HomeMy WebLinkAboutMiscellaneous - 202 HIGH STREET 4/30/2018 (2)r- `
I --,- r"")
v•tt"V ,e•\
n
Date .`....... / .... G' G........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
��This certifies that...............:...................................f..
has permission to perform .....
t �L.:'..........................................................
wiring in the building of ... 'cz- "c ...............................................
at /�.....�... ; .. ....................... , North Andover, Mass.
Fee �'........... Lic. No'?. 14;T/ .................................... ,............
% ELECTRICAL INS St
Check #`s"
i � I •
Commonwealth of Massachusetts official Use Only
Department of Fire Services Permit No. y(
BOARD OF FIRE PREVENTION REGULATIONS[ Occ 1 any and Fee Checked `Ca,
(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: 3 (,,� . a S
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)
Owner or Tenant VYl_�L .t- v„� at 5 tACC— Fltg,T-7-m 3 b c Telephone No. j -� (� 1 L •6�Sf
Owner's Address -:5-
Is this permit in conjunction with a building permit? Yes QZNo ❑ (Check Appropriate Box)
Purpose of Building _ g \ t} -,,.s T- e mac... Utility Authorization No.
Existing Service 1C00 Amps `2o / 2I* Volts Overhead X 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:
U,s c rL� AOC> D r" M o r'A -t- 74<-) jD Sj Q - Ptft Ate(
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: !f. 0,00 (When required by municipal policy.)
Work to Start: -3. / g d 16 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 Ck BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: L!F_Crnc e Cs 'f' LLC LIC. NO.:
Licensee: ,., c,�-r,N ( C�g,y r�.�2� Signature Q--� ��5� LIC. NO.: 7
(If applicable, enter "exempt " in the license number line) (� Bus. Tel. No.•� GL
Address: !,6 C 102-1- to CLQ \1>tZ G 2s+ --j �
tA Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. 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: $ ��j
v„ VJ ulc uuuwin
aoee May oe waivea Vy 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 ig g
Lrrnd. rnd.
Batte 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. Ton
No. of Alerting Devices
No. of Waste Disposers
Heat Pf1l
mber_
Tons
KW
No. of Self -Contained
To
Detection/Alertin Devices
No. of Dishwashers
S ace/tin KW
pg
Local ❑ Municipal
Connection❑Other
No. of Dryers
Healinces,
Security Systems:*
No. of Water
Heaters KW
No. of No. of
No. of Devices or E uivalent
Data Wirin
Signs Ballasts .
of DWirinevices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications iring:
No, of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: !f. 0,00 (When required by municipal policy.)
Work to Start: -3. / g d 16 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 Ck BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: L!F_Crnc e Cs 'f' LLC LIC. NO.:
Licensee: ,., c,�-r,N ( C�g,y r�.�2� Signature Q--� ��5� LIC. NO.: 7
(If applicable, enter "exempt " in the license number line) (� Bus. Tel. No.•� GL
Address: !,6 C 102-1- to CLQ \1>tZ G 2s+ --j �
tA Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. 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: $ ��j
9 fz-��A�
4 r
e
The Commonwealth of Massachusetts
14-614
Department of Industrial Accidents
Office of Investigations 600 Washington Street
Boston, MA 02111
iz www .a:uss.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Legibly
Name (Business/Organization/Individual);-2Ar--
Address: lrsc Ccs
City/State/Zip:_ 6�L-2 cyYt A- rel ?,--z-Phone #:_ 7 - 2-.%;? '1 – 7 `F
Are you an employer? Check the appropriate box:
1. [E I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a.sole proprietor or partner.
have hired the sub -contractors
listed on the attached sheet t
ship and have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[No workers' comp, insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No -workers' comp.
c. 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp, insurance required_]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. Building addition .
10.IE Electrical repairs or additions
11.0 Plumbing repairs or additions
12.[] Roof repairs
13.❑ Other
-r+ny uppucani xnat oneoks 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.
;Contactors 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: 12F�ILL le—
Policy # or Self -ins. Lie. #; Expiration Date:
Job Site Address: c;�y 2, VA t G 1+ S—r- City/State/zip:IS -kms i)a v C/1- ft1k e3f g iCS
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 certify under he pains and penalties of perjury that the information provided above is true and correct
8".)
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, assodiation, 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 cant' 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 nuanber listed below. Self-insured companies should enter their
self-insurance- license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under. "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and. fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN, MA 01833
978-352-8318 fax 978 —352-2858
pager 978-502-5921
July 1, 2007
Mr. Eric Peterson
202 High Street
North Andover MA. 01845
RE: Residence Mr. Eric Peter oni Sfreet; North Andover, MA. 01845
Dear Mr. Peterson
Per your request I visited the above site to review the LVL Beam consisting of 4-
1.75"* 16" LVLs supporting the first floor and structure above, span 16 feet.
I have reviewed the design of these LVL beams used in the structure and can
certify that the beams are acceptable and meet the loading conditions required by the
Massachusetts State Building Code.
Should you have any questions please do not hesitate to call.
Yours truly,
'
gawrenceH. Ogden, P.E. Structural 27765
D?
This certifies that .................
Date ?-. /- :�' . .
F NORTH ANDOVER
.PERMIT FOR PLUMBING
has permission to perform ..
plumbing in the,buildings of`' .........................
at . .... ! .. . , North Andover, Mass.
Fee.. ... Lic. NoG.... .... .............. .
PLUU BING INSPECTOR
Check #
7485
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FYrUNP
(Type or print) Date V !6 -7
NORTH ANDOVER, MASSACHUSETTS
Building Locations lX C.�6��P9
r,`[ i e ic-- soil -Owner's Name
New D Renovation
Replacement 13" Plans Submitted
Permit #
Amount $�
(Print or type) jD
Name
Address a®
I business
l
Name of Licensed Plumber or Gas Fitter
C� 0
Che k one: Certificate Installing Company
Corp.
Partner.
/� Firm/Co.
l/
INSURANCE COVERAGE Check on .
1 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 13 Other type of indemnity D 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 0 Agent 13
I herebv certify that all of the rletaile nnri inf-of:.... 11.....e ....6 Y:u_J .
- - - - - - �- kms• .&� I Vii III auuvc appncation are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
E31 -Pignature of Licensed Plumber Or Gas Fitter
lumber a% '? I
Gas Fitter License Number
0 Master
journeyman
Ea
w
U
o
z
F
vi
a
z
°
H
o
;
z
w
x
z
u
w
s
�,
a�
z09
�a
c
a
>
d
w
In
-
x
w
F
o
F
z
w>
w
a
z
d
0o
o
x
a
c
d
o
W
a
a
H
o
SU B-BASEM ENT
u
a
>
o
BASEMENT
1ST. FLOOR
2N D. F L 0 0 R
3RD. FLOOR
4TH. FLOOR
5TH. .FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type) jD
Name
Address a®
I business
l
Name of Licensed Plumber or Gas Fitter
C� 0
Che k one: Certificate Installing Company
Corp.
Partner.
/� Firm/Co.
l/
INSURANCE COVERAGE Check on .
1 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 13 Other type of indemnity D 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 0 Agent 13
I herebv certify that all of the rletaile nnri inf-of:.... 11.....e ....6 Y:u_J .
- - - - - - �- kms• .&� I Vii III auuvc appncation are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
E31 -Pignature of Licensed Plumber Or Gas Fitter
lumber a% '? I
Gas Fitter License Number
0 Master
journeyman
C-/ 0
Date. ---.1 (:;Ir 7. -- I .�7
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...... ............. 11 .................
has permission for gas installation .........
in the buildings of .. rlla7�-2 .................................. .
at 7; W4-47f,.4.0t," . --Z� .... , N ' orth Andover, Mass.
Feb,. Li4c7- No C-11 ..........
�GA;S��,W��E��ov
Check
6115
N / Z(
li�
i0/-.
���
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
/ Date
Building Location 0?9f�sf Owners Name L ►ri`C Re ier So -1 Permit # d
Amount /OS.
Tvne of Occunanev
New Renovation E� Replacement
FIXTURES
(Print or type) 0 CaInstalling Company Name 14 �-,, f 6 i."1 P j ✓P
Address , C
a C�3o 7
Rncinecc TAF-nhnnr _ ,, 3 G 2 19— I U G�
Plans Submitted Yes 1:1 No
Check one: Certificate
11 Corp.
E]Partner.'
11 Firm/Co.
Name of Licensed Plumber. Ka- C-, / D C -4 o" %,b P , /
Insurance Coverage: Indicate the a of insurance coverage by checking the appropriate box:
Liability insurance policy LJ Other type of indemnity El Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass efts ebin d ter 142 of the General Laws.
r
By: igna o Licennsea riumba
Type ofP umbing License
Title
City/Town TIMM lNumBer Master Journeyman
APPROVED (OFFICE USE ONLY
p
�r
NORTH ANDOVER BUILDING DEPARTMENT
400 Osgood Street
Tel: 978-688-9545
Fax: 978-688-9542
BUSINESS FORM FOR TOWN CLERK
DATE:
NAME: -t2`Z e �sd N
ADDRESS:
2-02- �� svrl-e��-
ZONING DISTRICT:
TYPE OF BUSINESS:
BUILDING LAYOUT PROVIDED: YES 1vu
AVAILABLE PARKING SPACES: 13
vL-1,e
ZONING BY LAW USAGE: YES NO A) m c9
BUILDING INSPECTOR SIGNATURE
ReviW 11.5.04
BUSINESS FORM FOR TOWN aDW
/I
D /77.
N2.� 1612 .. /
ate ...... x .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... 4-0.: T ....... ..........
............
has permission to perform ........ .....................................
wiring in the building of .....3 .QM. I ........... A)..1'As.0n .............................
C
...... : )l ..................... . .... . North Andov r, ass.
//a3 ......... ....................
ELECTRIC--'* ,***',
C 7 04/20/99 14:43 35.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Office Use Only
011e (10mmonwealtll of AuSat411101e Permit No.
Department of Public $afttli / Occupancy 3 Fee Checked
BOARD OF F1Rt PREVENTION REGULATIONS 527 CMR 12:000 peays blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4/13/99
City or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street S Number) 202 HTGH STREET
Owner or Tenant JAMI WILSON
Owner's Address (978) 683-1121
Is this permit in conjunction with q building permit: Yes ❑ No ® (Check Appropriate Boz)
Purpose of Building
„Existing Service Amps J Volts
New Service Amps _! Wits
y Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
Utility Authorization No.
Overhead ❑ Undgmd ❑
Overhead ❑ Undgmd ❑
No. of Meters
No. of Meters
No. of Lighting Outlets
No. of Hot Tubs
No. of nsformers Total
ltaKVA
No. of Lighting Fixtures
Swimming pool Above In•
grnd. ❑ gmd. ❑
Generators • KVA
No. of Receptacle Outlets
No. of ON Sumers
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of (las Sumer
FIRE ALARMS No. of Zones
No. of Detecdon and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
n ❑ Other
No. of Ranges
No. of Air Cond. Total
tons
No. of Disposals
Heat 'Tblal Total
No.ofPumps Tions KIN
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No. of No. of
8191`147 Ballasts
Low Vbitage
Wiring BURGLAR DEVICE
No. Hydro Massage lobs
No. of Moto- lbtat HP
'
OTHER: ONE SMOKE DETECTOR AND ONE HEAT DETECTOR
INSURANCE COVERAGE: Pursuant to tM requirements of Massachusetts general Laws
I haw a current Liability Insurance poky kmkm g Completed Operations Coverage or Its substantial equivalent. YES G NO O I
have submitted valid prod of same to the Olflce. YES O NO O If you have checked YES, pies" indicate the type of coverage by
checking the appropriate boot.
INSURANCE O BOND. O OTHER O (Please Specify)
Estimated lhlw of Electrical vAferk s
258.00 (Expiration Date)
Work to start 4/8/99 Inspection Date Requested: Rough Final 4/12/99
Signed under the Penalties of per)ury: r .
FIRM NAME UC. NO. 1 2 1C
Licensee nnna 1 d A- R ee v nature UC. NO.. 123 1111,_
Address 111 Morse StreaL Norwood. MA oe Bus. Tri. No. (203) 741-4008
All. Tel. No. (781) '278-11131
OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have so Insurance coverage or Its substantial equivalent as re•
qulred by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent
(Please chock one)
(Signature of Owner or Agent)
T>slephone No. _ .._ PERMIT FEES . 35.00
..re'r,
Date. //..J �:.�.!.....
4`, TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation ... `:.:`............ .
in the buildings of ... , < c
at .. . � k .? .../. �. �....`.. ........... North Andover, Mass,
Fee.. -. Lic. No.!7.7'.7.... .. .. . ` ? , .........
r GAS INSPECTOR
Check # ( �' j
38. 8
..� ---. •_ i vivorvnm ^r-rut;ATIOIN FOR PERMIT TO 00C;ASFIT('BNG
(Print or Type)
1f d / /Y / /Ae)w"y- , Mass. Date'
Zcx, Permit # 3
Building Location Owner's Name hZ(
T
ype of Occupancy��i
New ❑ Renovation Cl Replacement 2,1 I Pians Submitted: Yes No ❑
.kx
SUB—BSMT.
BASEMENT
IST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6THFLOOR
7TH FLOOR
STH FLOOR
Installing Company Name,
8er A `gym ma T A 12r"+
Address n A r ,h ra
�1r TN11Fn) til a U(k�{c/
Business Telephone_
Name of Licensed Plumber or Gas Fitter
. e_.
Check one:
❑ Corporation
❑ Partnership
2--firm/Co.
Certificate
INSURANCE COVERAGE:
I have a current Ipbility insurance policy or its substantiai equivalent which meets the requirements of MGL Ch. 142.
Yes 2' 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:
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 the pe i ed for this applicationLbecompliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws,�T of License: �i' k �Title Plumber n ure of cen u er C
tter .
City/Town JourneymanrUcense Number � J
NL
N
rt
W
N
to
¢
¢
Y
v
O
2
cc
N
}-
x
C7
J
H
=
ZV
<
0
F-
~
<
<
¢
Z
Z
0
•O
r
'-
W
cc
N
0
N
W
4
2
W
Z
O
!-
N
d
C
�
>UA
F
4
LU W
J
_
<=
tt
Uj
C
W
O
Q
W14 CC
W
Ir
=
2 <
W4
tC
<
C
F
r•
<
W
p
>
W1�+
W
< W
'=
>
O
t9
W
=
tL
Z.
O
3
Q
G
<
C
<
J
O
U
O
¢>
W
G
O
a
1Y F-
P I o
Installing Company Name,
8er A `gym ma T A 12r"+
Address n A r ,h ra
�1r TN11Fn) til a U(k�{c/
Business Telephone_
Name of Licensed Plumber or Gas Fitter
. e_.
Check one:
❑ Corporation
❑ Partnership
2--firm/Co.
Certificate
INSURANCE COVERAGE:
I have a current Ipbility insurance policy or its substantiai equivalent which meets the requirements of MGL Ch. 142.
Yes 2' 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:
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 the pe i ed for this applicationLbecompliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws,�T of License: �i' k �Title Plumber n ure of cen u er C
tter .
City/Town JourneymanrUcense Number � J
NL
Z
-
O
U .
W '
a
-
N
ti
Z
N
N
W
C7
O
d
W
W
LL
LLf(
W
S
U
HI
W
Y
N
/ All
F
Location
No. r?Q a J Date
,4oRTM
TOWN OF NORTH
ANDOVER
Certificate Occupancy
$
si ; ,
of
q
SS'"'°''<�'
CH SE
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
u
TOTAL
$
Check # + 3 / 0 6 1
16770 AAA
,� Building Inspector
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
? " F l5 3 ..r.�i'tyV r 'J Y:'!f :.:� k, Fy¢ i,; `zt nt, .,�. •c a . yY ,
y #rThis Section for Official Use Onl
BUILDING PERNUT NUMBER: t� oZ
DATE ISSUED: 5e_ / `a dD
SIGNATURE:
Buildin CommissionerAps1wor of Buildings Date
^"�sY.s
11 112.
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
S a57
Map Number Parcel Number -
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
Required
Provided
Re red
Provided
1.7 Water Supply M.G.L.C.40. 54)
Public ❑ Private ❑
1.5. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal On Site Disposal System ❑
2.1 Owner of Record
Name (P nt) Address for Service:
C
4 —?&' l '
Signature Telephone
2.2 Authorized Agent
Name Print Address for Service:: pp
Sign re Telephone
3.1 Licensed Construction Supervisor
Not Applicable ❑
Address
YAiz
License Number
O G S� / J /
Licensed Constru Supervisor:
Expiration Date
i ature Telephone
3. Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
I
Ro,
—
1, "�' �'"Ufa as Owner/Authorized
Agent
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury
Print NameAll
112lo-3
Signature of Owner/Agent Date
Item Estimated Cost (Dollars) to be
Completed by applicant,
permit
1. Building
0cre
(a) Building Permit Fee
60 0
Multiplier
2 Electrical
Q� 11-16/
(b) Estimated Total Cost of
C� ow
Construction from (6)
3 Plumbing
Building Building Permit fee t.l X (b)
�70
4 Mechanical (HVAC)
c'%
GO
5 Fire Protection
ZOO
6 Total (1+2+3+4+5)
-7
Check Number
}tib/ {. '�E{. k� 5.-1k ..lf x i"1:.:� :Gi y1.J �NS5x�� �1✓ - / �.+.. �5.LRtIF� 4f- '<. T� -. t..- t` q..`i A J:x Et f14i
r$ ayy H.; �: �-, M:' 7 �' +,§ 3,~ai tt+y. '-�7 s+;'-.., r� Hk ,� t< 1..+. d2:r �Y
rv,. -:ir,855 f=.,.,.. 'N''"�, r:3 ^)s1 gym.,! t �`1
.caA ,t''L3T .t,c. s el >N .�} �;
��fia
p�Rl
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 sr 2ND 3 RD
SPAN
DEMENSIONS OF SILLS
DEMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING x
MATERIAL OF CHIlvINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Xc.. ar +,w.✓ r <_ w
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the
issuance of the building permit.
Signed affidavit Attached Yea ....... F1 No....... ❑
SEC774A1 S - PREF SSIUI AI.1) i Atm C 1�TST t G IK t+V1 11C S F+p►R BI Il tCsS ►1 'RLI+ ' " TO
5.1 Registered Architect:
w Kos& 1 Q✓a j fSO(,
Name: gai-yu
a2O CPOU,5 5% r)& 02?-10
Address
Signature Telephone
Name:
Address:
Signature Total
Name:
Address
Signature Telephone
Name
A
Address
r
Signature Telephone
Name
Address
Signature
tr
Y
Company Name:
Responsible in Charge of Construction
Telephone
Area of Responsibility
Registration Number
Expiration Date
Not applicable ❑
Registration Number
Expiration Date
Area of Responsibility
Registration Number
t�
Area of Responsibility
Registration Number ,
Expiration Date
Not Applicable ❑
New Construction ❑
Existing Building ❑
Repair(s) ❑
TAlterations(s) t
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
�,eAWIAJJ5 AAr
A-2
A-5
❑ A-3
❑
0
BUILDING AREA EXISTING if applicable) PROPOSED
Number of Floors or Stories Include
Basement levels
Floor Area per Floor s
Total Area s
Total Heiaht (ft)
Independent Structural Engineenng Structural Peer Review Required Yes ❑ No ❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
Hereby authorize
Owner of the subject property
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
to act on
USE GROUP Check as applicable)
CONSTRUCTION TYPE
A Assembly
❑
A-1 ❑
A4 ❑
A-2
A-5
❑ A-3
❑
0
IA
IB
❑
❑
B Business
❑
2A
2B
2C
0
0
❑
C Educational ❑
F Factory ❑ F-1 ❑ F-2 0
H High Hazard
❑
3A
3B
❑
❑
(Institutional 0 I-1 0 I-2 ❑ I-3 ❑
M Mercantile
❑
4
0
R residential
❑
R-1 0
R-2
❑ R-3
0
5A
5B
❑
❑
S Storage 0 S-1 ❑ S-2 ❑
U Utility ❑ Specify:
M Mixed Use 0 Specify:
S Special Use 0 Specify:
COMPLETE THIS SECTION IF EXISTING BUBLDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Use Group:
Proposed Hazard Index 780 CMR 34:
BUILDING AREA EXISTING if applicable) PROPOSED
Number of Floors or Stories Include
Basement levels
Floor Area per Floor s
Total Area s
Total Heiaht (ft)
Independent Structural Engineenng Structural Peer Review Required Yes ❑ No ❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
Hereby authorize
Owner of the subject property
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
to act on
ECVED
YALE 3EP E2 2003
EtEPUBL.�
September 11, 2003
Michael McGuire
Building Inspector
Town of North Andover
27 Charles Street
North Andover, MA 01845
Re: Schneider Electric, One High Street, North Andover
North Andover Mills
Dear Mr. McGuire
We have reviewed the proposed construction documents for the interior build out and modifications to
Building No. 7, One High Street, North Andover Mills Complex for our tenant, Schneider Electric, and
approved the following construction documents —
Burt Hill Kosar Rittelman Associates, Architects, Drawings A101, A102, A103, A201, A202 and
A203 dated August 29, 2003
Attached please find three (3) complete sets of plans along with affidavits from all necessary architects
and engineers involved.
If you should have any questions in regard to these construction documents, please do not hesitate to
contact my office at any time. We would like to thank you in advance for your time in reviewing these
documents as quickly as possible in order that we may commence construction and realize critical time
elements.
Sincerely,
TIES USA
Stephen K. Smith
Senior Property Manager
cc: James E. Lesko III, Regional Director of Operations, Yale Properties USA (w/o enclosures)
Thomas A. Palmer, Schneider Electric (w/o enclosures)
Cross Point, 900 Chelmsford Street, Lowell, Massachusetts 01851 Tel.: (978) 453-6666 Fax: (978) 454-6394
AFFIDAVIT FOR
ARCHITECT AND ENGINEER
THE COMMONWEALTH OF MASSACHUSETTS
COMMONWEALTH OF MASSACHUSETTS )
SS:
COUNTY OF ESSEX )
On this 9th day of A gust, A.D. 2003, before me,
!' Linda S. Smiley, who, being
duly sworn, deposes and says that she will review the preparation
of tenant fit -out construction documents for Schneider Electric on
the First, Second, and Third floors of Building #7 at North
Andover Mills, in North Andover, Massachusetts; and that she
will review and/or provide for the proper checking of all the
working drawings and shop drawings for construction; and all
modifications to the existing structures will be designed for
construction in accordance with applicable provisions of Chapter
1, Section 116, Massachusetts State Building Code, and that such
plans conform to all the applicable provisions of the
Massachusetts State Building Code, and that all the materials
used in the construction will be selected by specification by her
or her registered professional Designee in accordance with the ��S 9,
oRED
A S. S F�
Controlled Materials Procedure therein defined. Fs
No. 10080
o NEINBURVPORT
MASS. ycv
�J
Linda. Smiley `'71 OF MPSSPG
Spkscri4ed and sworn to before me this 9 day
y of
Notary Public ,
My commission expires on �� 91
Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
Cif Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
1 am an employer providing w ers'f compensation for my employees working on this job.
Companyname: e1i� �t✓ �%I l Ni ( r��S, L40 �-
City: DlqvwPifZs Phone#- ? 8' / ✓ �Q�/
Insurance: Co. G7Y Policy # �- < ""CJ -4 -7
Company name: ,
Addre§s
Criy
Phone #:
Faibxe to secure coverage as required: under Section 25A or MGL 152 can lead to the it positlan cf crimina;
Penalties ofa fine upto$1,500:Ot1
and/or one years' imprisorvnent.as_NcWLas.ciWpenakiesjosbeiom -ctaMQP fineWO1Qo W)_,daiF AlpI 1
understand that a copy of this statement may beforwarded to" Office of Investigations of the DIA for overage verification.
db hereby ee�►tify ander Bre pains and penalties of perju y #A& a e #*miadon provided above iia ave and correct.
Signature Date
Print name pe
Official use only do not write in this area to be completed by city or town officiar
City or Town ermKjcensiLig
i
El Building Dept
[:]Check if irmnediale response is requred
❑ Licensing Board
❑
contact Selectman's Once
person Phone k ❑ Health Department
E] Other
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-W
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 properly
licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A.
The debris will be disposed of in:
L)J&A)&cj,
(Location of Facility)
(;�Iignature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this projec
through the Office of the Building Inspector
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fron
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 F
j LLS OUT THIS SECTION******* -****-**-**...-.,**APPLICANT KQ,)LL,c ��, loo! (ate, pL6d��l,C
LOCATION:' Assessor's Map Number
SUBDIVISION
STREET Alk 6i %
PHONE_g c)-Di7h
PARCEL
LOT (S)
ST_ NUMBER
**_ ************"*****OFFICIAL USE ONLY*******—**—*****
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
s�
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE -REJECTED
'UBLIC.WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
/REDEPARTMENT
ECEIVED BY BUILDING INSPECTO
vised 9197 jm
TE
m
m
m
m
m
H
'O
a Z
CD O
to
o.
� o
o p
CL
Cr
CCD O
a: CD
Cfl CD
COP)
'O
CD
0
H
d
_
m
0
CO)
'O
n
O
H
d
c�
CD
0
_
CD
CD
y
CD
CO2
0
CCD
CD0
C?�O of
y O Q H
dOSO 1 CO)
aO m C')
O CL m
h m rr C
Z =r.0H
CL 0
CD O m H p
CD
CD C41
O m �.
o. X1.0
O h CJ
VA �--� Cr] a a O • � :� :1�!
so o 5 =r -CD
CD
:
VJ mCD 1 C-rc :
C O'
y
0=1 CA M a
cr
O' 1 C
y m r m O • �i
CD:W
CO
o�
O O c
(n
�a3
A '�� k
o
rn
Cn
C/)
q
21
xg,
"
l
O
tri
z
P
O
rO
O
O
00
OR
w
l
(f/o
ply
O
z
rij
rA
v
y
O
C
(D