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Miscellaneous - 20 HEMLOCK STREET 4/30/2018
N o_ Q 0 �i g 0 0 0 0 Location YU �`/ /UC No. Date NaRTh TOWN OF NORTH ANDOVER o?o•,,`•O '•,Moi,. ' n 41 Certificate of Occupancy $ _ • i .; ; Building/Frame Permit Fee $ a. s'°''t�' S3 US Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 7J gr10/1,2/99 12:25 52.00 PAID Div. Public Works Z V V — � I i- i J U < Ln Z z Z V V — � I i h 7 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 Le -r J z��t�S ��r�,C��, /`i��►�'�iI LOCATION: Assessor's Map Number_ f�$ SUBDIVISION STREET2 G / J t M 4T PHONE 00 — 63 / 79e Z PARCEL� 0 LOT (S) ST. NUMBER ,C O ""*********O F F I C IAL USE ►VS-tal( sbla^ sun)'Nooti. Our -- RECOMMENDATIONS OF TOWN AGENTS: X 4-, 5*t o ^' CO CO ,TION ADMINISTRATOR TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: re // - CT!;e CO"I Gf-11G 611A, Cin C (? t lIL t r 0 ® (Location of Facility) Signature of Permit Applicant �Z L ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print A Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity EL�` am an employer providing workers' compensation for my employees working on this job. Comoanv name f/ A rr,,'c c , Address 2e 9/a Citv'IU� C yzcS�<r /"� fY - U� Phone # Insu Comoanv name: Address Phone #: Insurance Co. Policv # 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 (5100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under tpe pains and of perjury that the information provided above is true and correct. V14- Date v'�/�- ` n Gi Print name c� CY � k, 1�-r4e�, /Ulc /e S Phone # P� �� Official use only do not write in this area to be completed by city or town official' / City or Town Permit/Licensina ❑ Building Dept ❑Check if immediate response is required E] Licensing Board ❑ Selectman's Office Contact person: Phone Health Department ❑ Other ACORD CERTI PRODUCER 603-669-4567 hase & Durand Assoc. Inc. 119 Walnut -Street Manchester, NH 03104 Attn: INSURED American Profiles Co. Inc. 20 Blaine Street Manchester, NH 03102 .............. COMPANY AINE BONDING CO (HBIS) COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Co LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY ' PRODUCTS - COMP/OP AGG $ 2,000,000 A CLAIMS MADE X.., OCCUR'SCP 31175921 03/01/1999 : 03/01/2000 PERSONAL BADV INJURY $ 1,000,000 OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 300,000 MED EXP (Any one person) $ 5,000 AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT $ 500,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS A SCP 31175921 (Per person) :03/01/1999 ;03/01/2000 - - --- HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO ' OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE '$ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND XvJ� A i U- ii - TORY LIMITS ER EMPLOYERS' LIABILITY A TCO 95568466 04/08/1999 04/08/2000 EL EACH ACCIDENT $ 100,000 THE PROPRIETOR/ X INCL ' PARTNERS/EXECUTIVE EL DISEASE - POLICY LIMIT $ 500,000 OFFICERS ARE: EXCL EL DISEASE - EA EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSAlEHICI ES1cocr1AL ITEMS CERTIFICATE HOLDER' CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ROBERT G. DURAND VP ACORD 25-S (1/95) ' ©ACORD CORPORATION 1988 a CONSUMER INFORMATf ON FORM - "SUNROOiVtS" Massachusetts State Building Code (780 CMR; Appendix J, Section J1.1.2.3,1) The ,Ntassacl►usetis State Building Code (780 CNII) includes provisions to ensure that houses and House additions meet energy efficiency standards. This supplemental CONStAYIER MFOPLMATION FORNI is to be filed as pact of the building permit application when a builder/contractor or homeowner; constntcting/itstalling a house addition with very large percentage of glass to opaque wall; seeks to utilize a special energy conservation exemption option for. "sunroom" additions to an existing house (780 CMR, Appendix J, Section J1..1.2.3.1). This FORM is not intended to prevent a homeowner from selecting a "sunroom" of any size, configuration, orientation, form of construction or percent glazing, but rather is only intended to assist homeowners in becoming aware of some of the important energy conservation and year- round comfort considerations involved in selecting and utilizing a "sunroom" addition. The connection of ''sunroom" structures to residential buildings may create comfort and energy consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the main house. In the selection and constniction/installation of "sunrooms", included below is a non -required, open-ended list of product and design considerations dial a homeowner may wish to consider before actually - con stnic t i ng/i ristal I itig.a."s unroom ctuallyconstnicting/instalIitig.a."sunroom It is recommendedthat consumers carefully review these options with their designer, builder, or contractor, in order to minimize potential energy consumption andlor house discomfort issues. In addition, the qua l.'ttieations and reputation of the company or individuals to be hired are important considerations. PRODUCT AND DESIGN CONSIMERATIONS RELATED TO "SUNROONIS" • Solar Orientation and Natural Shading Type of Glazing • Insulating value • Solar heat gain • Frame materials • Glazing to frame sealing and gasketing materials/ seal durability and/or weather tightness of the sunroom • Adequate ventilntion - Operable windows and fans u Applied Shading Systems Insulation level in floors, walls, and ceilitlgs • Possible Sunroom isolation from the main house via a wall and/or door or slider • Heating and Cooling Nlethods! Efficiency, Zoning and Controls Homeowner Ack.nowledgtnent The Massachusetts State Building Code, Section J1.1.2,3.1, requires that the actual. proper,,_ owner (not the owner's agent or representative) acknowledge receipt of this CONSUNIER INTORNIATION FOltivl prior to issuance of a Building Permit for a project that includes "sunrooni" additions to an existing residential building. In accordance with this requirement, the undersigned hereby acknowledges that she/he has read . the information in this docn(n con ming sunroom comfort and energy conservation. S' Sigifirntce of Actual Building Ow r Date Print Name Address of Permitted Project roject location) Owner's telephone number Owner Address (if different than p y From : ALCHENY MARKETING GROUP PHONE No. : 207 495 2849 Sep.23 1999 8:22AN P03 AVIII)AViT 1' li,e trr�dcrsi ,nccl, fi,e -�vrler afthe property pi C_--Z,d," �-t����� lrcrehy VCl'IIj, Ilett 1 ltfrv4 t1ullrorizccl ��c ` Ich11S':,r1��Aii?S I S-illt l'r�fil � tri �►t�hly to 11ic lll►ilclin�; Dch,rrlrtlenl of tlfe C,'i!y i, ,.�. -.. _--..� . - -- .-�..— Cityittilc Icy cicl ns Ilgent obllillIlIg Inrilding prn-mil tinct, Or filly requireriiernls needed In nhlain hern�ils. �� (I (I Dale D ��......�...__ lie Vanvmeanureallii a�.i'�avaae,�icliteCGr (L ; DEPARTMENT OF PUBLIC SAFETY P_ERVISOR LICENSE rExpires: Birthdate: 8f21/2B08 08127/1955 ,. ii.Mr9��tl [I� 81 CHESTER RD 12 RAYNOND, .NH 03011 + �. Typical Deck and Rail Details 1 and 2 Family Dwellingssj-`�S P �-- t4-r� If the deck you wish to build will be sigtuficantly different than the one duplicated, so inform the Plans Examiner. ELEVATION A t HANDRn X—\ //H A 5/4 x 6" cap 2" x 2" trim W"- 2" x 4" rail 36" 1" x 4" trim 3/8" x 4" carriage bolt Vertical measurement 2" x 2" pickets (max 4" opening) 4" x 4" rail post (ms 5' o.c.) A— 2" x 4" rail Joists (1) P 1/2" x 6" carriage bolt -a SrrppOrt c01111Ins (3)--r roonng (a) —C, \g 514 x 6" decking Exterior wall IIS I Flashing, \ �� I Nouse bond (2) — C �ItL� Two 2" x 10" 2" x 2" -- beam ledger (fasten Nvith 16d nails 8" o.c.) II J0 z or joist hang --s SECTION W 1 *---' i made at the t fid' G !/ ` - 5 S / leading edge � S � -2ix i s �-i �q eo �' of the tread �)C p 40 (Gd r �r p 1) The sizing of load bearing members is based on lumber having an Fb (fiber bending) value of 1400 psi (pounds per square inch). Pressure treated lumber is required for the load bearing lumber and does meet this bending strength requirement. Joists should not overhang a beam more than 2 feet. The most important issue is to provide for adequate support and connections. 2"x 8" nrny span i ) Q0' n ") Spaced 16" a. c. (on center) 2) Fasten with 3/8"x 5" lag screw 16" o.c. and three 16d nails per 16"space 3) Spaced ?' o.c. typical. Size determined by elevation or tributary load 4) 12% 12"x 8"precast o' poured block or sono tube (i nininnun 2500 psi concrete) 2000 psf is presumed allowed soil pressure to determine footing Si -e. 5) Open sides of stairs with a total rise of more than 30" above the floor or grade below shall have guardrails not less than 34" in height measured vertically from the nosing of the treads. 6) if/leen risers are closed, all treads pray have a uniform projection not to exceed 1 V:" R,, maximum height risers, 10" mininnun tread e.rclrrsive of nosing JANE: 97W202 01/15/97 b 1N U 1 ii P1.1 DATE I REVISlOh15 I DRAWN BY: DAVID CENTORBI CWD BY: I MEASURED BY: DAIE: I SCALE: HCHE I - _� NOV-05-57 12:24 PM TEMO SHIPPING 8102860410+265 P.04 ROOF SPAN CALCULATIONS COOPER _. --- __ A... SPAN...(feet)........._._...- --- --- -. .. —12.00 B LOADING CONDITIONS -- —" -'--- LIVE LOAD (psf) 47.00 - -- DEAD LOAD (Psi-- . TOTAL LOAD (PSS ---._..—.------- .—. 49.00_ � ---- ---- -•-----•- C MATERIAL SPECIFICATIONS f --- 7— FOAM CORE THICKNESS (inches) _4.25 _ FOAM CORE DENSITY (Pco 2,00 E= (Psi) 480 (Psi) _ 35 -- - --- G` (Psi) 620 -- -- ALUMINUM THICKNESS - ..........----------(inches). 0.032- -- 10,100,000 D SECTION PROPERTIES " `- --- C (inches) 4.25 - ---"- - -- (inches) - 0.032 -- --- -. . —_-- Inches 0.032 H inchesL 4.31 • -- - - - (Inches) 0.384 A2 ....... - (inches) 0.384 E ALUMINUM WORKING STRESS -- " _ ...----.-(Psi)_. .._11.818_— ---- F Y (inches) — - - 2.16 --; ------ -- -- --(inches) 3 52 Sinches — ---- i - - - ( ) 1.63 G BENDING STRESS_--- - - (psi) -- ---- 6,485 IS LESS THAN 11,818 _ _ ____ Bending Stress is Acceptable H SHEAR STRESS F, = WL/(H+C)12 5 72 — ISLE___ SS THAN 35 Shear Stress is Acceptable I SKIN BUCKLING STRESS (psi) Cry = 0.5(cube root)(E)(EJ(G,) 7 215iS GREATER THAN 6,485 Skin Buckling Stress is Acceptable J ALLOWABLE DEFLECTION - - --' ... - . .._...._._...._....-----..._.....__ _._ .-.. (inches) DEFLECTION = U120 1.20 —_ QEFLECTION (Inches) 0.96 IS LESS THAN •1.20 1728)/384EI+WL''/4(H+C)G, - OBET p - ...— _ Deflection is Acceptable VA ~ ! y TEMO SUNROOMS INC 11/5/97 Pape 2 HHV -05-97 12:24 P11 TEr10 SHIPPING 8102860410+265 P.03 ROOF SPAN CALCULATIONS COOPER SPAN (feet) 12.00 -- — HOR C, I] d by TEMO SUNROOMS INC. 11/5/97 Page 1 ---•..—..--- -� - --- LOAD DEAD psi ..._... - - ..----....._-- _. 47.00' - —+- - -- 2.00 -- ---- TOTALLOAD (psf) --- - . _ 49.00 -- — " -- -- - -- Foam Dimension - C (inches) •�'-- 4.25 One Pound -- Foam Two Pound ----------- Foam Foam Density (pcf) - - - 2.00 - Ec (psi) --... -- _ - --- 480 200 -- 480 — F, (psi) —. l 35i—_ 20 —_ I - 35 Gc.(Vsi) - 620; 300 620 T1 (inches) - -- _ 0.0321 — - - --- T2 (inches) — 0,032' H (inches) -- 4.31 Al (inches) +—' 0.384 A2 (inches)' - -- - 0.384 E (psi) - - --.. _ _ 10,100,000 Aluminum Working Stress (psi) i,818 -' - Y (inches) - .- - 2.16 - I (inches)' -- - - _ 3.52 "' S (inches) --_. .. 1.63 Bending Stress (psi) 6,485 Shear Stress (psi) __.. _. 5.72 -- ---- --- Skin Buckling (psi) 7,215 --- —`--- Allowable Deflection (ruches) -._.. 1.20 — -•-----...D.. -- etual eflection_ (Inches) - 0.98 --, ---- HOR C, I] d by TEMO SUNROOMS INC. 11/5/97 Page 1 a _, cLOS1IRE S P� J L� qi LA11 n g I t:1 Qom' III D t ��--� ,c — I°f II 1 rII'Irnairl (y'GI)�Ki i6'l GG•/EML f/OI0 •7 V1a nice _ J � ile �OMt v.�•e)E_9-5eE 0 I FRI- 10, ' u I`I n 81 1p� (JelS I a N I'� �� n •'I f i u S uze III )Ij r r. t r od° F D I' °�� A111 QI 6 _, cLOS1IRE S P� �R��a ��lppu�sseppgq:11 P qi LA11 n g I t:1 Qom' III D t ��--� ,c — I°f II 1 rII'Irnairl (y'GI)�Ki i6'l GG•/EML f/OI0 •7 V1a nice _ J � ile �OMt v.�•e)E_9-5eE 0 I FRI- 10, ' u �, GI 81 1p� (JelS I a N it 1'0 Ohl III �� n •'I f i u S l7/ r f� r od° F D I' °�� A111 _, cLOS1IRE S P� �R��a ��lppu�sseppgq:11 P qi LA11 phi ti 4� I t:1 Qom' � I t �r ,c �•_ 14._rn �a,.���.1 0� YY Ill rII'Irnairl (y'GI)�Ki i6'l GG•/EML f/OI0 •7 V1a nice _ J it �I ile �OMt v.�•e)E_9-5eE T•�ola0 �l On+,Jr_eo llo.- d9o9 -- I 1� Co 110 _, cLOS1IRE S �E I M. --- -___.— cl n. �R��a ��lppu�sseppgq:11 �vl�(eo qi LA11 phi ti 4� r o r'17�j � �E rI - Ea + _ •�. 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TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ..... ... ...................................... / .................................. has permission to perform ............. ............... w ........................... .. .. .... ....... wiring in the building of ....................... -..' ..... zn� ........................................ at ... North Andover, Mass. .......... �T; .... ......................................... ...... -30 (0 Fee,:5 ................. Lic. No. . ........................................ ; ...................... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 7hE C0MV1QNJW-4LTHOF+1yIASYACRU,.S'ETIS Office Use only ��(( DE��9Ir:1VTOFPIJBLICSAFE'IY Permit No. / / 161�j BOARD 0FflflEPREV=0NREGUl4770NS527CW 1107 Occupancy &Fees Checked , PPLICA TIONFOR PEST TO PFRFORMELE=(R AL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. JMAP�PARCEL Location (Street & Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes F-1 No M (Check Appropriate Box) Purpose of Building Existing Service / 0 O Amps H& / Z Volts New Service Amps / Volts Utility Authorization o. / Overhead Underground No. of Meters -- j Overhead Underground No. of Meters F Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total ® KVA No. of Lighting Fixtures / SwunmingPool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bumcrs FIRE ALARMS No. of Zones No. of Ranges 4 No. of Air Cond. Total Tons No. of Detection and No. of Disposals -No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal ED Other No. of Dryers Heating Devices KW Conncctions No. of Water Heaters KW No. of No. of Sims Bailasis No. Hydro Massage Tubs No.tOfMotors Total HP OTEER- _V" t b 14 IhavzsthnaDdvandproofcfs=totheOfSm YES :• I• • 1511 '.:r r.•1 ol.os. �mr Al 91 Liar�eR��c -JC�1 �� f: BtnarussTelNo.Z, A2 Arllrr�c � !i- [-nyyJ p 5-1 /1/ /In Alt TU Na % _26 '3 � J OWl`lER'SINSURANCE WAIVER; IamawatethatlheLiarrx t�Oes mthavetheirstuancean�aiis st�t�tialec,�avala�.as�gmedbylvl�ssadasells(��aalLaws anddrimysign tmcnthispmilaFphmttalwaicusthistec�ami (Plea eck one) O Agent Telephone No. PERMIT FEE igmature of Uwner Date. '�-LI . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� � This certifies that . .... .... ............... . has permission to perform,_, plumbing, in the buildings of/..`"'�?!..... . at�..�—ti-J'. . ` ....... .... , orth Andover, Mass. n Fee.. �. Lic. No. (f�..._ ...... . PLUMBING INSPECTOR Check # 578 .46 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMB (Type or print) NORTH ANDOVER; MASSACHUSETTS _ � Date 'C.79-03 - Building Location Owners Name Permit #.r ` Amount ,►t Type of Occupancy New 0 Renovation Replacement ❑ Plans Submitted Yes 0 No FTXTTIRES (Print, or type) Check one: Certificate installing Company Name c.� El Corp. / Address El Partner. Business Telephone Firm/Co- Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance co rage by checking the appropriate box: ❑ Liability insurance policy El Other type of indemnity 0 Bond Insurance Waiver: I, the undersigned, have b ade aware that the licensee of this application does not have any one of the abc ' surance Signature tionl wner 0 Agent11 I hereby certify that all of the details and informe submitted (or entered) in above application are true and accurate to tt 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 Msachusn State PluTbing Code and Chapter 142 of the General Laws. ,D (OFFICE USE ONLY Type of PlumbingVicense License NumDer Master Journeyman Date.., q ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................. has permission to perfor;'M r.76.4.420497;?'.�. ............................................ wiring in the building of ........................................ v atc:2'� ...... .......... North Andover, Mass. ELECTRICAL INSF R Check# 9,12� 8452 4 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permci Permit No. t�446 -' Occupancy and Fee Checked i [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives otice of his or her intention to perform the electrical work described below. Location (Street & Numher) c�)O Owner or Tenant Owner's Address r Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters No. of Recessed Luminaires "u"n No. of Ceil: Susp. (PNo. iaVE may oe waived b the ins ector or Wires. of TotalTransformers KVA No. of Luminaire Outlets No. of Hot TubsGenerators KVA No. of Luminaires Swimming Pool Ab❑ o. o mergency ig g Batte Units No. of Receptacle Outlets No. of OR Burners'FIRE ffFN ALARMS No. of Zones No: of Switches No. of Gas BurnersNo. of etection and Initiatin Devices No. of Ranges No. of Air Cond.TotNo. of Alerting Devices No. of Waste Disposers Heat PSPumbe Totals: No. of Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or Equivalent —Data of DWirinevices or Equivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: No. of Devices or Equivalent OTHER: � �, 1,f � � �_ Attach additional detail if desired; or as required by the Inspector of Wires. Estimated Value of Electrical Wor : �-� (When required by municipal policy.) Work to Start: Id -3 1 U 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 and ena ' s of perjury, that the information on this application is true and complete. FIRM NAMErj Q'` 1 LIC. NO.: Licensee: � .9 � c�. n t''C / ci LIC. N e-21 (If applicable, enter "ex t' in jhe lic a umber ine.) Address: , �Q ,!rJ` -- Bus. Tel. N : `t'; ��`' € Alt. Tel. No.: *Per M.G.1/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. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t� 3 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizadon/Fndividual): ��ed;1 % Address: q94�4 li� /'1 AM! City/.State/Zip: Uri) � Phone #: . Are you an employer? Check the appropriate box: Type of project (required): L Q I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time):* 2. have hired the subcontractors 7, Q Remodeling I am a.sole pmprietor or partner- listed on the attached sheet. t ship and have no employees These subcontractors have 8. Q Demolition working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5.,0 We are a corporation and its 9. 0 Building addition required.) officers have exercised their 10.❑ Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4), and we have no 12.0 Roof repairs insurance required.) t employees. [No workers' 13 n Other comp. insurance required-) -Any appircautthat checks bo)C#1 must also fill outthe 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. 4contractors that cheat: this box mustattaehed an additionai sheet showing the name of the sub -contractors and their workers' comp. policy information. I am anemployer that is providing workers' compensation insurance for M employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/statelzip: 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 $4500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner, of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insumnee'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 that the application for the permit or license is being requested, notthe 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 numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as 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, MIA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia I Date. -3'% . `�. 5. .... . Of NORTH 1ti TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that�� .. ..e-�..�! ........r... ......... . has permission for gas installatio ........:...... . in the buildings of A-. ..... ............... . at ")-j. x'/'- �`��? .� ....... North, Andover, Mass. Fee. . ` .. Lic. No. �� e ....... GASINS PE OR Check# c�0 6599 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Lgqations Owner's Name New ❑ Renovation ❑ Replacement ❑ G SU B -BASEME —NT BASEM ENT 1ST. FLOOR TND. FLOOR 3RD. FLOOR 4TH. FLOOR STH. FLOOR 6TH: FLOOR 7TH. .FL 0RR. STH. FLOOR (Print or type) Name Address Date /gyp j d� Permit # A�-5'q Amount $ coo Submitted ❑ x--, 41 -- Name of.Licensed Plumber'or Gas Fitter 110"I .A , ® - Check one: Certificate Installing Company ❑ Corp. '�. ❑ Partner. ® Firm/Co. INSURANCE COVERAGE I have a current liability Insurancrpolicy or it's substantial equivalent. Chheckko If you have checked es please in ate the type coverage by checking the appropriate box. No❑ Liability insurance policy � Other type of indemnity D Bond 13 Qwner's Insurance Waiver: lam aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ 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 Gas Code C)W I,9Af the General Laws. By: Title City/Town, APPROVED (OFFICE USE ONLY) Stgnature of Licensed Plumber Or Gas Fitter ❑ Plumber ,,0--,Z— —7 ❑ — �? i Gas Fitter License , �umoIer Master ❑ Journeyman U O O W w C9 c� z x w a W d w C x F a� W o ca J x--, 41 -- Name of.Licensed Plumber'or Gas Fitter 110"I .A , ® - Check one: Certificate Installing Company ❑ Corp. '�. ❑ Partner. ® Firm/Co. INSURANCE COVERAGE I have a current liability Insurancrpolicy or it's substantial equivalent. Chheckko If you have checked es please in ate the type coverage by checking the appropriate box. No❑ Liability insurance policy � Other type of indemnity D Bond 13 Qwner's Insurance Waiver: lam aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ 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 Gas Code C)W I,9Af the General Laws. By: Title City/Town, APPROVED (OFFICE USE ONLY) Stgnature of Licensed Plumber Or Gas Fitter ❑ Plumber ,,0--,Z— —7 ❑ — �? i Gas Fitter License , �umoIer Master ❑ Journeyman 343._ Date . r.. ... .. ..'...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ......................... has permission for gas installation :�,.....a-:-?.�-�. ........... := in the buildings of ........... ........................ at ........ .. ............... . North.Andover, Mass. Fee.!..::.:.. Lic.No. � � ,) 't. ?-'........ GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer N ASSACHUSETTS UN FORM APPLICATON FOR PERMIT TO DO GAS FITTING ✓Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations New ❑ Owner's Name Date 19 I ❑ Replacement ❑ Plans S /milted ❑ 'ermit9 Amount S (Print or type) Check one: Certificate Installing Company Name ❑ Corp. Address ❑ Partner. Business Telephone ❑ 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 ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the MaA General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's ,4gen[ Owner ❑ ,lgent ❑ i hereby certify that all of the details and intbtmation I have submitted (or entered) in above application are true ana accurate to the best of my knowledge and that all plumbing work and installations pertbrmed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe :Massachusetts StateGeode and Ch ter 142 ofgene. I Laws. By: Title City/Town APPROVED f uFric:= use �)NLY) Signature /License/Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter777-nse Numoer ❑ iviasier ❑ Journeyman Date.^//f :...�I�T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING w v j This certifies that :...<- ? -a'.. ......... has permission to plumbing in the buildings of ............... C at1=.. ;............ .North Andover, Mass. c� Fee. ..... Lic. No. ,6.4:i �.. `.. f � �1............ . f PLUMBING INSPECTOR Check # 7907 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Date Permit # Amount e'er I Ype or uccu anc New Lj Renovation Replacement, 13 Plans Submitted yes ❑ No Tr Yj"rTT7D v -c• krnni or type)/40 /W/ /K, jl/w� Installing Company Name��- Check one: Certificate Corp. Address d? G 0Partner. Business elep e /} 0 Firm/Co. Name of Licensed Plumber: Insurance Coveraee: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy I...1 Other type of indemnity ❑ Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of three insurance this application does not have any one of the above a Signature Owner ❑ r Agent hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumb g Co dChapter General Laws. By' ivnainrNM i / /l/. City/Town APPROVED wFicE usE oNLy Type of Plumbing License icense um er MasterJourneyman Date ... .. 3 ''SG.... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........ r ': f, has permission for gas installation:..- iq the buildings of ... ?"' ' ... ...................... �.......`. North Andover, Mass. Fee.., t ..f_,. Lic. No........... .....�. e !?..:� ...... ( GAS INSPECTOf��� WHITE: Applicant CANARY: Building Do t. PINK: Treasurer MAN t--11 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO GAS FITTING Type or print) Date NORTH ANDOVER, MASSACHUSETTS `p Building Locations Permit #`'�` Amount S 14,owner's Name New 011-� Renovation ❑ Plans Submitted ❑ (Print or type) Check one: Certificate Installing Company -•Name �"` �� �^ ❑ Corp. Address�,l/�_�yT ❑ Partner. tj Business Telephone��� _ 7 t�S'3 Firm/Co. Name of Licensed Plumber or Gas Fitter ,r p �' G' --7`6 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owners 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: El of Owner or Owner's Agent Owner ❑ Agent I hereby certtty that all of the details and intormanon t nave submitted (or entered) in aoove appucatton are true anu accurdx w me best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the 'Massachusetts State Gas Code and Chapter 142 of the General Laws. • ' itle ityiTown a PROVED (OFFICE USE ON(.Y) Signature of Licensed Plumber Or G • Fitter ❑ Plumber I ��j ❑ Gas Fitter tcense (Numoer ❑ iViaster Journeyman k Location ::,> C) 4', 10 C- /C No. � Date TOWN OF NORTH ANDOVER M : , Certificate of Occupancy $ /00 MUS Building/Frame Permit Fee $ AG Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 17328 '�,A -� Building Inspector fz TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �4 BUILDING PERMIT NUMBER:/ DATE ISSUED: / O SIGNATURE: / tAt L Building Columfssioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 PropertyAddress: " %1 1.2 Assessors Map and Parcel Number: o y t�DloO Map Number Parcel Number a 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'redProvided R red Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public 0 Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT flisloric iSCrICt: eS No 2.1 Owner of Record S�P.-,CLh Y? I 'o-Q/Name (Print) l - Address for Service : Yv� Teleph 2. wner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone M rn z O rn L-1 SECTION 4 - WORKERS COMPENSATION'(M.G.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ate' "'�"-'� 3 ♦ � SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFCIAL;SEU+iLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X tbl /-Z-z;'_ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AuTHoR&WTION TO BE COMPLETED WHEN HERS AGENT OR CONTRACT PLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property ereby authorize to act on ehalf, in all mgtters relative to w uthorized by this building permit application. afore of Owner Date CTION 7b OWNER/AUTHORIZE AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2 ND 3 RD SPAN DRvIENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE fi CA m m X CA S m 0O2 •0 ,OC",F Z CD O ar :v m CL n� o v 06 Q � d S � CD O CD _L o CO CD CO) .0 CD M O y d D! O CO) c 0 c CO) d CD O rM CD CCD CO) CD CO) A CD 3 t CD y 0 O 0 e w?., o c,yOcr H S d O < ® CO) CL a m 0 � C% fm C2 CL m z 7D CD "' CD .* to a) VJ ? mad O y CD -40 m ti p o gmm`: a a a O Oz y. CCD' 0! C =rO R '�^ CL y > c �m Vd m CD N CD n am O w m 3 . O N z �� 06 C/)o Z S. OCA fO VJ y y W m d C40:,. O O m :h ° o o A CD OCD �z c C2 CD C NORI C (D d rt C o M �' d :v o p Q •r rte �' . (p o .r �YJ n M O 7d w. o G r � G M 7AA z N OR .7 0 � GL W C �^ n -< o Q. \ ; 0 td x 1' ej Q fir Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION Number Street Address "HOMEOWNER PRESENT MAILING ADDRESS City Town Home State Map / lot Work Phone The current exemption for "homedwners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than onehome in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING Zip Code rT' North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number `7i is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit AppliVant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 70288 Date .. `f ...... ..... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .............. ?....................... . has permission for gas installation ... �-...! '.................. . in the buildings of...e.`.............:..'.................... at .......... `.. -... f .................. North Andover, Mass. Fee...::.... Lic. No........... .................... , .... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer V F P :,� �IASSACHUS UNIFORM APPL c ON FOR PERMIT TO DO GAS FITTING PARCEL _ /1)/7 /7 or print) Date f 19 r iwtcfH ANDOVER, MASSACHUSETTS Building Locations ��G�t Permit# Amount $ Owner's Name �_ j`,� Y New ❑ Renovation ❑ Replacement © Plans Submitted ❑ (Print or Name of Licensed Plumber or Gas Fitter ,� Check one: Certificate Installing Company ❑ Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M No❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ID Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Statef as Code aChapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ,Q Plumber. �-3 a 0 Gas Fitter (cense umber ❑ Master Journeyman W Z m z C r W � C C 7 ,. N z W y �, z .. Z %I W Z / SUB-BASEM ENT B A S E M E N T A. 5T. FLOGR N D. FLO G R 3RD. FLOOR 4T H. F L O G R 5 T H F L O O R 6T If . F L O O R 7T If FLOG R 4:4 sTF1. F L 0 0 R (Print or Name of Licensed Plumber or Gas Fitter ,� Check one: Certificate Installing Company ❑ Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M No❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ID Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Statef as Code aChapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ,Q Plumber. �-3 a 0 Gas Fitter (cense umber ❑ Master Journeyman