Loading...
HomeMy WebLinkAboutMiscellaneous - 20 DEWEY STREET 4/30/2018 (3) 0 M `� Date.'. . .. . ... .... .... NORTH pf of TOWN OF NORTH ANDOVER .+ o PERMIT FOR GAS INSTALLATION 'ISS HUS This certifies that . . . !y. ! has permission for gas installation . . . 4.'" . . . . . . . . . . in the buildings of . . J0. . .D.4 . . . . . . .S 1. . . . . . . . . . . . . . . . . . + at . . .a . . fl'� '!�. . . �?- . N h •ov Mass. Fee. . S . . . Lic. L43 GASINSPECT Check# L43'�' 8079 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: gyp-)r?I'1 , MA. Date: 11 Permit# Building Location: D'3 0� t y S Owners Name: ro r-�cr✓ Type of Occupancy: Commercial ❑ Educational❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES - - - - - - - - - Lu LU Cl) w J.- to co V = Z Q m 2 0 Lu W OU f4 0 = W W Z z z z CO W 0 Q w M W ro O x o 0 > W 0 W LU O W HLu X Lu O Q O = LL Z W W Z 0 J P h O Z J 0 u- = W H W W O Q tr w w ' m W O Z O y 2 > Z H _ V D LL t9 (9 x x -j O a H > > > O SUB BSMT. BASEMENT 15TFLOOR 2 u FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 61H FLOOR ' 7 FLOOR 8 FLOOR Installing Company Name: Check One Only Certificate# _ +" �r J J r� �l t;�-t�t; 4 ❑Corporation Address:_ I-✓ L J— '-)1- City/Town: fl"-e i Ii✓n State: A-,A El Partnership Business Tel: X17 % , ,. I I F Fax: [�1.Firm/Company Name of Licensed Plumber/Gas Fitter: ► V ,p,q l jl+, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes e'No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / By Type of License: _ El Plumber itle 1E]gas E Master Fitter Signature of Licensed Plumber/Gas Fitter CitylTown ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑LP Installer The Commonwealth of Massachusetts Departinent of Industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers Applicant Information Please Print Le:=ibly• ' Name(Business/Organization/individual): Ar 5 J P C(14-'-IV U - - Address: City/State/ZiP:_ +"�'t Racof'S I Phone#: rAre you an employer?Check the appropriate box: I am a em to er with 4. r7. E] f project(required):'P Y ❑ I am a general contractor and I employees(full and/orpart-time).* have hired the sub-contractorsew construction. am a sole proprietor or partner- listed on the attached sheet.t emodeling 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. El We are a corporation and its 9. E]Building addition required.] officers have exercised their 10.El Electrical repairs or additions 3.E3.1 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 in•surance required]t employees- [No workers' 12-El Roof repairs comp.insurance required.] 13.[:]Other *A`Y ar`Plicant that cheeks bo.=.41 yin u..t aIsn frll aut fhe section below shon,in,�476-i T Homeowners who submit this affidavit indicating they are doing all work and then lure 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 is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:__ Ci /State/Zi :_.N r 1't- 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 ofM.GL 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 DTA.for insurance coverage verification. Ido hereby certify under the pains and pen¢lties of perimi,that the information provided above is true and correct. Sip-nature- ) Date Phone#: FFOther only. Do not write in this area,to be completed by city or town official n: Permit(License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone A r 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 6r 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 dwellinghouse.of another-whoo-employs persons.to-lo-maintenance,..construction or-repair-work-on-such dwelling-house-. - - -.----or on the grounds or building appurtenant thereto sball 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'contractors)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. Bc 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 b rt't'_ri ed+60 �riity Gr toCh thYt tha a,Vpli4�ur?for the pe:x�I o�liyyYSF iS b�'ttg req'.?�StPdI not.the D partmorit 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 wo4ld'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 oflnvestibatiDns 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-8.77 MAS.SAFE Revised 5-26-05 Fax#6.17-727-7749 � i vrwtar.rmss..govfdia 933Datea-.4•�•° 12.- ppRTh 4 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS US r� This certifies that . . .,S. . S. . . . . . . ...i�--�( has permission to perform ate— �. . . . . . . . . .`. . . . . . . plumbing in the buildings of . L '?`. L ."� L . . . . . . . . . at . . . . . . . . . . , No h A ver, Mass. Fee. . 1: Lic. No.. . PLUMBIN SPECTOR Check # L�= MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT'TO PERFORM PLUMBING WORK ~• 3 CITY I% DATE] ��`�°jli� 1PERMITi# .IOBSITEADDRESS ---Q Owl e-y S i J OWNEWSNAME p OWNERA.DDRESS+ TEL IFAXI TYPIE•Ok OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL IV( PRINT RENOVATip CPIANS SUBMITTED: 'YES 1 I NO] 9CLEARLY.Y NEW.11�j lV:� � kEPLACEMENT;�� FIXTURES FLOOR-* ESM 1 2 T34 5 B 7 a 9 10' '11 12 13 14 BATHTUB OROSS CONNECTION{DEVICEDEDICATED SPI=CIALWASTE'SYSTEhiV....bE01GAFEDGAS/OIUSANDSYSTEM ; DEDICATED GREASE SYSTEM : .:. _5 : . . . _ :... ._ i.. ..j........: .... __ .. .. ... I ; ... .._I .:. DEDICATED GRAY WATER SYSTEM I _ :�. ... 1..........; DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIP! l FOOD DISPOSER i . . . i . ...1:. l'. . . !... I FLOORIAREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I.... . . :1 .. I . - i -• • LAVATORY • ROOF DRAIN -- ...... SHOWER STALL SERVIOEIMOP SINK TOILET URINAL . . ..., —- ---- - ---I' - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i _-- _-- f .OTHER INSURANCE COVERAGE: have a ctirrent. iis'itratice policy.ttr its stifiMantial pquiValent which meets the regtlirerdenls of MGL Ch. 142. YES IVNO( IF YOU CHECKEOYES,PLEASEINDICATETH 'YPEOFCOUFRAGEBYC14ECKINGTHE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I I BOND[• OWN E0 INSURANCE:WAIVER;f ant aware that the licensee.rloes not have ilia insurance coverage required by Cfiapi:6142 of site Massachuselts General taws,and thatiq signature on this perwit application v+aives this regttiretnetit. (HECK-ONEONLY:_ OWNER AGEWT.{ SIGNATURE bF OWNEI20R AGENT 1 hereby certify Ilial all of[lie details and ififonnation I liavesubmilted of dntered regarding'.this application ate true and accutate,to the best of my knowiddge and that all plumbing work and Installations performed under the permit issued for this application will be in pompliance frith all Pertinent pfpylsidn of the Massachusetts State*Plumbing Code and Chaptgt 142 of the General Laws. PLUMBER'S NAME[ LICENSEIIl i `It,� u SIGNATURE MPC''/ JP I CORPORATION 1 .111i jPARTNERSNIPj' Jill' LLC I I# COMPANY NAME A r�,D.j5 ADDRESS CITYI r` e1, ISTATE i`'►A� 1 ZIP 4 D i c L� I TEL FAX I CELL j h;�(,)3`'.1EMAIL . . . i _�t�1F7�k]C PT�71�IDdING][1�TSP7,CTrONT%TO E,9 iSL;L,o-w I"©r or.g rcr, usn'CNL,Y FWAL VN PECTION NOTrS Vis-•we... THIS APPLQCAT10MSEM-S AS THE PEyt T• Q" L�' Ki FEE::$. PERMFr 9 7"2�/�Z_ ]PlG1�TwT 1^ ,5�1L 5�I..NCTEs # gg# t ��:� �'lrs��t7l�titiol�[vefi(ltt�,j�lT�lr`s'�tr�)`i�ts�,�l� A�fi(r�`fitx2itfn�,t"It(tTttsfl�tal.•��c(r�i�fs %ic 'o`Itriresfr`gir�iorrs 4� tsltlrrgtoit�SYt�e1t 3ps`lou;A&Q2rlt ''r" �iuic�tt►.►lrcrs3�pil(frt #�,t� Tcct:`S�C61t1110�15�ttRU1[!T,tttslt,�rnit~��Af�icl'€t}�i f �itifite�s(Goit�i'ttlf`OJ:'S-,!►�Cfi�1YC3it1{SI��t�tlt��eti�; { .,ilt�itIic[ttt€�tfot•[7ui�ioie . � I �p .. _ ��p7e5s1::t'►•iitE:T,•`i{i3:i # a4iUtlt'�13lj�Uft��jO�itlt`[L�2�i[iiRrltttJf1•idualy J�..A r5.�r[y 5 �L•v;� l�-)i. (, - 1 L 4�.{��1rS{�tI���11]+`. �-e Z"[�}�•e/ �1�'.. „ �.iltOjlP,e Y��` .. . . . . .... _ . .. . , r }dtr{tir eiftiiT4}xr2 Cticci�Et[a�ti}i(otn Fate bdr; Tp�; f�ttajccE�itiifTieij; l-©lifttznenfTrlb"cct�iQ►�. .- _ �i.[ �antngeftctalcuitlydc(o;niitl ' i ccs ftt hudror fc a � ISCIF di[S([icGti4lt y { ttitLtiut�).- ilateittrtcitilesu��coritiaalots 2;��nttlflSOTej)rcpricforort)nt-{ilGr.- listetlbtt:(i'iettt(�Fitetis�ieeF,� �• dncmoll'cti�ig Alpatt&li voitocnilf goose 7[]es!%sub CO. DetitolFligit '<totkiltg.fmiuE:l'ittlny�almci�yt Evoi�ers'cptttP.(nsin�nttce. `.. [I�a teor cts�eotitp tn5pt ncp �:D ti e;�ge s cbiTtoclt;ioff anil its J.[('�Iiiftltl+g-odtlitioR n�itTf [Lj ofticersLns%gc�crcfsecilhetr IO.p�Ii[eclrjrn1iz111irs.Df-rtddi[io(is 3.❑I itnt.tifibnieouiieritoit>s itl�goiX ri�Tltofe�eati Moll'Or* �l; �l;�l'ritntlftugttipair�ortfdditioft� tft3�eTl;[T`fa•tirbrkci�!coml�. ,i:S2faf(4),Ontf�Eoii"we1lo - E2: ttoofrepa6; F+isurnnccrcgoii`etlfi i lit�fo1'cCs.[l�iatt'oreis` {usttr+niCor enllircffj 1 ,[ OTifcr t�liYF.�7(51�C:11t11111C1i;i1S 1!QSt't litliilf:]i0rllfC•i!tl1ii 52itiJatt�ll 19$1:01\ll�ltl•.IflIL 7l�ira td(IT�}7L;tlt011 f.O�l:S•TllrJtlil]#SJ;! l:ilfiT:8l11t:1•>1�"tl0sutttitlltis ef17,tirit IndiatlitT Icy}•tre[te'nSn11u•.�ii:fnd 11t:r+ttircduGhitCot itr,�aiis utt!,lsu�ytii nitf+t oYti3t�i1�Rdita7nT�Su�L. • At.�%Tf�s;tlsstliutlu.�tfiuhArntr.ca:fatixdrnr::(3ii'ict,�lsiattshauilr�lf:�lurlt�iCl'n�ctib-r.�;llrtai+r�;fdl#[;i[yftitii:[t a+i:�ir,}titXblC�ituyit+t[_ lrirldnll>Eur�rJvtrc�rllte[frjirvt�trlitlgr[rnrlc�rs'erfirrf�cirrscrfioirb[s[rrnlccr',fbrtrlveirOnfrea.�3elnu�lsllleErerllctttltrtifnUslf��`� li�nritrarlalr. . 1.gstlra[tce:�ontl?an}�1,litrit��... :JovSito Z) p g 4 � �1�ISft1(�IZIJS>r'°�ur.�'t? t�-v�L�rc� ✓h✓� Litnctttt co{fasprQ ott:o i et5'colu�ieti5�t loltiib]%�t�YTc�itu'n(iptr f�a�etsJtbt�T(ig llieyiolfcS;Tiig([ilei:i#t[tt:br�tti�i7ialsiTnfc)t 1aifttroCclSqure titehip6lisrequk6dt#tld Sectioni&Ao1'Mfifr c.152rnn[estitoltieiTtiliosltfa>Qfccriititiattitttafltcspla >tilt=tgsto:Sf,SQQAQattctfotofi���ear[#npKsotnnei#tiasw6l[[is civil petidWis.ill lLeformoEnSTOPAVOWOpol- tin tt�itlir 6rup(41-50.00 n efa}+ngitfnst(tiG viofalor, t3o alt ise<i Qtaf ticajfy bf¢iisslatEnf crit ifftl}�Gz fotivar feQ to tfle office of [ntes[`t ailotmot'(f+e DTA toriosurnhcecayerageselificntilm, I�ilvrierc•t,��ccrlr��trrrrlc�r•rlreflotiltr�nrlpe/r�tltieso�`�lelrtntrlirrr[!r4=�[jCO1�111rT(DJlprbf�Irl��tf'n�iarr^!s!i{r�tiilt(cAcr.'Z•c� �• " 1?116+re ry tT,rnitr+is4atril�j�arrnfrcxirrri[rrill�rr[err,inlrecalti�ileleiL<< I�ollatiltolJtcTal; i fitj'Oi-101ti'tl;_ .-•• •i'ekdtiltl�Sgeliself 1 'tSSnF[igliT!(C+Df•tC:t:fcil'creoilc)d ' it.Agnixt°orl-101tl[2.FTnFttlingoojja iine[ft 3.G1f,00 v'tOoslt .CfscfrFctt�usttec{os`t:I'In�ui7Enginsjle£foi� i[i �t E'eftso#i� 'liott 1l; r n'IassncliusE[tsGeui'rtr,Iz �>scT apfe: SZiec}(ii a�tt>I elilpin�rersio�pYat�idetgnr:cis?c¢in i its t o rfortltei>•entpTosow, �tii'�ttant fo:fiil�stafiife atr�u��o�y�e�is te�iitedas.`..,ei�ei�perso�•Ii>iftte�eti�ica o€aizotGcrtuder�t�ycontragtol~•liite,, etpi��o€Sttikliec},.prnifik un'i!#tii r ' 4ucrr/ lo,}erisifeineas"fin iviticial,gaifitersliin;,aS4Cia{ioh;cpXptrtion pz oElzeiei{ZelitiGytor�uy t�k�bb' iibra 1;thefoi�goingengagetTija;�onti en{prptise,aizi'�iu�liccliirgthe:IegatizprbsCntativ�s:bl~ale�easecten�pf6j�ei,ort�,e •xece;��ergrCzrts{ee�gfeetiittii��id�ral,ltarGtersTiip�,nssoctation:o>_otherlegRT`etifit};eit{Ii�o�,tin •pavpIayces FI'olYeYe�rtne .Quite o£b.du'elliitg lioise�haviFig nat'i)iare tiiau tiizerrapar[inettts:ancl:jvlib ri5sicfesitiereiir;:or-the otcupant oftlle t10v1(iifgllon oroti. -ierwlibeinpl*OY.T iersbns.f6d6aizaiiztena►ice,eotis[itic[ib�to�'re airKtor;`oti5ttclitT}��Iliiaglioisst takpu:itiegrozantiso;�Gt►itcliitg�Ifpprienattf thereto-s�ialf�not�taeiittse:of suclt.eitt�aloyntenf Gecteeutecl`fb Ge�i gnapfa��er;" �t��L ci};rptcr ii$2;:�"15�{6}.�jso${rates that'`•`esol'i'•'sf'�E�Q�jocn�i llcensiila iigvllct�s71tt1ti�itliT3o1 Ttlte�sstBice Or' etaet [b n.lice?isobt iertni�taope.>IleaGIis IIesso rFo:donst-rirctistiildinksirefhato]ttribimeaiflr:r'oi'a)ljv :�l,)�licarit�4��•Yras liutprntiueeii.ttcce�Zf�IrlaeE�xclelmce nPcort)lrlinttce1vitimflteitrstii•sinep�o�er�gea.et}uiret]'� t�.tIditibnaTl};�GI1 el1eliter I5��25C(7)state;:"�teitlrer ine�cb)nt)lo)a1Y�aTfrt llorady�ofits paliticatsubdivjsion�s�1t1 eilt�rutto any contract#'ortTaepetfpmlatmcaofpUtiligiYorT;ttUtil�ece�favTeeviitEliceof�ornpliauceiYitlitiiFinsurttnpe ise�iiiretnen{softtiscitapFerjtl�to�;;ctapre;eti{etl�otIreeortfraetingaut�zo�ita;" - � . Eleaseflfoui tT>Yi`pts:Ire';Collle315afioo rjii'atitUoni Icfal�U'F.>V7t dirt"t�tetibxestita[a It'(�;btirsi rtatiou�it�if � I'•- +.> � � �' •� Fri.. 3' - 1. , • �inresGtles'sfitj�supply�stt�-coniCVracCioortn(sp}a�it�etue(;CIs)L,Caticicessm(cs��tidpltorternttlt��Cshimum. ) � bj ie (spaslongSu�ithfizeuceeurtt�i�ldcyatee?sopPe a*iitrim liferiatersofpariiters;ar itofreouiredto0W311tivorkess`c�nrpensat''instreariee.IfanLAGarLLPdoesItatv e telray°essstzpolic}�isrecgt4redJ!b.jtdrisedtizaifhiSiiffFdaYitutay6�stibmitfecifotheDep,tYiuienFol fndlts[rial �.cCidsnts�forconFirrtaatiQtibfitistnancaivovetage. A'[soUesltrelosigrinuticl;ttetheCtt'�tlatlity 'xheri!'ridaVit:shotti_t� beeetur+tetitu tile,ciEy ortotsm that tttettppligaiiou for the petuaitor license isUeinarequestcd,iroL'ilrelle1rarimPs`s of ' Intlitstrial�lecicieii�. SltatiYciyoith���;atzy•�uesT�orrsxpgar��urg;llteiats�6i•ifybitarereilaitedfo:oG.tauza14�0rkcrS' i >;ugipz}t�,a{iotrpolie};pleaseeatl titep,jiatiine�t tjhtltenuulGer�is{get belotu.-��If-jnsttis;tT•cpllaprtiies�ti�ultlentertlteir etF i3stttolice license ntrmbcroit;tlt"pptopriateline. Citta or To Erit f3fricltiTs — �'leasel}c�ttretlia@the��IiilatrltisFoti�lel+ btrttlirirzfetlIegibl}: �'Tisbep�t#tfreiatltaspraxlaecTa..spriepaitlr�Gotttitit gEfti;,-afkicTat+it fofj,�o{t.Fb ffl'oti�in#h„evettffheOftic�pfitai�estigatiottxltijs fo Coi>,tncLy�ourbg;ti-�vi�ihoflp�tlicant, ' P1eA$ab6 sure#to fill in thepennitll cepse:tttanber which�Yii 1.6s.tised i<s a;rel eteuc�allttltbet:In adtTi[ioit,nn applietnt fTsafmusf=strGiititnmitliiplepemitillicense applicatiotis•`irm tiny*,gitraiiyeagueetl'oral}=sttUmfEone�ff_rdaxifindicafingctnrent �bTic}Flnfotuaafiors(ifnecessary��alcituc�ei".ToGSiCFAdcTress"titeapplicatit'shotriclwrite"ai[Iocaiionslu (ci��oX `- io ti ii}"'A cppk oftlze ath'daS�it thattiasl5een ofFci Tlj<slantped of ntarkeci by ihe.cit}f o:fou-m niay be-provided fa Ilia nliplicantasproafftraFaYalitlptftdtct�itisbtiiilafor itturaperutft`sprlicenses. tietY.tiftidaYit�mus{h efilledpilie,•tch I veK�r.lT9zeret homeots°nerorcitizertisoGtaititilg.Irlicenseoilrrrttittuotralatedfaanj�Ttttsi,te;sorcotiiutercialientuie F a eto license orperarit to burnIeaYes cte_)saidpersotmis NOrrzcluiratl tq cpltiplete fails afficlls?€. --- ;`}�ottinaiFiiatioefar�attpo�pr)'�fioitaii$slioit�iiS�Ot�Ilai'tririi}io�tiestion§, ;c";�zss do.rroi liesitafa tagiyemts it call_ �'i:a?��pai-h,lent'saticTr�ss,telephone-nrsdfaxlmt►t7lTier .. ' T D6padmelit Of 11du§iegil A¢CLtivnts l Oyfce of Itl'frsi% aa]t _ 600�tVastiitigtol>.Sfreet - - 'BOs1011,AIA.0111 X Tot 0,617"127 4p4D eXt.4Q6 ui`1a�"17 T>tik�SA�E � I ek+isXil G.�� V,). GI7,7271749 •.i.hassgoT. dia F Date..... NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ACHUS Thiscertifies that .................................................... ........................................ has permission to perform % ....... .................................................... wiring in the building of.......... ..... ........................................... ...... 7......................... .... .North Andover,Mass. 00 Fee�() .... .........—........ Lic.No ..... ... .......... ELECTRICAL INSP, CTOW' Check # 0653 f ' - - Commonwealth of Massachusetts official Use only Department of Fire Services PermitNo._ 'tp6 1:--;,) BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2- 7 dL City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intenti9p to perform the electrical work described below. Location(Street&Number)—,4 Owner or Tenant J o Telephone No. Owner's Address Is this permit in conju�jction w' h a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 11 5 i Cg 4l-v Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: X c-+ `R2 mcg de-, 1 Completion of thefollowing 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- Elo.o cy Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: _.. _. _...................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW Signs of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: -1' (i-7 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ( C)0 (When required by municipal policy.) Work to Start: 0 - g-1 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 co erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [& BOND ❑ OTHER ❑ (Specify:) I certify,under the sins and pe ies of erjury,that the information on this a cation is true and complete. FIRM NAME: 7 h of S�0 Cl [ LIC.NO.: z. Licensee: 7'oy�� pp��pr Signatures LIC.NO.: (Ifapplicable,enter"exempt"in t7d license number line.) Bus.Tel.No.<7&7(o/-3(.R 8 Address: iin j r`acv ^o% O t Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires DepadKent of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one ❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE.$ i EEECMCAL PE MT INTO. — INSPECTOR'REPORT: ELECT['RUCAL INSPECTOR s ' MIKSP :Failed-•[ ] Be-inspectionrequirecT($50.00)-•[ j (Tnsp ctors°i9igna e•no..nztials) Date 2.FD.VAL M83M,+CTION; Passed - Failed—[ ] Re-inspection required($50.00)-•[ In spectors'c mments: 954ectors'sign e o initials) Date 3.TJNDES GROUND Ii�TECTIOIY: passed—[ ] Failed--[ ] Re-inspection required($50.00)-[ ] inspectors'comments: z (Inspectors'Signature-no initials) Date 4.INSpECTION—I9ERCE': - DAT 1 CA U E-D NAS T±ONAL C: � ; NA1YlE•. passed—[ ] FaUed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature•-no initials) Date • . i 5.INSPECTION-•OMR: passed—[ ] Tailed—[ ] "Re-Inspection required($50.00)••[ ] rZors signatuxe••no initials) Date ' I DOOR TAGS.ARE TO BE FILLED OUT AND LEFT OSI`RITE IF TUE AREA.TO BE INSPECTED IS NOT ACCESSIBLE AND A RE INSPECTION OF$50.00 IS TO BE CHARGED. y - The Commonwealth of Massachusetts - - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �(��� _,3,`Q- Address: 1k �_b ✓A a WV WL 6iA City/State/Zip` � ,,4 A,-L o ( P-?6� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. (K I am a sole proprietor or partner- listed on the attached sheet.$ E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition ` [No workers' comp.insurance 5. ❑ We are a corporation and its 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 12.❑Roof repairs insurance required.]t employees. [No workers' 13.0 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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. Ido hereby cer 'y Zunerhe p ' s and penalties of perjury that the information provided above is true and correct. Si ature: Date: 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#: f f� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date,( �1ORT1{ F- TOWN OF NORTH ANDOVER . ; PERM-IT FOR WIRING ,SSACMUS� This certifies that .... .oJ' has permission to perform . . ® /Qjnrp ;/ j n^---C---- ........... wiring in the building of...TU! Z. at. v..... z Gl.... ,,ff°! ,North Andover,Mass. Feee�l.... ............... Lic.No...�Y;�i��..�... 1119 ,f4033 $I.ECMlCALlNSPECMR ~ " Check # / t 10577 1 ' Commonwealth of Massachusetts Official Use Only Permit N°. 77 Department of Fire Services ), 6S' i Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [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),C),527 CMR 12.00 MA ( (v (PLEASE PRINT ININK OR TYPE ALLINFORTION) Date: Q(b U ZOIZ City or Town oh 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. N Location(Street&Number) 'Z CD -vii— y S� \Owner or Tenant �UG—Z_ Qp 2-rL N phone No, L � Tele �1"7 (']U 3 3 8y Owner's Address `20 V Is this permit in conjunction with a building permit? Yes ❑ No V�- (Check Appropriate Box) Purpose of Building 05,De of Utility Authorization No. Existing Service 2007 Amps 12-4P Ztd Volts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ;V45141L 4 i fl agu— ,q � 20 �vkIAl Qt4 kl- 01-bur ,L�l� �w f� s Completion of the followingtable 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- ❑ o.o Emergency Lighting rnd. rnd. Battely Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of Detection and No.of Switches No.of Gas Burners No.Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/AlertinIZ Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal l ❑ Other Connnection No.of Dryers Heating Appliances Kir Security Systems:* No.of Devices or Equivalent No.of WaterK`1, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lee cal Work: 3006�'' (When required by municipal policy.) Work to Start: 0171f Z11,01Z Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete FIRM NAME: LIC.NO.: Licensee: 1 i-416!!�2 �:, MCC,— Signature ` LIC.NO.:3 ?' E (If applicable,a ter"exempt" n the license n�??ber�li,�,ne� Bus.Tel.No. 7 1[� Address: V I�IV�, Hv1t161rClItLC. //LI 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 bylaw. my s' a e below,I hereby waive this requirement. I am the(check one owner ❑owner's agent. Owner/Agent G u PERMIT FEE: $ Signature Telephone No.(0/7 /7d 3 3� The Commonwealth ofMassachusefts -Department oflntdustriad.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 5� www.massgovldia Workers' Compensation Insurance Affidavit:Builders/Contractors)Electricians/Plumbers A licant Information Please Print Le 'bl Name(Business/Organization/Individual):t— s Address: 6Vr_ .City/State/Zip:_ y&V9j11t., Yn4 Phone#: 97 31 �5e(p2 Ftre employer?Check the appropriate box: employer with 4. general Type ofproject(required): yees(full and/or part- ' ennt * ❑hae hired the subcontractorsontractor and)LIE] re 6. ❑New construction Inole proprietor or partner listed on the attached shRet.t 7. ❑Remodeling have no employees These sub-contractors have for me in any capacity, workers'comp,insurance. 8' Demolition [Nokers'comp.insurance 5. ❑ We are a corporation and its 9 El Building addition .] 'officers have exercised their 10.❑Electrical repairs or additions omeowner doing all work right of exemption per MGL1L❑Plumbing repairs or additions [No workers'comp. c.152, §1(4),and we have no e required.]t em to ees. 12.0 Roofrepairs p Y [No workerscomp,insurance required] 13.0 Other 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 anew affidavit mi g catin such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-conhactors and their workers'comp.policyinformation. lam an employer tliatisproviding workers'compensation insurancefoY information. my employees Below is tlzepOlicy and'ab site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: — Job Site Address: City/State/Zip- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a EMO up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP ORDER and 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 a fine Investigations of the DIA for insurance coverage verification. d0 IZerehy fr fy under the p andpenalfleS Ofperjusy that the 3 infOYmatiOn provided above is true and carrect. \ I nature: Date: O � Z Official use only. Do not write an this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector Contact Person: Phone#: r 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 employee, MGL chapter 152, §25C(6)also states that"everystate or local licensing agency shall•withhold the issuanceor 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),addresses)andphone 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 maybe 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit notrelated to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance fory our cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Due-Con-monwealtia oA SVI'assacht?setts Department of Industrial Accidents Office of Investigations _ 400 Washington Street Boston}MA,02111 Tel.#617.-727-4900.ext 404 ox 1-877-M-ASS.AFE Revised 5-26-05 Fay,#617-727-7749 W.mias&govMa. TOWN OF NORTH ANDOVER PERMIT FOR 'WIRING SSACMUS This certifies that .....1. 40 ..... ........................................... has permission to perform ..., ............ ... ...... .. ..... wiring in the building of L.... ...................................................... at.P.L.......... ......�d.. ...................... .North Andover,Mass SES Fee,.er............ Lic.No.............. ........................................................... ELECTRICAL INSPECTOR Check # 'N 0577 Official Use only Commonwealth of Massachusetts Department of Fire Services Permit No. 10S- `7 7 Occupancy and Fee Checked b 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 INK OR TYPE ALL INFORMATION) Date: )llo g1101 I 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) ZD 5`1 Owner or Tenant -::FO c C p0 2 -i,-=n) Telephone No. Owner's Address 20 bc-iVa Is this permit in conjunction with a building permit? Yes ❑ No Ul- (Check Appropriate Box) Purpose of Building ieS l _ Utility Authorization No. Existing Service 2V�� Amps 20/2-qO Volts Overhead- Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters * Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ( �4� SU884A9 _ A L Completion of the ollowin 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 ISA No.of Luminaires Swimming Pool ove ❑ - ❑ o.-of Emergency Lighting rnd. grnd. 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. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices or Equivalent OTHER: goo" Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: �� (When required by municipal policy.) I. Work to Start: D I 11 OL2011 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: 4{ Z. a tC r✓ Signature �— � LIC.NO.: (If applicable,enter "exempt"in the license n mber line.) Bus.Tel.No.:j7I i I`I G%0� Address: q� UiPLAiQb Aa/, RA1ZpP, l U,, 14-'t018 j Alt.Tel.No.: *Per MG.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. B�y sig bel w,I hereby waive this requirement. I am the(check one - owner ❑owner's agent. Owner/Agent / �/7 U ���,y PERMIT FEE: $ S �_ Signature Telephone No. 7 t � 'CQMNIOWEALTH OF MASSACHUSETTS,Y z ELECTRICIANS 77, ASA .EG JOURNEYMAN ELECT ' IS WES.THE"ABOVE LICENSE TO RIC1.0,f THOMAS" F'.PRICE . .. 4'3 UPLAND AVE .' AVERHILL. "MA 01035 ,4 { 348'`9 ; E 0,7/31/13 J ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le:nbIy Name (Business/Organ ization/Individual): �� t Address: ITL U�Pc ,�-lf� City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [1I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction `q,:�4 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. �o workers' comp.insurance 5. 9. Building addition p. ❑ We are a corporation and its required.] officers have exercised their I AOZElectrical 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 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other -.ny applicant that che%a s box ul must also fill Out the se�iion bele«,shee,���:xqcompensation 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 c fy under the and penalties of perjury that the information provided above is true and correct Signature: Date: dt Phone#: IN acTn!� Official use only. Do not write in this area, to be completed by city or town officiaL Cita or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing 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 than the application for the permit or license is being requestYd,not the Depi rtment.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 'elf-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 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-72.7-7749 Revised 5-26-05 mmvu%mass.govfdia Date.....7." ..................... 1+ &ORTI{ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SgACMUSE� This certifies that ..........11 /. 1 ....��� "'�c./G........................... has permission to perform ....... 1 17%D.............................................. wiring in the building ofT....PPI TE:lil................................................... r at............. :��... �. "fit,.i ........ ................ ,North Andover,Mass. 0 Fee.....� -�l".8.. Lic.No..1 PT? tea..'................. . . .f....�'r,.... ELE ICAL INSPECTOR Check # 6785 Commonwealth of Massachusetts Official Use Only Permit No. 6 �� Department of Fire Services ®p Occupancy and Fee Checked �s� BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of : (A 914 DOJCR, To thelnspectorof Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street & Numbel) �0 DR u.)-Ql S±Re e-� Owner or Tenant —jo@` TelephoneNo. O Owners s Address Sglnh le, Is this permit in conjunction with a building permit? Yes ❑ No ❑ (CheckAppropriate Box) Purpose-of Building F SYn i+L l Utility Authorization No. Existing Service _�Od Amps t 91b_/__q+bVolts Overhead Undgrd ❑ No.of Meters New Service __________ Amps _______ /________ Volts Overhead[] Undgrd ❑ No.of Meters Numberof FeedersandAmpacity Location and Nature of ProposedElectrical Work : igew ADIOI}(011\ 0!, 13 p►= 146J5f, L.1ylt�� Roc, 13PJ1�nc3w, — i3�� j► Completiolefthefollowin tablemaybewaivecbythelnspectoPDfWires. No.of RecessedFottures No.of Ceil.-Susp.(Puddle)Fans o.of Total Transfor mers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ n- o.o mergenc Ig Ing rnd. rnd. Battery Units i No.of Receptacl®utlets No.of Oil Burners F1RP-ALARMS No.of Zones No.of switchesNo.of Gas Burners o.o ec e onan 10 Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices Hea No.of Waste Disposers t Pump urrber ITo_n_s_ .KW___ No.of Self-Contained Totals: : i " - _ Detection/Alertihg Devices No.of Dishwashers Space/Aredieating KW Local Municipal El El Other Conna�ion No.of Dryers Heating Appliances KW ecCSystems: No.of Devicesor E uiv dent No.of Water KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devicesor E uiv dent 1 No.HydromassagEBathtubs No.of Motors Total HP TelecommunicationWiring: No.of Devicesor E uiv dent OTHER: Attachadditionabetailif desiredor asrequiredbythelnspectorofwires. 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 i completed operations coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE © BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. I certify,underthepainsandpenaltiesDf perjury, thattheinformation on this applicatioris true andcomplete. FIRM NAME : Vaine Electric LIC. NO.: 10971 A Licensee: David Vaine Signature LIC, NO.: 10971 A Address: 170 East Broadway Haverhill, Ma. 01830 Bus. Tel. No.: 978-42 Alt. Tel. No.: 978-5211-4464 -2464 OWNER i S INSURANCE WAIVER : I am aware that the Licensee doemothavethe liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owneris agent. Owner/Agent [PERMIT FEE: $ Signature ------------------------------------------------------TelephoneNo. O. 2 �� 1PPOLITO Dr-sGN A550CIATE-5rAXCOWJza ET P o.E).X ' RECEIVED ToPs�ic�d,Massachusetts O 1985 (978)887-55+1- JUL 6 1' 2006 BUILDING DEPT. DATE: July 24, 2006 TIME: 5:40 PM TO: Jerry Brown North Andover Building Department FAX: 978.688.9542 FROM: Tim Ippolito RE: Construction Control Affidavit for: 20--Dew.ey--Street, North Andover, MA Number of pages: 2 (including cover sheet) Jerry, included in this transmission is a co of the Construction Control Affidavit. This i copy s the form I typically use when performing this service. I'll put an original copy of this fax and the affidavit in the mail tomorrow morning. Please call if you have any questions or need additional information. Thank you. IPPOLITO Dr-,516N A550CIATE.5 P.0.50X 1 1 6 Topsfield,Massackusetts O 1983 (978)887-55+ CONSTRUCTION CONTROL AFFIDAVIT REPORT DATE: July 24, 2006 REPORT NUMBER: Progress- 001 In accordance with Section 116.2.2 of the Massachusetts State Building Code,I, Timothy Ippolito , being a registered professional architect,hereby certify that I have reviewed construction progress with respect to the engineered beam installation on the above date and that,to the best of my knowledge, all work has been performed in a manner consistent with the design and engineering. PROJECT NAME: Porten Residence PROJECT LOCATION: 20 Dewey Street North Andover,MA 01845 NATURE OF PROJECT: Addition to single-family residence y�EpE AqC� e�a>o��Y o.rppol r�r� 0. 10592 SIGNATURE: BOSTON, F` MASS. O~�f�1lM Of M15�''`�3' 07/24/2006 17:44 9783727965 IPP(LITD DESIGN ASSO PAGE 02 IPPOUTO DENGN A5SUGIATES i'.0.5o.st6 TopAak{.Mead u"ftmouji) (M)ee7-99+q- CONSTRUMON CONDRQ"t�nAvn' REPORT DATE: hh 24,2006 REPORT NUMBER: Progress-001 to accordance with Section 116.2.2 of the Massachusetts State Building Cock,1, hwiw being a registered professional architect,hereby certify that i have reviewed consbWion progress with respect to the engineered beam installation on the above date and that,to the best of Amy knowledge,all work has been performed in a manner consistent with the design and engineering. PROJECT NAME: Porten Residence PROJECT LOCATION: C 20 IAewey Street l NoMLAndPvg&R201 845 NATURE OF PROJECT: Addition to sin e-family residence o. No. low O SIGNATURE: ttb3TO1y, MAS$ 07/24/2006 17:44 9783727965 IPPOLITO DESIGN ASSO PAGE 01 IPPOLITO DF-51GN A550CIATr-5 FAXC NER, T P.D•6OX►►6 Torskeld,Ma&"&wetta o 19e y (s7e)eaf-33++ DATE: July 24,2006 TIME: 5:40 PM TO: Jerry Brown North Andover Building Department FAX: 978.688.9542 FROM: Tim Ippolito RE: Construction Control Affidavit for: 20 Dewey street[ I North Andover,MA Number of pages: 2 (including cover sheet) Jerry,included in this transmission is a copy of the Construction Control Affidavit.This is the forth I typically use when performing this service.I'll put an original copy of this fax and the affidavit in the mail tomorrow morning. Please call if you have any questions or meed additional information. Thank you. ate.7 12—.�01y. NORTH �',,�•� .1�o TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING i ,SSACMUSE� This certifies that ' . . . • • . . •'rd. . . • has permission to perform . . . .da plumbing in the buildings of . . . . . . . . . . . . . , North Andover, Mass. - Fee.l. .*. Lic. No.�v.rY� . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # 7025 14 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS DateGl Building Location �0 Pck'e S NO Owners Name \T 0 e �d��-�Q Permit# /doviUL Amount — Type of Occupancy P . New Renovation Replacement Plans Submitted Yes ❑ No ❑ FIXTURES F' cf � a O Wa z 3 z W � A r� d O SLSfflmE p &�41VIIVT '' i ISI:M(CR 2'1`II FI M j 3M FI" 4M HDM sm Fl" MM" 7M MOOR)HIDM (Print or type) Check one: Certificate Installing Company Name 6 L ���� � � fm✓� ❑ Corp. Address ^/Or 77 f 4 w ❑ Partner. 21-7/0 ice. 1 BusinessTelephone � Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicatff type of insurance coverage by checking the appropriate box: Liability insurance policy ' Other type of indemnity ❑ Bond El Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 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 Plumbi Code nd Chapter 142 of the General Laws. C. By: Signature O cense um er Title Type of Plumbing License � G S �I City/Town License iNumiler Master ❑ Journeyman APPROVED(OFFICE USE ONLY C 111 Zate.. Z dl!. ..... . Y L. MORTM 3�0'*."D 1..1 -L TOWN OF NORTH ANDOVER O � 9 • - PERMIT FOR GAS INSTALLATION �,SS�fHUSEt v This certifies that ?. . . . . . . . . . . . . . . . . . r has permission for gas installation . in the buildings of . . .T°cC:. . . PD.-?-. . . . . . . . . . . . . . . . . :. at D. . . i !''�G�. .�. . . . . . . . . North Andover, Mass. . Fee. . �0 Lic. No..�v "�,� !. . . . .1 . �AS INSPECTOR Check# 5654 MASSACMSEM UNIFORM APPUCATON FOR PERM TO DO GAS FrrMG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS �^ Building Locations Do DQ u--p- `' S �- Permit# ►/ /J dy� ,,p Amount$ 36 ` Owner's Name ' `�' �ta>° 1 'aR � �� New Renovation Replacement ❑ Plans Submitted09 U ❑ x F O z o Hw 00 E-4 0 0 Q w w F C7H z F z F W CW G7co� j O EW U H a og A 0 a VO a D Q a F O SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) }J Check one: Certificate Installing Company Name c� `" V �-f.`^' a l C� ) ❑ Corp. Address r v Cr LL-+, Partner. /C IQ 0 Y.S Business Te ep one -2 3 ] (� -7 D U Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑- If you have checked yes,please indic e the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusettj State Gas Code and hapter 142 of the General Laws. C. ' BY: ,Signature of Licensed Plumber Or Gas Fitter Title 1:1Plumber /;) p � -t City/Town r-1 Gas Fitter License Numoer ❑ Master APPROVED(OFFICE USE ONLY) 0—lourneyman Location=,�70 No. `7�% U Datec�,17 �aRT� TOWN OF NORTH ANDOVER M�'• • t9 • ; ,' Certificate of Occupancy $ ^CNUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ? Check # 141128 z Building Inspector f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT�NUMBER: �� DATE ISSUED: 11111M 18 SIGNATURE: /k (CA0060� Building Commissioner/Infector of Buildings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0/0 No4z, o t/F✓� MA Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: F,4- 6,Soo 57 '504. Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yar S fv�-( Rear Yard Required Provide R red Provided Required Provided 30l t 1 30 0 1.7 Water Swply M.G.L.C.40. 54) ' 1.5. Flood Zone Information: _/ 1.8 Sewerage Disposal System: D Public (dam Private ❑ Zone Outside Flood Zone M Municipal On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record I N (Print) Address for Service Signatute V Telephone 2.2 Owger of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number (�A11�t�rL �c�►-►�r►z�-c`�� 11 Address _ i (' I � O D 30( M a WynC-rO k n ��=LKJ'� OU 4. Expiration 'bate Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 'PAUL `i g0A-b C7y,)(-7 Name M 60A-6 GSA�W— CcnTr—ACTOYL Registration Number r Address 3 g ( YY1ML4-w%.d'r Yr.10 n CA--Y-- --'Z""� Expiration 4te St' nature Telephone Y/ . i 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 rmit. Signed affidavit Attached Yes.......®INo.......0. SECTION 5 Description of Proposed Work check all applicable) New Construction 11 eExisting Building Repair(s) t4-1 Alterations(s) ❑•_ Addition 44-- Accessory Bldg. ❑ Demolition ❑ Other , 0... Specify R Brief Description of Proposed Work: ' rr0 Cil `7 r X 1 2' Roams -ro dfx 15?M 5 'go us e Y s r n 1 3' M SECTION 6-ESTIMATED CONSTRUCTION COSTS ItemEstimated Cost(Dollar)to be OFFICIAL USE-t?NLY - a Completed by 2Lmiit applicant 1. Building (a) Building Permit Fee ©, 0 d Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing — Building Permit fee tel X (b) 4 Mechanical(HVAC) 5 Fire Protection — 1 6 Total 1+2+3+4+5 cjpG-dG Check Number T SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT '- /n1 l�l��h� w, as Owner/Authorized Agent of subject property ., ' Hereby authorize to act on My Kalf,in all matters relative to work authorized by this building pernut application. Signature of 6wner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, a)Ak J• C,uvw���G,�^e`w 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 �QIe J• nn � �v, Print N e ��3► J2aDv Si ature of Owner/A i ent Date NO.OF STORIES oovvt- SIZE 17 k'/2' BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 ZX to 2ND 3RD SPAN I2I DIN ENSIONS OF SILLS DIMENSIONS OF POSTS DM ENSIONS OF GIRDERS Zx SCJ' x 3 HEIGHT OF FOUNDATION -- THICKNESS SIZE OF FOOTING 20'X 20& -- !o el vEP 7-- X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND So IS BUILDING CONNECTED TO NATURAL GAS LINE MW FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. .............:..................................... ........................ APPLICANT �a�� N�^� �*-� PHONE q �yl�c] ASSESSORS MAP NUMBER 010 LOTNUMBER 00al- SUBDIVISION LOT NUMBER STREET STREET NUMBER A10 OFFICIAL USE ONLY losonnoommoons Now RECOMMENDATIONS OF TOWN AGENTS IN5 16 i *soon sommaxo oo, r �fl DATE APPROVED �✓ CONSERVATION ADMINISTRATOR DATE REJECTED COMMENTS i DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED a FOOD INSPECTOR—HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR—HEALTH DATE REJECTED i COMMENTS i i PUBLIC WORKS—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT I{ DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE 9'U� ORTH REGISTRY OF p i. ,`.-RENC E. �ED� . RECEIVED MASS. po JOYCE BRADSHAW f `;-(JE COPY: ATTEST. TOWN CLERK NORTH ANDOVER Y e 1000 JUN 28 P 2: 30 ' fihl�ra� y tltatiw�, PE17mmmorlm North Andover have eed hm t Zoning Board of Appeals &Z aoa 27 Charles Street Phone(978) 683-9-541 North Andover, Massachusetts 01845 4Mt Fax (978) 688-9542 Any appeals shall be filed NOTICE OF DECISION ' within(20)days ait,the ';t;,,CNC Year 2000 date of filing of this noti, +'✓ °e= t• in the office of the Town Clerk. Pmnu-t � DeWeV Street I NAME: Dale J. Cunningham FE�: 6/27/2000 ADDRESS: U DeweyStreet North Andover. 2 ( PETITION- 020-2000 BEARING: 6/20/2000 '✓"j'7 The Board of Appeals held a regular meeting on Tuesdav evening application Dale J. Cunnint, 20 Dewey Street, North Andover,tettit(A... Petitioner sMrcquestindie g a Variance from the requirements of Section 7 Paragraph 7.1. 7 2 & 7.3 for a relief of front and side setbacks in order to enclose an existing open deck with screening. C! from Section 9, Pam-p-aph 9.1 in order to enclose an e.�isting open dectk on n is � stin requesting a Special Permit A A. lot. P g non-conforming The following members were present: William J. Sullivan. John Pallone. Scott Karpinski. Ellen t�icInnre. George Earley. '8 +� 4 ! '. tto GRANT a �'i�1 ALA'I"DID Upon a motion made by Scott Karpinski and 2nd �� dimensional Variance for a frontsetback of 11',1eft side setback of 1one. the B'oand riard ghtdside setback of 11' and for a Special Permit from Section 9. Paragraph.9.1 in order to alter and enclose an existing open deck with screening on a pre-exis�g non-conforming lot,on the condition that.the new proposed deck remain the same size as the existing deck with the elevation not to exceed as shown on the plan of land by: Scott. L. Giles. RPLS, '13 972, 50 Dear Meadow Road, North Andover, MA dated 3/20/2000. The Board finds that the variance granted to the petitioner is because the petitioner has satisfied the provisions of Section 10,Paragraph 10.4 of the Zoning Bylaw and that the tin from the intent and purpose' of these variance will not adversely affect the neighborhood or derogate the aPPlicant has satisfied the provision of Section 9,paragraph 9.1 of the Zoning Bylaw andthatsudCh chancet, �ttension or alteration shall not be substantially more detrimental than the existing non-conlormin�structure to the neighborhood. Voting in favor: William J. Sullivan, John Pallone, Scott Karpinski,Ellen McIntire, George Earley. Furthermore,if the rights authorized by the variance are not exercised within one(1)year of the date of the grant,they shall lapse,and may be re-established only after notic c,and a new heating. Furthermore,if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two(2)year period from the date on which the Special Permit was granted unless substantial use or construction has commenced.they shall lapse and may be re-established only after notice,and a new hearing. By order of the1Z g Board of Appeals. ml/decisions2000/20 William J. Su ivan Chairman PLAN OF LAND IN ' NORTH ANDOVER, MASS. OWNED 8Y DALE CUNNINGHAM SCALE: I"=20' DATE:2/28/2000 0' 20' 40' 60' THE ZONING DIST. Scott L. Giles R.P.L.S. IS R4. Frank. S. Giles 50 Deer Meadow Road North Andover, Mass. DEWEY STREET 100'TO MA08LEHEAD STREET N 74-17-00 E 50.00' +� HSE.#16 HSE.#24 #20 14+� EXIST. HSE. FND. 2 cn w is W 0 0 1114A O tti YEROZOLIMSKY o ROCCA 14'+1- 0 t O EXISi_OPEN DECK TO BE ENCLOSED — — — ---- L.C. PLAN 9399C --- ----� LOT 10 00 h —� Proposed 4, 18' � 1 14 ASSESSOR§MAP 10 �uilclirig 11' 1 i '��► PARCEL 17 +-- +- rm Profile - Elevation E� n1 s. 3972 tion .. S me 74-17-0o w 50.00' � QUINN CUNNINGHAM THIS IS To CERTIFY THAT 1 HAVE CONFORiwEb WITH t148 ?ULES.ANb AEGULAT1-ONS OF THE REGIS`TE'RS 6#bEtbS iN PA&AAING THISIPLAN NOR-rH ANDOVER BOARD I APPEALS THE PROPERTY LINES SHOWN ARE,THE LINES DIVIDING EXISTING OWNERSHIP—S,AND THE LINES OF STREETS ANU GVAY SH©INIV AIME THOSE OF P 8L.IC Oft PRIVATE ST14E TS AVS ALREADY OR W ESTABLlSWEO N ,,AND 0 NEW LINES FOR DIVISION OF.EaC(,STING OWNER IP OR NEW WAYS ARE SHOWN. DAT OF FILING: DATE OF HEARING: DATE OF APPROVAL: 0 4 �l PT J GC LA c2 —5 �0P tc"D,4 i Registry of Deeds Northern District of Essex County Lawrence, MA 01840 07/31/00 CU14NINGHAHM JCII # 110 Rec: Type FLAN 10.00 Copies 1.00 # 111 Rec: Type NOTC 10.00 Total 111.00 # 1111 Payment Check 111.00 THANK YOU! Thomas J. Burke Register of Deeds ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Boston, Mass. 02111 Workers'Compensation Insurance Aff1davit Please Print Name: Location: City Phone 0 am a homeowner performing all work myself. a1 am a sole proprietor and have no one working in any capacity EE�I-am an employer providing workers' compensation for my employees working on tthhiis�job. Company name' '?A u t_ —r A b Address 3 8 � YYl tnn U►1 O`i'i� �- City' L HAW\ Phone#: (oo 3 b 3 S'- 9, 22 d) insurance Co Frt_ AoA,e.(( K4- 1 Policy# 11A X17 L/O _ Company name AtA1>F 2 I c& Cr,.,��►n e S Address Cet3DL40c-, City VOL Ca eY Phone#: gc 6g�-� Insurance Co. T � L G C_ cv� t l". e-U JN4M)l Policy# bad/9 dl0 Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cert' �ehe ains and penalties of perjury that the information provided above is true and correct. Signature Date �Uv Print name U�- AD Phone# ConrtIe7 f-R E D C 117#r"(4 Tn5u'aae- 'Gr 1 n'P"P'1z*r1a1 Y78- q 5 S -- 18�o S— Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andover f tAoRT►1 0 6 t t Building Department o 27 Charles Street North Andover Massachusetts 01845 4 Z .^ (978) 688-9545 Fax (978) 688-9542 �� `°`�" �• ,0 4�RArea PP. C3 9SSACHUS�� 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 cl 1, s150a. The debris will be disposed of in/at: 4 yrs Facility locatio Signature of Applicant 0 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. � 7 �lte �ana�nzanu�ea�i a���,2asac%�uJr,/,t6 F BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 065046 Birthdate 06/25/1968 i a Expires 06/25/2002 Tr.no: 25615 Restricted To: 700 PAUL T GOAD 381 MAMMOTH RD I PELHAM, NH 03076 Administrator (�`\s`` �/e�ponvr amu�eal!/c�,a/�.aducdtuaelta'. x HOME IMPROVEMENT CONTRACTOR <'.. , Registration"#"'123826a _ F =t paul'-T- Goad ' 381 Mammoth Ad At" 2A G� co am NH 0307b s 'ADMINISTRATOR w. r r w.4.:L....ak.x..4...v."r.+.+.7T.ra3✓�.:..� n- y'' - .�_ ♦ __ +]r 1 i 1 I� NORTH Town of Andover No. y O o dover, Mass., T � - COC LA MIC MF WICK ORATED 7 S H BOARD OF HEALTH Food/Kitchen . PERMIT T D Septic System THIS CERTIFIES THAT...... A.I ..........e&*VJV/#'V. hA BUILDING INSPECTOR .. .............�........................................... ........... Foundation has permission to erect.6 .. )46e!. buildingon ..07............. 'w '.y.......s'. ............. . Rough t0 be occupied as..... . �.. • � / Cie C/'r Chimney i ..... ................................................P................................... ................................. 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 Inspection, Alteration and C pstruction of Buildings in the Town of North Andover. D PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Pry 2 QA DOC Rough PERMIT EXPIRES IN 6 MONTHS L-�'' �' Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION/pST Rough ................. ............... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. ` SEE REVERSE SIDE smoke Det. 3568 Date. q7?'.. ... .......... NaRT'+ TOWN OF NORTH ANDOVER 3?pp���to ,e 1ti�Q PERMIT FOR GAS INSTALLATION F 9 �O�.no✓r'qh SSACHUSEt This certifies that /`rte' l •.• ^c✓u .:� . � has permission for gas installation_. "?`4 �' • . . • • in the buildings of J. . . . . . . . . . .. . • • • • at ?. "'` 7 - • • • • • • • • • • • • •, North Andover, Mass. Fee.' . Lic.No. . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) _ 2. , Mass. Date_ 1- 19 &00 Permit # Building Location, :2'1 UPGt12t� f Owner's Name 60 Al ti,9M y4 Type of Occupancy 2Si dr New ❑ Renovation ❑ Replacement ( Plans S bmitted: Yes[] No ❑ N N � Y W � N N V Z cc N x N x x x W W x O U m F- y J N A CC CC y, O W f. Q Z O F- w Ix m w () a '� W y a c at R N x N tl tl W x Z x O, > W W W w z Q x x a n a W t' tu H x N a Z Q W , Q C ~ H yW y O > W }. W J +. W Q W > x W n Z. Q x Q Q 0 0 W a O p H x x '.x O tl x u. n 3 c tl V x y a a F- O SUB—BSMT. BASEMENT 1ST FLOOR 2N0 FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Instaili6;P Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET X] Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .. 971 -68,7-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked Vis, please indicate the type coverage by checking the appropriate box. .1A liability Insurance policy 1� Other type of Indemnity El god ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sagent Owner❑ Agent ❑ , I hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and aaxr�gte to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (j i 75; T e of License: Title Plumber Signature of Licensed Plumber or Gas Gasfitter City/Town Master License Number 8697 APPROVED O FIC SE ONLY Journeyman Vl BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPEC71ON FEE N0. APPLICATION FOR PERMIT TO aDO GASFITTING < NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE GAS INSPECTOR _ _ Date d?A T) 2835 l 4, TOWN OF NORTH ANDOVER 3? •` � 0c ' PERMIT FOR PLUMBING .'SSACHUS� This certifies that . . . Q. . . . . . . . . . . . . . r u ' has permission to perform . . . . . �. .i. . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . .//.L .Z . 4' . . . . . . . . . . . . . . . . . . . . at . . ,").U. .D r .=.,Y . .Y4 . . . . . . . . . . . . . , rth Andover, Mass. Fee. d��.,.�: . .Lic. No..af.3.�'3. . . . . . . ��'.y . . . . . . . •PLUMBING INSPECTOR 03/01/96 10:24 20.00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) c A? O rIel/- Mass. Date 1 g Permit # Building Locationn e t!J eq, i= Owners Nam ,/! CCT Type of Occupancy.:2i 5 17 E-�j New ❑ Renovation ❑ Replacement 2 Pians Submitted: Yes ❑ No ❑ FIXTURES 2 N < Z Y F- Vf J N O Z = W W W Y J N V < N O O N Z N < cc ¢ _ ~ N Z O Z N a J N W N F- W N W < C X F- 0 Y < N W Z d H Q m df Z < W N Z a O W O O W < y cc 2 < W W = < S 3 O Z = Y d C H < z < W u. Y W ~ V > H O = = N F' z o o ti ZW f' O v s < ~ < < r N H < < O < J J < cc ct a < O < 1-- 0 - o SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing.Company Name mmATAe7 Check one: Certificate Address ?j r_ C0 RC N/Y)Af) /--pj ❑ Corporation /r E!Ni'6710 . yo A U 1TyLl/ ❑ Partnership Business Telephone (14L-i97 ! 2- rm/Co. ^ Name of Licensed Plumbed e3 Fe T req e ` INSURANCE COVERAGE: I have a current 1112bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ .4 If you have checked ves, please /Indicate the type coverage by checking the appropriate box A liability Insurance policy 1d Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent❑ 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apteof the eral laws � r . ' re o cen um r Title Type of Ucense: Master&/ Joumeymar❑ CttyR 0 I U ONL Ucense Number �33 5 BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES 1 PROGRESS INSPECTIONS . FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED ` DATE 19 PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) L'o'^— (` Aid/607C-),' Mass. Date ` 19 Permit # 1.79 Building Location (SLO Deloeyy/ Owner's Na &- 47A IA' d Type of Occupancy lRE51 7C.'N ri P� New ❑ Renovation ❑ Replacement 2111" Plans Submitted: Yes❑ No ❑ N N W N Y = Q N GN N V y Q N Z O z N Z W W Q O V m F' _ J_ N W0 0 1" ;j F' Z 0 W ¢ 4; Q: Q O 0 r W Z F N 0 W < Z z (� Vf 0 W V W N < � D W W y W = < = G Z W Q W W �� = H J W a IL W V J G7 f- Z F- Y F Q < i O O W W O 1A FZ- Z < W < C x 0 C7 S U. O 3 G 0 J 0 Lr > G O. 0 SUB-8SMT. BASEMENT ISTFLOOR 2ND FLOOR 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name "A(-Ae�ZT Check one: Certificate � Address 30 00A(H m r4 ry L M. ❑ Corporation Al E T H U E fJ 01 rl 0 l k / ❑ Partnership Business Telephone 9 5"7 f @,-'Firm/Co. Name of licensed Plumber or Gas Fitter "'R o ilE N? A• 5 A M M H i A Rr') l INSURANCE COVERAGE: I have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes. please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 the pe i ed for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. By Tvna of License: A �z , A.., mber n ure of cen u _ or fitter Title tter er License Number x,333 City/Town yman BELOW FOR OFFICE USE ONLY , FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE ' NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR OASFITTER LIC. NO. PERMIT GRANTED DATE l9---- OAS INSPECTOR f i `$�'�''.�y,.�a....`Ti: -.-"�"M,�''".t".�;w.,.f yx,..;:�.'r-..c.�--•....�.,.,,�„:Y,.�.v�+na�lik:7"�*'0-"`''�a.zl1- t Ta3 Date. 9 '�.t H0RTM 4, TOWN OF NORTH ANDOVER pfs^pro ,e, p PERMIT FOR GAS INSTALLATION �9 SS, USEt V frr This certifies that . . .�A . . .. ..". . ''��.. .. has permission for gas installation . . .(-/-� 7.. . . . . . . . . . . . . . . . . in the buildings of . .//.. .?. . . . .!. . . . . . . . . . . . . . . . . . . . . . . . at NwhAndover, Mads. Fee J, Lic. No.. GAS INSPECTOR" WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File f pORTM, :°•+"°�' "° Zoning Bylaw Review Form Town Of North Andover Building Department artment ��' 27 Charles St. North Andover, MA. 01845 s"`""g` Phone 978-688-9545 Fax 978-688-9542 Street: 20 Dewey St Ma /Lot: 10127 Applicant: Dale Cunningham Request: Enclose existing11'x 16' open deck Date: 5/8/00 Please be advised that after review of your Application andI Plans your Application is DENIED for the following Zoning Bylaw reasons: Zoning Item Notes Item Notes A Lot Area F Frontage 1 Lot area Insufficient Yes 1 Frontage Insufficient Yes 2 Lot Area Preexisting Yes 2 Frontage Complies 3 Lot Area Complies 3 Preexisting frontage Yes 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed Yes G Contiguous Building Area 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required 3 Preexisting CBA Yes 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient Yes 2 Complies Yes 3 Left Side Insufficient Yes 3 Preexisting Height Yes 4 Right Side Insufficient Yes 4 Insufficient Information 5 Rear Insufficient l Building Coverage 6 Preexisting setback(s) Yes 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting Yes 1 Not in Watershed Yes 4 Insufficient Information 2 In Watershed j Sign 3 Lot prior to 10/24/94 1 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking 1 In District review required 1 More Parking Required 2 Not in district Yes 2 Parking Complies 3 Insufficient Information Remedy for the above is checked below. Item # Special Permits Planning Board Item # Variance Site Plan Review Special Permit Setback Variance Access other than Frontage Special Permit Parking Variance Frontage Exception Lot Special PermitLot Area Variance Common Drivewav Special Permit Height Variance Congregate Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Permits Zoning Board Independent Elderly Housing Special Permit Special Permit Non-Conforming Use ZBA Large Estate Condo Special Permit Earth Removal Special Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential Special Permit Special Permit for Si In R-6 Density Special Permit A-2 Other special permit pre-existing C-6 nonconforming lot F-3 Watershed Special Permit --SupplyAdditional Information The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies,misleading information,or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department.The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation nnjfor the above file. Building Department Official Signature Application Received Application Denied DrtiafS�nt,: If Faxed Phone Number/Date: Plan Review Narrative The following narrative is provided to further explain the reasons for denial for the building permit for the property indicated on the reverse side: A-2,C-6,F-3 A special permit is required to extend a pre-existing non-conforming lot due to " area, frontage, front and side setbacks to enclose an existing open deck which does not meet the side setback Referred To: Fire Health Police X Zoning Board Conservation Department of Public Works Planning Historical Commission Other BUILDING DEPT ZoningBylawDenia12000 PLAN OF LAND IN NORTH ANDOVER, MASS. OWNED BY DALE CUNNINGHAM SCALE: 1"=20' DATE.-2/28/2000 0' 20' 40' 60' THE ZONING DIST. Scott L. Giles R.P.L.S. IS R4. Frank. S. Giles 50 Deer Meadow Road North Andover, Mass. DEWEY STREET 100'TO MARBLEHEAD STREET N 74-17-00 E 50.00' + HSE.#16 HSE.#24 #20 14'+1- EXIST 4'+1EXIST. HSE. FND. Z cn V r 1 W C) O m � I Q! + v YEROZOLIMSKY o o ROCCA 0 EXIST.OPEN DECK TO BE ENCLOSED L.C. PLAN 9399C 1 LOT 10 4 z x 6500 S.F. . Proposed 14' 18' p�A1i pf I - ASSESSORS MAP 10 Building 11' PARCEL 27 Profile - Elevation .. - LES ! H: I n.t.s. Ij I y IST find S 74-17-00 W 50.00' I I i QUINN CUNNINGHAM I THIS IS TO CERTIFY THAT I HAVE CONFORMED WITH THE RULES AND REGULATIONS OF THE NORTH ANDOVER REGISTERS OF DEEDS IN PREPARING THIS PLAN BOARD OF APPEALS THE PROPERTY LINES SHOWN ARE THE LINES DIVIDING EXISTING OWNERSHIPS,AND THE LINES OF STREETS AND WAYS SHOWN ARE THOSE OF PUBLIC OR PRIVATE STREETS OR WAYS ALREADY ESTABLISHED,AND NO NEW LINES FOR DIVISION OF EXISTING 77T HOWN. .I DATE OF FILING: DATE OF HEARING: DATE OF APPROVAL: Town of North Andover ,1 Project: Building Department E N°RTFf 27 CHARLES ST 12' x 17' existing deck 978-688-9545 + : enclosure APPLICANT : Dale Cunningham �9SS^CF1U5�t�� �20�De'wey-St' `Nortff over,MA 01845 DATE: December 6;1999 Title of Plans and Documents: as above Please be advised that after review of your Building Permit Application and Plans that your Application is DENIED for the following reasons: Zoning ' Use not allowed in District Not in conformance with Phased Develo ment Violation of Height Limitations Sign exceeds requirements X Violation of Setback Front Side X Rear X Insufficient Lot Area Insufficient Parking olation of Building Covera-e Insufficient Open Space Use re uires permits prior to Building Permit Si n re uires ermits prior to Building Permit Form U not com tete bv other departments Not in conformance with Growth By-Law X I Other INSUFFICIENT FRONTAGE Remedy for the above is checked below. X Dimensional Variance Special Permit for Watershed Review Special Permit for Site Plan Review Special Permit for si n Complete Form U sign-offs Copy of Recorded Variance Information indicating Non-conforming status Copy of Recorded Special Permit Other X I Other Non-conforming special permit Plan Review The plans and documentation submitted have the following inadequacies: 1.Information Is not provided,2.Requires additional information, 3.Information requires more clarification,4. Information is incorrect. 5.All of the above. Foundation Plan Plumbing Plans Subsurface investigation Certified Plot Plan with proposed structure Construction Plans 116 Affidavit Mechanical Plans and or details Plans Stamped by proper discipline Electrical Plans and or details Framing Plan Fire Sprinkler and Alarm Plan Roofing Footing Plan Plans to scale Utilities Site Plan Water Suppiv Sewage Disposal Waste Disposal Other see reverse ADA and or ABPA re uirements Administration The documentation submitted has the following inadequacies: 1.Information Is not provided.2.Requires additional information. 3.Information requires more clarification.4. Information is incorrect.5.All of the above. Water Fee State Builders License Sewer Fee Workman's Compensation Building Permit Fee Homeowners Improvement Registration Buildin Permit Application Homeowners Exemption Form Other Other The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based or verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies,misleading information or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department.The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file.You must file a new building permit application f9rfn and b gin the permitting process. z&I'LL'i"Ig 1 Bi6ilding Department Official Signature Application Received If faxed: Application Denied Denial Sent Referral recommended: Fire - Health Police X Zoninq Board Conservation Department of Public Works -Planning Historical Commission Other BUILDING DEPT cc: William Scott Revised 9197 jm Plan Review Narrative The following narrative is provided to further explain the reasons for denial for the building permit for the property indicated on the reverse side: tS� 4s ,., s{y0eiF3(��p t� °hls �� ar ra. �a3A 1 �� Q 1rf. 74"' �,' 51^}z trLc .w 4r dit1.. 3`z " mak T�,: ��: '��A' kttl .W,,,.•S jf4i7- \ �HjSrt .;;M� �ySv3irVh.:x�J4`P ;�'�.F � y13,�`,c , i... "I'll c y Y Fp' fYt �y txLat#z 4+fit��,M, ;h� 'IC@111 , " � x: 't.s..z: . P•. kb d°, {pah ,Sl� r1az� ,.AsS Section'7 Dimensional Requirements: R4 District requires 12,500 Square foot lot,100 &Table 2 feet of frontage, 30 foot front and rear setbacks and 15 foot side setbacks. Section 9(9.1) Non conforming lots require a finding from the Board of Appeals t 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 �f}LE Cc,1'N�11in4N M PHONE �f0 Vl q LOCATION: Assessor's Map Number D 2 PARCEL— SUBDIVISION LOT (S) STREET W kr, ST. NUMBER �O ****** OFF1ClAL USE RECOMMENDATIONS OF TOWN AGENTS: fi s`tevs�►^'�-^'�^' °"'�°n`"'�Y £Ncles� �D�/b a��r: �, 1 a CONSERVATION ADMINISTRATOR DATE APPROVED_ i 0skij U�- , DATEREJECTEDCOMMENTS y-e k TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATEAPPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY SUILDiNG !,NISPECTCR DATE Revised 9\97 jm MORTGAGE PLOT PLAN EK SURVEY INC. MORTGAGOR CuNLh1J6r/)v1 DEED REF. 13 P ADDRESS OF PRINCIPLE BUILDING PLAN REF. _ 93 7?c z A(W-y DA• OF INSPECTION ACI 171 /997 tLlAAl0ll� c� / 30 w GflT/0 �60o n 8 \ $ t�ll a N W1. l- ►o`� .Oo NOTE* This mortgage Inspection ras prepated ,�V' 11•URTHER SATE THAT IN WY PROFESSIONAL specttkdly for mortgage Purposes and Is not to o� OPINION the be L. �, P��ple /s and accessory no �responabltty for damaged upon Ox a es EX sUttvlrY aooipb RUDEL N outbulclrtgs. �o�/� reltanca by anyone other than the sold t'arta 368 t with the s61,b0dc Mqutnments of the local and tb asatgns Ih connection ldtlt its propa>.d zOf ing °r'taAOes� and Unt no enohraochm mortgage financing to sold mortgagor. ,'• �`'S�yof�iSTE s�� propearttyy 1 ase{as%VW Way ooro» enLt CERTIFICATION M 1111111. Property Ie not In o Flood Hazard Ana Thb cartlttoatlon le based on the tocatlon of servey markers E3 3. Property is In' ' Flppa H�tAf'd kea. of othav, and does not represent a property survey, theroton 3. Informatlon 13-+&MIAC1att t4 slaf MIns Flood H=vd. oKaats shown ore not to be bled for the establishment of Flood Nanoid dototminsd troth tW est Fbdcrd Flood proD�y Mes- Insurance Rate Map Pandy PERMIT NO. APPLICATION FOR PERMIT TO BUILD*****x**NORTH ANDOVER, MA ,NIAP NO. LOTNO. C! 2. RECORD OF OWNERSIIIP DATE BOOK PAGE 'LONE; SUB DIV. LOTNO. 1-0CAI'ION (V, '41/Do1/ie2 PURPOSE OF BUILDINc� f�j-aG�G�r 0�4� �?cisTiv+ U�iL — SCrL��i j N 0\\NER'S NANII. VA LC C(-JA.)A11/UC f-l/f!1 NO.OF STORIES " C SIZE OWNER'S ADDRESS 20 -D � v .— BASE6IENTORSLAII VE.IiL� 1 5 f �! ���4�i 011�i�—, FLOOR TIMBERS O SIZE F g IS'r 2 N 3RD :\RCIII'1'IiCT S N:\i\I E: •— �x BUILDER'S NANIE, {f SPAN t DISTANCE TO NEARESTBUILDING DIMENSIONS OF SILLS Z�/ DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS 2�f o AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BIM-DING NEW SIZE OF FOOTING IS BUILDING ADDI'I70N Y > 61ATEI2LAI.OF C11111NE1' i IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLET)LAND WILL BUILDING CONFORNI TO RF.QUIRENIF.NTS OF CODE ti/C IS BIIIIA)ING CONNECTED TO TO\YN IY:ITER Y�� BOARD OF APPEALS ACTION, IF ANY — 1S BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL.GAS LINE A14 1\ti I I1C'I KENS 3. PROPERTI'INFORNIA'I'{ON -- LAND COST EST. BLDG. COSTj poo, ego IIMA: 1 ['11.1,OUT SECTIONS 1-3 EST.BLDG. COST PER SQ. FT. EST. BLDG. COST PER 11006E 1:1.1-CTIZIC METERS MAST BE ON OUTSIDE OF BUILDING SEPTIC PERNIIT NO. \TI'ACIIFI)GARAGES NIUST CONFORNI TO STATE FIRE REGULATIONS 4. APPROVED BY: I'LANS NIIIST RE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPEC'1.011 DATE FILED O\YNERS TEL# ��'/7 J — `/ g GQ// qq CONTR.TEi.# ,ff CONTR.I.IC# �61 S ��14 S1C;NATURE OF OWNER OR AUTHORIZED AGEN•I �K c ILLC.# i d 3 $,2 i+Icllnn=r GRANTED - - 19 — Revised 5/5/99 .11\1 BUILDING DEPARTNIENT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL:c.40 S 54,a condition of Building Permit Number - Is that,the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: .07 Location of Fa�ility Signature of Permit Applicant fq..•y I� Date - NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector d7Gl�1 E C"Jit�h��2 l �ti?f�bb'l 6bJ l?'t 1 fv /Pt/U'00 U ce- /V4, m 0 w w a o 1 A a Fov-3T' t EW L` Acr- o f AoVSE) 16 121 I � , J �..� / i ' k L I- c Me�naCE , I f' IM RequiRED c et?- 'Ply (A.100-l'-> 51HO&'IW-f 17 e, 7 -Fim-15t; -- 3 2,7 -P,4t-e ewivitlii?5-qA04 ff 44`&WE:It- t3011, lr—J. ><, -tee .2 x tk) 51 ke. dE.hb$•. .r a? --, �, n 7a i,�, .v'r? as: - :.t ����i:O1 �{ >�V �,. +��ry: Vi'<•?#�d'1 '' t S� i 'fir; 1L'" � IIIYYY MMMkkk-r ,kph �, ,1` `t� k� � � i��9��.■ '� }. ,ph &�S,S " { r � # P'r m� �* >• rip . a k'r �� 1 � � �t� ''1'�k��. tj r i 7 F :a. .z:� r t�+ __� Q� 1 �° �r � v � e�. R I4 "'4 l,�•,!.nye.t=. �' p`v' yid lyy,. '�ft�'�'' ��,1 l t 4 ��1.• � r - } Q ' . s � ../ O�✓�"K[OOQQiI(14eK01., T,'�'' "i'+�`rk r 4 "' c kr t t ;�'�fi,�"y;' 'rig. FI..o by s,:. 1 77 DEPARTMENT YPUBIIC SRfETY " ` ` ' �_ T aomaiswiway�,y 1< r z•x 9L0£0<HN�aey - OF t CONSTRa I . . Zdtl,A `ylOmNeN TS£ , ".. ► SUPERVISOR LICENSE. Nur t °peog i I dr x Y 'rExpires: Birthdate: �' ne r cS iyj rs t �' r $i01tii/vot •�,Alotlei rdzl J w 1tl04IliI0NI 4d4- PA d41py .I9Z8£ZjNuot�e11st6aa ;, �.b010da1N0o 1N30A0adWIdW0l� 381 MA�t MPTN RD x ��,.. . .�, PE1 f"arwNll, 93676 �p�"'��°""�` _iy:fir. .1.. �.. -'""� --'—.mss^+•.-. • CDN TR ACT 5rrA-rF S . .._ vildX._.__/_7_X/_a.__. ._ R /�_.... _--- ©ver-_ee<;5-1tig 19! Ofex �a�y7�roR E � f 1 V 1 �. j�• - t C� 1 '' A Xi The Commonwealth of Massachusetts Department of Industrial._.9ccidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit dame .A tj L- T 0Aj-,> Please Print Name- PAO L Location: 4M A O AAOT l-1 tD Cit/ A L l-{A nth Phone # Z-20 I am a homeowner pe;-rcrming all work myself. ❑ j 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. Comoanv name "P4y(. 'C d o-qD Address 3 rO R M rAOT(A (L� ` L RA M--,, iv��1- Phone T (��3"�. 5 2217 City' �E Insurance Co. ,)V( 14 �C�ale(t Policy ►V(o V c7f����'7 / ��`�i'�� f Company name: Address Clh/. Phone#- Insurance Co. Policv Failure to secure coverage as required under Section 25A or ii1Gl. 152 can lead to the imposition cr crimir.ai penalties of a fine up to 61,500.00 and/or one years' imorsenment as well as civil penalties in tfte form cf a STOP WORK ORDER and a rine of(5100.00) a day against me. I uncerstand that a copy of this statement may be forwarded to the Office cf Investigations of the DIA for coverage verification. 1 do hereby comfy under the ns and penalties of perjury that the information provided above is true and correct. Signature Date Print name �� U�- �d0 Phone Official use only do not write in this area to be completed by city cr town cr iciai City or Town Permit/Ucensine ❑ Building Dept ❑G`eck d immediate response is required ❑ Licensing Board Cj Selectman's Office Contact person: Phone r: ❑ health Department Other