HomeMy WebLinkAboutMiscellaneous - 20 Clark Street C<.>Al
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Date z.5�6, .. . .. .. .
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NORTP4
of °0 TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
�,SSACMUSEt
This certifies that . . . . . . . . . . . . . • . . . . . .
has permission for gas installation . . .F.4 f Ie. T. . . . . . . . . . . .
in the buildings of . . ., s . . . .1!,4 . . . . . . . . . . . . . . . . . . . .
at . ., .). .�:. . .( . .l. /�.�.�'. . . . . . . . . .. North Andover, Mass.
Fee. . a . .�. Lic. No.�h. . s. . .. . . . . ) % ...: . : . . . . . .
GAS INSPECTOR a
Check# S
7f62
f-
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date II
NORTH ANDOVER,MASSACHUSETTS
Building Locations 1t S 1 Permit# _ 7��L
1 L 1 6`+7 L t,/C OA+AAmount$
Owner's Name
New Renovation ❑ Replacement ❑ Plans Submitted
C
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SUB -BASEM ENT
'
B A S E M ENT
FG
1ST. FLOOR
2ND . FLOOR
r 3RD . FLOOR
4TH . FLOOR
5TH . FLOOR---------
6 T H
LOOR6TH . FLOOR
7TH . FLOOR _..:.__. ..
8TH . FLOOR
(Print or type)
Name 1°A( J;i<'-') t4�k, Check one: Certificate Installing Company
� �.1� s
Corp.
Address
Partner.
Business I a ep one 61 ff`Fi Co.
Name of Licensed Plumber or Gas Fitter S 11 q,i,� r�cls 1
INSURANCE COVERAGE Check o
I have a current liability Insurance blicy or it's substantial equivalent. Yes No
If you have checked yes,please' dicate 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.
Signature of Owner or Owner's Agent Check one:Owner 0 Agent
1 hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title Plumber _4 L a/—
City/Town Gas Fitter License Number
�4aster
APPROVED(OFFICE USE ONLY) Journeyman fn d
f!���
i.,
The Commonwealth of Massachusetts
Department o f industrial Accidents
Office of Investigations
Uf 600 TVashington Street
Boston, M14 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print LeQibl
Name(Business/Organization/Individual): ��3�� {�`, a
L
Address: —,I C 1 ate-- S ;
City/State/Zip: ✓, -e ;ti,, Phone#:
Are you an employer?Check the appropriate box.:
1.ElI am a em to er with 4. Type of project(requited):
P Y ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0111,am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
r ship and have no employees These sub=contractors have
working for me in any capacity. workers' comp.insurance, g' E]Demolition
[No workers' comp.inc�irance 5. ❑ We are a corporation and its 9. ❑Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I 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
insurance required.]t 12.❑Roof repairs
q ] employees. [No workers'
comp.insurance required] 13.0 Other
Any applicant that checks box#1 must also fill out the section belox-soot:nb=hqcomp=sation inform
fi tunHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors musty polisubmit a new•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 police and job site
information.
Insurance Company Name: r,� s 5 o C .e/n Y`_o L.)y P, , t�/ 3
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:_ ` t�-J < L4
City/State/Zip:nJ,)1Yt+
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 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
Simature: f'�"�
Date.: I],-)
Phone#: ( s
Eon only. Do not write in this area, to be completed by city or town official.
n• Permit/Licensehority(circle one):Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorson:
Phone#:
Information as d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association ox-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 acceptableevidence 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 cerdficate(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-nested,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 p=xnits 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
Of Of Investia atlans
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised.5-26-05
Fax # 617-72.7-7749
vrvrw.mass..gov/dia
Date.
NORTH TOWN OF NORTH ANDOVER
o41 PERMIT FOR PLUMBING
�SSACNUS� r
This certifies that . . . .A� I!�.<G . j. . . �)l.`?. . . . . . . . . . . . . . . .
has permission to perform . 2. C . jOq v
plumbing in the buildings of . . . . .�... . f — .
at. . . . . . . . . . << ?!'. ... . . . . . . . . ., . . ., North Andover, Mass.
Fee.IM. . . .Lic. No.. ?,`�l�' . . . . . `� . . . . . . . .
PLUMBING INSPECTOR
Check # `J
854;
Q
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
Building Location p� C,l i1,- S; Date h, ! 1.)
)
Permit#
Owner l i fa i 1, "t (�,�1'►/� Amount p
New E Renovation Replacement 13Plans Submitted Yes
No
FIXTURES
SUDEM
B�SF1vII�Tf
IST IIOOR i
2%ELO R
im IIDW
41HRDM
51H 919",
61H IIDQt
AR IIDOR
8IH 1HI:0(R
Cwt or type) Check one: Certificate
Installing Company Name (,
_ - ❑ Corp.
Address
ElPartner.
Business Telephone �+ ��- _�(�a1
_ aFirm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the of insurance coverage by checking thea nate box:
Liability insurance policy Other type of indemnity Bond
Insurance Waiver: L the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
ugnature Owner ❑
Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By:
Signature or Lice—usdalILU
Title Type of Plumbing License
City/Town own 114 G-
incense Master
APPROVED(OFFICE USE ONLY LLL� Journeyman.........iii
A#
9
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Ut 600 Washington Street
Boston, M14 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le ibl
Name(Business/Organization/Individual): PAA
Address: i✓CT��. S
City/State/Zip: ✓`,•e r(-,-t t1 rpy tom,y Phone#: 7 i- 6 Fa-A L
Are you an employer?Check the appropriate box:
i.❑ I am a employer with 4, Type of project(required):
❑ I am a general contractor and I
mployees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers' comp,insurance. 8. ❑Demolition
[No workers' comp. insurance 5. ❑ We are a corporation and its 9 ❑Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself P § (4),
y [No workers'comp. c. 152, 1and we have no
insurance required.] t employees. [No workers' 12.[]Roof repairs
comp.insurance required.] 13.❑Other
t -n
" v applicant that checks box#1 m 01 must also out the section below sann
f
o � R* _
compensation,Policy infoation.
homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 isproviding workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: Lo- -e I --,
Policy#or Self-ins. Lic.#:
Expiration Date:
Job Site Address: 5-0 C(-tir►e S City/State/Zip: 1I f-1,..1).),/PT
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 certifQywunder the pains and penalties of perjury that the information provided above is true and correct
Signature: Y'�
Date.: -� d• r �
Phone
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written_"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(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&,at the application far 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.ext 406 or 1-8 77-MASSAFE
Revised 5-26-05
Fax#617-72.7-7749
www.mas&.gov/dia
Date.. . .,!. . .. .. . ... ... . .
,tpRTh
1%
�` TOWN OF NORTH ANDOVER
p A
' PERMIT FOR GAS INSTALLATION
,to.•' qh
S'AcMus ..
This certifies that/. ��' `0. ./ . . -<—. . . . 1. . . . . . . . . .
has permission for gas-,installation . . . . . . . . . .
in the buildings of . . . . . . . . . . , .
at ' ���'��. . � �`�. . > -� .� , North Andover, Mass.
Fee/7.:?,.. . . Lic. ��r,''.c . . . . . . . . .
��� / GAS INS �C�OR
Check#
6667
MASSACHUSETTS UNIFORM APPUCATON FOR PERNIlT TO DO GAS FITTIlNG
(Type or print) Date 71
NORTH ANDOVER, MASSACHUSETTS '
Building Locations C k,- l�C� F
Permit# to G1/. �
2►'2��-P/1G�QG7 Amount$
-r� Owners Name
New Renovation Replacement Plans Submitted
� a
w
W p m F x F
Z r O C F dFF >• •• C)
w F w cC p O C Z F�
C U w F O rd:t
� C w E• z H W W C7 � fzl F W F � 0
a p ra C z E. �, w Z O z W 0 F
x 3 v a U °x > c a F c
SUB -BASEMENT
B A S E M ENT
]ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH .' FLOOR
/print or type
Name Check one: Certificate Installing Company
D Corp.
Address
DPartner.
usmess 1 a ep one Z '
Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE
I have a current liability Insurance,policy or it's substantial equivalent. Check one:
li:you have checked Les,please indicate the type coverage by checking the appropriate boxYes D NoD
13
Liability insurance policy D Other type of indemnity
13 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance co
Mass. General Laws,and that my signature on this permit application waives this requiremenge required by Chapter 142 of the
Signature of Owner or Owner's Agent Check one:
Owner D Agent13
t 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 setts State Gas Code and Chapter of the General Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title Plumber
City/Town, L/7-71
^ L
,. Gas Fitter icenseNu...-.,
Master
APPROVED(OFFICE USE ONLY) [3 Journeyman
1
Location aO eJ. A/e X Ago ac�
No. Date -9/10 l G
Y
NORTq TOWN OF NORTH ANDOVER
Ofi114e , ��.
3? � 6OL
` Certificate of Occupancy $
CNUSE<� Building/Frame Permit Fee $ c,200 r
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ a oD
Check #
17545 Z& &et�n�
/ Building Inspector
i
a w The Commonwealth of Massachusetts
d DeparPment of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
'�+ Sy•„� Workers'Compensation Insurance Affidavit
Name Please Print
Name: i� l
Location: lf�y/
City Phone #
0
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers'compensation for my employees working on this job.
Company name:
Address
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$1,5W.00
andlor one years'imprisorwnent.as.well_as_civil.penaliesintbeforrn d 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.
1 do hereby. rtify un r th pains and pen It es erjury that the information provided above is true and correct.
Signature
Print nameZ k4ZL7Phone# �S 7rG (�A�
Official use only do not write in this area to be completed by city or town official'
City or Town PermitlLicensin
gg ❑
[]Check Dept
if immediate response is required ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone#: ❑ Health Department
❑ Other
µQATF{
Town of North Andover o� • " _ ' ��
Building Department
27,Charles Street
North Andover, MA. 01845 ,''`•g°''"��y
�SSACNt15Et
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB LOCATION
Number Street Address Map/lot
"HOMEOWNER
Name Horne Phone Work Phone
PRESENT MAILING ADDRESS
City Town State Zip Code
The current exemption for"homedwners"was extended to include owner-occupied dwellings
of.two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling,attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned"homeowner"certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
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
c11, S150A.
The debris will be disposed of in:
(Location of Facility)
Sinature of Permit pplicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
:Jlze Loomv�r�eu�e�� o�✓�Gaaaa�.�.u6e�ta
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 018687
Birthdate: 01/04/1.950
Expires:01/04/200$ Tr.no: 12954
Restricted: 00
FRANCIS VALENTE
7 ZACHARY CROSSING
i•mix= ( o2GbLy /�
THE CONMONWEAi.TH OP MAASSACHMUS TTS
TOWN-OF NOR11 ANDOVER."TOW.-N
BUSINESS CER T. M. CATE
1N CflNP+Qjt�iIItY W1TB'?$E Y'xOVISYONS cor C &rm dn;S[}*D�IIYb.AND.TBN,
MCUON MV$•,OF 7=. G314!Z ,L LAVW, A4 Ai1�pDl4�'TSR. UNDE Dr �ttEBY
DBCLAIMM THAT A BOA UNmm-MIL T=OF:'
YN•TM T'OWN'OV NOUTH ANDOVEB;.MA.gUCMX9iI 6.
By.mm.]OLMVVMG NA WYP19WNS; ):
NAME RVMZNCE
_ aRu' Svu.w.An� z ���w�► 5r. WrtNca_.t��4 60.� .
.6IGNSD: I .
,
GbUTOltac SICKATOleli-�
BICTtiNX 8xt,NATUXZ'
Bsux.COtww. �.. ,
PICRSMAIXY A'PPEA>it1OSR.B kI M8'TEMA*DVR NAMD: ). '
LL
AND MADE OAT8'THAT TAZ'FOltZGOYNG•B-TATSAIX14T IS
C1aRTIRICA,TX E715: 0 i lot., ' a
PATRICIA A.BY
Notary Public
]1'd' Commonwealth of Massac setts
My Commission Ex res
September 6,200
NORTH
t
0 of
% zs A dover, Mass.,
COCMICMEWICK V
ADRATED 0'Pa` �y
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
// .... BUILDING INSPECTOR
THIS CERTIFIES THAT..�4.Ov� ....... A�� 041*
...... r `..T� ..r Foundation
,✓far •i- DCM. � o�
has permission to erect.../........... ........�............ buildings on ..Q � � Rough
.................... ...................................................
to be occupied as.......... ... • �O ��� A�rs Chimney
Ar...... ............ .... ....... .......... ..... ........................ ........................
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final •
this office, and to the provisions of the Codes and By-Laws relating to th;7;;�
Alteration and Construction of
Buildings In the Town of North Andover. lly/tv/ "=NOW PLUMBING INSPECTOR`
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
f^C Aj.o A?cAlati Final
�, 4,,> q,v PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
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..... ................. .
BUILDING INSPECTOR `�
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
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dependent Tire, Inc.
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341 Merrimack Street
Lawrence,MA 01843
Tel. (978)689-3900
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FORM U - LOT RELEASE FORM
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***********************
APPLICANT PHONE
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET T. NUMBER42,�)
******************OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT iia/),/e S .0 Pit�kle.� y� SM )e ecf��Ply•� f` e� �A . ,� ,lcw�vJ
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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W o CERTIFICATE O
o CER ®� NORTH ANDOVER
a TOWN
o O
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IB
Date:
zo permit Number
Z o Building THIS CERTIFIES THAT
CO oo cif
U > TSE BUILDING LOCATED ON TSE
WITS
w Q , p� A r" IN ACDCE D S CR Ol' ER
,I,E BUILDING CO
�D AS S STA' CER'I'�FICATE O��1
Z m M MAY BE OCC ' MASSACSUSETT
PROVISIONS OF TSE Y APPLY- .Y t� Ae
z ULATIONS AS MAY
REG � �
�,PC3 o o I t .-�-, �m
a !3, t c'�' Building�SPector
W n0. z C 02 l3 A �`� S
r of C3)
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_ 4Andover
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LA over, Mass.,
\V
I� COCKICMEWICK VA.
7�ADRATED PPa �5
S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
THIS CERTIFIES THAT 04 OV 4......�A ��I r, . . .... �`..T�r rFoundationDING
BUIL INSPECTOR
has permission to erect.../. 144"10 01"0... buildings on a CIA R K 9 ...................... Rough
...... ......................... ..................................
to be occupied as.......... ...............� .......,�!. O /�i�/'...S A��I 5....tl� r I"LOOP C.%., Chimney
..�...... .......................
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final ( `, /
this office, and to the provisions of the Codes and By-Laws relating to the I pection, Alteration and Construction of /
Buildings in the Town of North Andover. �y/�� ��� PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
� rc7'�poe A' v~ Final
,p,4,, p,G vt=w PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTION STARTS �-E�CAL INSPECTOR
Rough i6_l 3'n Y O'C 1-' l
.......
......... ................................ Service
01
BUILDING INSPECTOR
Occupancy Permit Required to Occupy Building GAS INSPEdTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To BeDone FIRE DEPARTMENT,
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det. ._. �� (� ��i 1 P
f
Date......k1.� ..
NORTN
TOWN OF NORTH ANDOVER
O
PERMIT FOR WIRING
"s •D�I�TID��``�
,SSACMUS(c�
This certifies that .......0...... .........!9.w..a.............. ...........................
{
j has permission to perform E.. �''
wiring in the building of.....fH �sr�c= K. ..., �rr. .......................
j
at...� ..Q.� L .t! .... .. ............................... .�North Andov S.
TFee..1:.�.e........... Lic.No:��l.�.. .:���?....,�!..`"..
.... ..........
ELECTRICALINSPECMR
Check #
i
5401
•+••—� lromrxonuraaun o� rr/aaeautudaGc7 �-
vnwo..w
(Rev.11/99) rv,
cc� cc77Permit Number.
Occupancy&Fee I
BOARD OF FIRE PREVENT TION REGULATIONS
APPLICATION FOR PEL TO PERFORM ELECTRICAL WORK
(ALL WORK TO BE PERF ''Wrrfi THE MASSACHtISErIS ELECTRICAL CODE 527 CMR 12:00)
PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: ? a
-City or Town of: To 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)
Owner or Tenant: �N
Owners Address:
Is this permit in conjunction with a Building Permit? Yes c No e— 11Check Appropriate Box)
Purpose of Building: r, Y li—c K 9 Utility Authorization#:
Existing Service: 26,,C/Amps Z olts Overhead Underground.13 . #of Meters
ti New Servicer Amps / Volts Overhead 17 Underground.❑ #of Meters:
Number of Feeders and Ampacity:
Location and Nature of Proposed Electrical Work: L✓1 -t 7—
No.
No.of Recessed Fixtures No.of Cell:Susp.(Paddle)Fans No. of Transtonners Total KVA
No.Of Lighting Outlets No. of Hot Tubs Generators KVA
No. of Lighting Fixtures Swimming Pool: Above ground o In Ground ❑ #of Emergency Lighting Battery Units
No.of Receptacle Outlets No. of 011 Burners Fire Alarms #of Zones
#of Detection&Initiating Devices
.No.of Switches No.of Gas Burners #of Sounding Devices:
#of Self Contained
Detecdon/Sounding Devices T_
No.of Ranges No.. of Air Conditlaners TOTAL TONS:
Local❑ Municipal Connection❑ Other ❑
No. of Waste Disposals Heat Pump Totals: Security Systems:
Number. TONS: KW: No.of Devices or Equivalent
No.of Dishwashers Space(Area Heating: KW Data Wiring,No..of Devices or Equivalent:
No.of Dryers ,. Heating Appliances KW Telecommunications Wiring:No of Devices or
Equivalent:
No, of Water Heaters KW No. of Signs: #of Ballasts: OTHER.
#of Hydro Massage Tubs No. of Motors Total HP
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 substantialequivv nt The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit
Issuing office. CHECK ONE: INSURANCE BOND o OTHER ❑ Please specify:
Estimated Value of Electrical Work$ (When required by municipal policy)
Work to Start: -7 "u / Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify,under the pains and penalties of perjury,that the Information on this application is true and complete./
Firm Name: �� LIC. �7p�3
Licensee: c /.=_ �!_-s s `� Signature: LIC.#. /,r! gf 3-3-
(if applicable,enter ex In the license er line)
v � y��
Address: S 7 `%/e- 4-- Bus.Tal.# ��7—Z/F`7-Att.Tel.r
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 o OR Agent o
Signature of Owner/Agent: Telephone
Date.. .......
TOWN OF NORTH ANDOVER
0
#- PERMIT FOR WIRING
4K
C u
HU
'Zz
This certifies that ................/
.....
has permission to perform ...................................
wiring in the building of.j� .....................
at,�.............................. ..................................... .North Andover,Mass.
-b ............ Lic.No.,? K.
Fee A ........./.... A V� F.
e" -�iBLEcrRI*C*A*'LI*Ns*P"E'cr'0*'R
Check #
5397
THE COMMOATREALTHOFMASSACHUSETIS OfficS.UseAffly
DEPARTIAIDVPOFPUBLICSgFMY
Permit No.
BOAROOFFMPREVF1MONREIGULWONS527(M]2.W -
Occupancy&Fees Checked
APPLICA77ONFOR PERMIT 0 PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 v (/
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4 r� o 7
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform a el ctrical work described below.
Location(Street&Number) 42, Q /q /E' 0 2 a
Owner or Tenant P2 d e 0 C n
Owner's Address 5 Ot W1 -e-
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Purpose of Building 11 Utility Authorization No.
Existing Service Amps1,2 61.2df Volts Overhead Underground No.of Meters
New Service Amps Volts Overhead Underground No.of Meters
Number of Feeders and Ampacity h C �'' G�c✓' c r/, �S
Location and Nature of Proposed Electrical Work JV e t.✓ io <�c t a- ply i 70�-i p7
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total
KVA
No.of Lighting Fixtures Swimming Pool Above Below Generators KVA
round ground
No.of Receptacle Outlets fJ No.of Oil Bumers No.of Emergency Lighting Battery Units
No.of Switch Outlets
No.of Gas Burners
No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones
Tons
No.of Disposals No.of Heat Total Total No.of Detection and
Pumps Tons KW Initiating Devices
'o.of Dishwashers Space Area Heating KW No.of Sounding Devices
t No.of Self Contained �o
Detection/Sounding Devices
IVo.of Dryers Heating Devices KW Local Municipal Other
No.of Water Heaters KW No.of No.of Connections
igns Bailasis
No.Hydro Massage Tubs No.of Motors Total HP
OTHER•
htsu mceComage Ra�arilothecegtmen�nlsofMassact>u�ttsGalaalLaws
IhareaamatliabH9yhmnano RAyinckdTCorTJ0le OLffW=CDWW0rAsWbg&tWWpMht1771yES NO
tl rddrlg nldladva6dptoofofsaneotheOffioe YES LOW El Ifyouhamdrel�dYES,piemhkm eWofcowrageby
,:WSURANCE box BOND OTHER ftweSpec i y) FiTiradmDme
WodcmStat r - / ( - G . Estin*dValuedUXttWWcdc$ 2, °o o !
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OWNER'SINSL ANCEWANFR,IamawarethattheLiarisedoesinthavetheinstuatloecovfrageoritssubstantiale9tlivalai[isleC}1![PdbyN1as�dusetlsGaxra(laws
and da Ir y signahne on this pemfflitaim waives this legtmement
(Please check one) Owner M Agent
signature or Owner or
Telephone No. PERMIT FEE$
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TOWN OF NORTH ANDOVER DiuijuLoi iG DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING M
OTHER+THAN A.dONE
QOR TWO FAMILY DWELLING
'tYR-1-7- 2.; d 1116 S—ectic--for A -.aVF ' -,e,� 'c J. S� �r -s r. ✓- f.T,
.r ..a• :. r. rrr.>` , B�i�daTS�E�FL
BUILDING PERINET NUINMER: z s DATE ISSUED: w
SIGNATURE: //Ay
Buildin&CommissionerAnspe6ctior dBuildings Date
1.1Property Address:r 1.2 Assessors Map and Parcel Number:
® � o
AlU; 4 N,)o V t Q HA 0 4(15 Map Num Parcel Number
1.3 Zoning Information: I.4 Property Dimensions: v
Zoning District Proposed Use Lot Area(sf) frontage ft "+
1.6 2gUII.IDING SETBACKS(ft) M
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: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑
2. ner of Record
1d
ame(Print) Address for Service
Signature Telephone
2.2 Authorized Agent
ame Print Address for Service:
- -- .--�
Si re Telephone 1 Z
.. :c( 55'i,3 „Iso .r ,:•e:+ «.�R.f7+ c� 90
3.1 Licensed Construction Supervisor Not Applicable ❑
,1?
Address License Number O
Licensed nstruction Superv' r: /
Expira ion Date
Sig tore Telephone 7 r
31 Registered Home Improvement Contractor Not Applicable ❑
o parry Name Registration Number
Address
/ Expiration Date Z
Si re Tel one
G)J
is
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 Yea.......❑ No.......❑
SELA�-( ON.
"TRUen
19x7Et 1 X. 1�Fii�.S a � Ffd� § i't 1Z .�ig; g94%'i s� �:31itSJg'98EPU'L..1r .�S.t`ff+ PD� 8..11Tr
5.1 Registered Architect:
Name:
Address
Signature Telephone
R�gfske�ed tee�txnst� �s� Y
Area of Responsibility
Name:
Registration Number
Address:
Expiration Date
Signature Total
Not applicable ❑
Name:
Registration Number
Address
Signature Telephone Expiration Date
Name Area of Responsibility
Address
Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Company Name: Not Applicable ❑
Responsible in Charge of Construction
New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) Addition 0
Accessory Bldg. ❑ Demolition 0 Other ❑ Specify
Brief Description of Proposed Mork:
g- 77
% GES SeT � �� � �l✓��
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ lA ❑
A-4 0 A-5 0 1B 0
B Business 0 2A
C Educational ❑ 2B 0
F Factory ❑ F-1 0 F-2 ❑ 2C 0
H High Hazard ❑ 3A ❑
IInstitutional ❑ 1-1 ❑ I-2 ❑ I-3 ❑ 3B ❑
M Mercantile ❑ 4 0
R residential ❑ R-1 0 R-2 ❑ R-3 0 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
U Utility ❑ Specify:
M Mixed Use 0 Specify:
S Special Use 0 Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
BUILDING AREA EXISTING if applicable) PROPOSED
Number of Floors or Stories Include
Basement levels
Floor Area per Floor(s
Total Area(s
Total Height ft
I
Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
SECTION 10a Owner Authorization- TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
Hereby authorizes to act on
My behalf,
in all n�arers relative two work authorized by this building permit application
Signature of Owner Date
Y xy
I, as Owner/Authorized
Agent
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury
Print Name
Signature of Owner/Agent Date
Item Estimated Cost(Dollars)to be
Co pleted by permit applicant t ,;
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction from(6)
3 Plumbing Building Permit fee (a) X(b)
4 Mechanical(HVAC) v�
5 Fire Protection
6 Total (1+2+3+4+5) � 00� Check Number
�JN �}C r d�Y_' � R`4 3N+�`x„'$ � }'t� ,1 : �,Y�31�k i':.� F ` .] ; 1 �.a Y f x�ti { ��F ➢r�^✓i= �1 ki t F.. Y �.� � ,. y
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 sr 2ND 3RD
SPAN
DEMENSIONS OF SILLS
DEMENSIONS 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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