OF NORTH ANDOVER Certificate of Occupancy $ `-- Building/Frame Permit Fee $ Foundation Permit Fee $ � , P AA,,�� ther Permit Fee $ �tnnection Fee $ APR �"` o Mater Connection Fee $ T�AL No. Andover Coll �eetor. _ Building4lnspector I J Div. Public Works Location �� ! f' -� ' ✓ �� No. Date 4ld a TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Ar Connection Fee $ u~ 4 `� GiQt�� ater,Connection Fee $ � 4 TWALio $ pnn� NT =dIngnspeofor / 4 No. Div. Public Works P APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ////,t/A � / \ v PAGE 1 MAP +40. LOT NO. 12 RECORD OF OWNERSHIP IDATE (BOOK 'PAGE ZONE SUB DIV. LOT NO. 410 LOCATION PURPOSE OF BUILDING OWNER'S NAME T NO. OF STORIES SIZE _ A d4tw "`7iT4 - OWNER'S ADDRESS y„ BASEMENT OR SLAB Q S6 rn& Y7 -p ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST ^ lO 2ND /� y//� 3RD BUILDER'S NAME SPANsi- DISTANCE TO NEAREST BUILDIN& DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS /ID DISTANCE FROM LOT LINES - SIDES REAR /©o '" "' GIRDERS a x %5 i1 F TT+HICKNESS AREA OF LOT / 1 ®Q - FRONTAGE 1�© / / HEIGHT OF FOUNDATION �� f_ �� f� IS BUILDING NEW (.t f�/� SIZE OF FOOTING X / IS BUILDING ADDITION �I�I -�, Y Veil MATERIAL OF CHIMNEY IS BUILDING ALTERATION .� _ IS BUILDING ON SOLID OR FILLED -LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE !!ff IS BUILDING CONNECTED TO TOWN WATER S-, 2 �J BOARD OF APPEALS ACTION. IF ANY \/I �4�+ W- IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPON LAND C68T \ ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS i. PLANS MUST BE FILED AND APPROVED BY BUILDING I Ejo% 7 LEEE PAID - DP4 DATE FILED Y/z- /y 2--^ LL//FI /I A FE PERMIT GRANTED Alan ay, 19 5'Y LESS F � �p BOARD OF SELECTMEN fRAME3M1i BUILDING INSPECTOR OWNER TEL. b c) 2 N BOARD OF HEALTH PLANNING BOARD PERMIT FOR FOUNDATION ONLY SEE BOTH SIDES EST. B cosr ti REGULATED BY PARA: 112.7 S.B.C. PAGE 1 FILL CUT SECTIONS 1 - 3 - �,y EST. BLDG. COST PER BQ. FT. BATE: -3' L FEE PAID: 41 EST. BLDG. PAGE 2 FILL OUT SECTIONS 1 - 12 COST PER ROOM `'LDING SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING PERMIT FOR FRAMM. ' U 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS i. PLANS MUST BE FILED AND APPROVED BY BUILDING I Ejo% 7 LEEE PAID - DP4 DATE FILED Y/z- /y 2--^ LL//FI /I A FE PERMIT GRANTED Alan ay, 19 5'Y LESS F � �p BOARD OF SELECTMEN fRAME3M1i BUILDING INSPECTOR OWNER TEL. b c) 2 N BOARD OF HEALTH PLANNING BOARD BUILDING RECORD , 1 OCCUPANCY 12 SINGLE FAMILY s ES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFI FII CES __ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ B 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY WALL UNFIN. _ _ 3 BASEMENT 11 AREA FULL FIN. B'M'T' AREA FIN. ATTIC AREA _ w NO BM'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 41 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING D —COMM ASBESTOS SIDING _ COM�,nCN _ VERT. SIDING ASPH. TILE f STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING — —�- STONE ON FRAME _ SUPERIOR I POOR IUATE ADEQNONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBRELMANSARD I _TOILET RM. 12 FIX.) _ J « FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS -' }^• GAS 7 NO. OF ROOMS ' OIL ELECTRIC fy B'M'T 2nd _ I 1st 13rd NO HEATING Foiui U . TOWN OF NORTH ANDOVER LOT RELEASE FORkI SUBDIVISION�-C� ASSESSORS MAP SUBDIVISION LOT(S) �-o t 4.4 `7 V'f st Ltla PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET APPLICANTO �7 h ` lGPHONE Iv p� -,�j DATE OF APPLICATION // hy y f TOWN USE BELOW THIS LINE CONSERVATION COMMISSION I ) � k -LAW -X CONSERVATION ADMIN. BOARD OF HEALTH HZiLTH SANITARIAN DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT WATER CONNECTIO x FIRE DEPT. �' r RECEIVED BY BUILDING INSPECTION DATE DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuarice of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. C- Lp- O z 44 G— m rl CA to 111 2 uj ICLM /..ice C O Z: a� ;c o c u 0 0 ce a ° °° LA as O C as 0 O0 •i C 1 : l�` a► = O u C d 1 rA t v 40 of d v $ O: _ 3: rA rA W W 3 'S r U•E O c'ui `. v ° o It a / •� ILh 66 Z Z Z W O O d u v < h Z W Q Z Z V OC m m L C J L L U t Y W j` j `. O O L C O C C C oC U ii Q LL fS m LL Ic U. m y uj ICLM /..ice C O Z: a� ;c o c u 0 0 J z O z O Q z D O U, ccO LL H O: LLJ CL ME ZD F�- z 0 M .w •z :v m 1 0 LLJ Li w v *d V ," .a r_1 0 E 09 O Z �lm 0 anCL C to c 0 m WD tvJ 0 Z a ° °° LA as O C as 0 •i C 1 : l�` a► = O u C d 1 rA t v 40 d v $ O: _ 3: rA rA OG 3 'S r U•E c'ui `. v ° o It a / •� y IL u O• C O J z O z O Q z D O U, ccO LL H O: LLJ CL ME ZD F�- z 0 M .w •z :v m 1 0 LLJ Li w v *d V ," .a r_1 0 E 09 O Z �lm 0 anCL C to c 0 m WD tvJ 0 Z •i C �r C d 1 t v 40 d OG •� 'S r U•E c'ui `. v ° o .. a d •� J z O z O Q z D O U, ccO LL H O: LLJ CL ME ZD F�- z 0 M .w •z :v m 1 0 LLJ Li w v *d V ," .a r_1 0 E 09 O Z �lm 0 anCL C to c 0 m WD tvJ 0 Z 0mv 94 T -el tr)C FICIa (n. i\1'I'li"\I .s l: Ca )N ERVATION I'I.ANNIN( j E. ►I\'I';I► IN ► W !'1.i1NNIN(; (;t)IllAll!Nl'l'1' 1)1sV131.01'A1l NT KAH-1 :h' 1 1.1'. NI LSO )N CHIMNEY APPLICAF1014 ANU 1'L131I1- .Ili) il.►ifi!i•) i i"i PERNI'I'. # 1544 - C-� OCATION bf S A1NER' S NAME: UILDERIS NAME: 'S NAME: oSri', N'S ADDRESS: I -t CA /t11= U ASON' S TELEPHONE: 4 i.,•. ATERIAL OF CHIMNEY: r;'L N,ERIOR CHIMNEY: I-XIERIOIZ CHIMNEY: EMBER AND SIZE OF FLUES: 2, .. HTCKNESS OF HEARTH: ' 1 4 11 LU cUbiney an OiAen.Cace con)a� I to Vle ne.qub(elllell.(:3 u( the tulle and have ,tutm talc( egt,tationz 6ee)1 kece-Zved: vf'9MI4 4TE: 6 s IGNATURE OF MASON: I-RMIT GRANTED: )BERT NICETTA '.(ILDING INSPEC JSPECTEU: h1ARKS: IF FEE ZS" , ct-O N Ol Ol N GY w w IL LU O r d � 7 � p I— rS-S2 d V 00 'Q N d N F Q U 0 v 4 W Q U U y 9 F� dl A U QDU d V" 4Y d c� Q t� U ii F 3 � � y v Z C'y 3 w 3 p a c W G> w > >. J a I. W- J z c w C orA p z V o w 5 O d � 7 � p I— rS-S2 d V 00 'Q N d N F Q U 0 v 4 W Q 4w cr- s. 11 Q } V O v Z ¢ W f�/l: o y �Qw .z ° d . z u U ¢ m �Z aLL rA • � a. r E Q Cn o = Q E z o 0 v �^ V a��. a W U a r ZD ,o4.— C y 3: 3 > w c! '_-' o�z m ZX O r • �•L. •• .a C ~ W N � dl 4. 'C ... i..i. �: t1 • s s e •�re lJ.+ • 0: •� ° N g ccw F v1 y a e 4 o s 00 d .'' 0 r 61 O .r .p .0 04 a --� d 40 d _ u, O WCL W D L Vt- O 0 I Z W 99 O Lu d IA 96 Q -- m G t E E - j t V g L,� 3 ` t U. 10 m Y c .y _ ¢ c_ 2 c Q V) iZ c Q ii m co 4 U Q } V O v Z ¢ W f�/l: o y �Qw .z ° d . z u U ¢ m �Z aLL rA • � a. r E Q Cn o = Q E z o 0 v �^ V a��. a W U a r ZD ,o4.— C y 3: 3 > w c! '_-' o�z m ZX O r • �•L. •• .a C ~ W N � dl 4. 'C ... i..i. �: t1 • s s e •�re lJ.+ • 0: •� ° N g ccw F v1 y a e 4 o s 00 d .'' 0 r 61 O .r .p .0 04 a --� d 40 d _ u, O WCL W D L 0 z H 0 .y a E 4 C c O u 0 v 0 CL a. E c d W O b0 V z = •� CL 0 w 0 00 V 0 0 z