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HomeMy WebLinkAboutMiscellaneous - 206 WAVERLY ROAD 4/30/2018 (2)sCY) n om r b Q So 0 0 f t r -,- �� 1_ O cc O �ICU r c= C a o E CD E Q L N .w c d CD E a, c c v 0 v L N 4D 3 m m ca J U) , M' > c = 0), O = d > N _ O O C t U Q :a y d .Q E'� O U. o z CL - y o 0 T o� L Q Q d CD cc 0 r--0 -0 IM O r •a CD Q L L CC (D -'s O U) O V N W 0 -0.. O O LL •� (n O C. t O W �E 0 .E 0 V Q 0-0 O U) °' '> c 2 cco O c O F t A- O. 0 U E N CL t N c a� as m L O c O N N t O z O Q J O W :a c� 0 m Z V cn L�L/I L� Lf a. x Z, w0 � U N cn LLJ W J V �l H 0 Ilt .,v 0 o v Z O N I O .� G1 �� •� m m ' C ^p W 0 cc O cn � Q o v J aW O CL VVI Y CL 0 W Wa O0 W a 'N m Z p m p� W LL N v z v \ U L G 0 c O N O O L LL N LL' U LL L j O O d' LL U 'L O v N O LL L O K LL ++ v O 7 aL+ m N N O cc O �ICU r c= C a o E CD E Q L N .w c d CD E a, c c v 0 v L N 4D 3 m m ca J U) , M' > c = 0), O = d > N _ O O C t U Q :a y d .Q E'� O U. o z CL - y o 0 T o� L Q Q d CD cc 0 r--0 -0 IM O r •a CD Q L L CC (D -'s O U) O V N W 0 -0.. O O LL •� (n O C. t O W �E 0 .E 0 V Q 0-0 O U) °' '> c 2 cco O c O F t A- O. 0 U E N CL t N c a� as m L O c O N N t O z O Q J O W :a c� 0 m Z V cn L�L/I L� Lf a. x Z, w0 � U N cn LLJ W J V �l H 0 Ilt .,v 0 o v Z O N I O .� G1 �� •� m m ' C ^p W 0 cc O cn � Q o v J aW O CL VVI Y CL 0 11381 ,?bate ...... TOWN OF NORTH ANDOVER I This certifies that ... ..... . ..... ......... .............................................. .................. has permission to perform ..... plumbing in the buildings of ......... ......................................... .. ..... ..... ....... North Andover, Mass. at. .......... &-) ........... Fee.-3� .......... Lic. . ........................................... ..................................... PLUMBING INSPECTOR PERMIT FOR PLUMBING . Check # 20 t) -(0 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES -50 D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY� OTHER TYPE OF INDEMNITY Q BOND0.I 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 [2 AGENT 10 SIGNATURE OF OWNER OR AGENT 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 al �Pertin provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �LICENSE # _ 6 SIGNATURE MP D JP CORPORATION DI # PARTNERSHIP ©# LLC COMPANY NAME ADDRESS G✓ CITY1 /'11 u,�_y`Y_._._..-..._..._.._..__I STATE ; ZIP G% llG il TEL FAX � ( CELL L— EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 ' CITY _�/ MA DATE�PERMIT # JOBSITEADDRESS S NAME POWNER ADDRESS I TEL[ _FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Df EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: Df RENOVATION: ® REPLACEMENT: Ea' PLANS SUBMITTED: YES ® NOD FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND SYSTEM ! DEDICATED GREASE SYSTEM 1= _...____[ —_... d DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER f -.-- _..i I .-----_-(--...�f. I .. _.._.._._._l I ._.—_I __-._....-_f FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK I _1 _. _.� .__.._-) --__ f f LAVATORY) ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ _.._I J _[ I _I f J f i I ___I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER __..�...._�._....__._ f I ._ __..---1----._.-i � _—I � I + f f .....___.-[ J==—[ _I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES -50 D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY� OTHER TYPE OF INDEMNITY Q BOND0.I 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 [2 AGENT 10 SIGNATURE OF OWNER OR AGENT 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 al �Pertin provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �LICENSE # _ 6 SIGNATURE MP D JP CORPORATION DI # PARTNERSHIP ©# LLC COMPANY NAME ADDRESS G✓ CITY1 /'11 u,�_y`Y_._._..-..._..._.._..__I STATE ; ZIP G% llG il TEL FAX � ( CELL L— EMAIL o o z y ❑ iui w LL 6 The Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street, Suite 100 Boston, MA. 02114-2017 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. lxpp (I Name (Business/Oigabization/fudivldual):_ Address: h `� r/ City/State/Zip: /' 1 C Y i P d` Are you an employer? Check the appropriate box: #: 579 1.[] I am a employer with employees (frill and/or part-time,). 2. am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and 1. have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL C. 152 81M and we have no employees. [No workers' comp. insurance required.] W/ Type of project ()'equirerl); 7. ❑ NbVd6nstrnctlon 8. [] RemodcMg 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions IZO.PilTmibing repairs or additions 13TI Ro6f repairs 14.[] Other *Any applicant that check's box #] . must also fill out the section below showing their workers' compensation policy information. 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 b11, ox must attached an additional sheet showing the name of the sub contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date,-. lob Site Address: 006 C,1j %LCity/State/Zip: /(/ U Dov !A �liQ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required underMGL e. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA. for insurance coverage verification. dct X do hereby certify pains of perjury that the information provided above is true an , come . official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. city/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Information and Instructions �. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employ,'ees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hit', 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant,wh6 has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(1) 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'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 retained 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 PIease 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 "fob 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 NOTrequired to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AMSSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia :ANO GA5F 1TTL'IER5 E FOLLOW A JOURNEYMAN `PLUMBtB ADAM Date ..... . TOWN OF NORTH ANDOVER PERMIT FOR WIRING A'-4 '3- C_ This certifies that ......................... has permission to pedwin ......... ............. 0 C-,.,( ........................ 4 ........................ I A-4 winng in thejjuilding of ........ ........................................................................................... at 6' ',/ . ............ . North Andover, Mass. .............. ....................................... . ......................... Fee Lic. No. ,2 . ........ ...... ....... LEC n..UCAL INS� JCR Check 4t 112 7.21 �°'� Commonwealth o� If (aasacltueeifs Official Use Only cc�� ec77 Permit No. eUepartment o�}ire �ervice� BOARD OF FIRE PREVENTION REGULATIONSOccupancy 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 (M7), 5 7 CMR 12.00 (PLEASE PRINT IN INK OR TIP INF/ TION) Date: �5'S City or Town of: WR iV j -&v To the Inspector of Wires: By this application the undersigned give notice of his or her intention to perform the electrical work described below. Location (Street & Number) jl�fi J� j Owner or Tenant �y,��' Telephone No. Owner's Address 4�4 »-,.C, Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps,k t L(C�Volts Overhead JZ 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: Comnletion ofthe followin r tahle mmu he wnived by the /ncnerior of Wires No. of Recessed Luminaires 7 No. of Ceil.-Susp. (Paddle) Fans o• of Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above [IIn-EJo. rnd. grnd. o Emergency Lighting Battery Units No. of Receptacle Outlets j No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. 3 of Gas Burners o. of Detection and Initiating Devices No. of Ranges j No. of Air Cond. Tonal No. of Alerting Devices No. of Waste Disposers eat Pump Totals: _ um er _ons _ _ " ' o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑. Other Connection No. of Dryers Heating Appliances KW security ystems:* No. of Devices or Equivalent No. of Water KW Heaters —No --or— No. o Signs Ballasts Data Wiring: No. of Devices or uivalent No. Hydromassage Bathtubs !No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector q f !Hires. Estimated Value of ec E� 'cal Work: L<� (When required by municipal policy.) Work to Start: _ 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 penalties of perjury, that Tinton otr dais applicatiot: is true and completeFIRM NAME:+�, J/,c , C + C/C! LLQ LIC. NO.: Licensee:Signature �� _ LIC. NO.: "J' (1f applicable, enter "exempt" ' the icer a number line-) Bus. Tel. No.: 7"e-4'8i-lnl Address: Liz -tr-�) ��✓r°i- ft99 fv,,-Y,5 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-6V, security work requires Deparfinent 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. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner> ageDt. Owner/Agent Signature Telephone No. PERMIT FEE. $ 6 J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: Phone #: qV re you an employer? Check the appropriate box: 1. I am a employer with 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 5. � We are a corporation and its required.] re 3. El I qu a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1 (4), and we have no employees. [No workers' come. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ 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 a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name: N Policy # or Self -ins. Lic. # �(%/ V �z%�l/� 7 / Expiration Date:�� Job Site City/State/Zip:./ j, :� &0 ocl-� Attach a copy of the workers'rnmpensation 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 unde theca andgenalt ofperjury 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 of wiaL 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 #: Commonwealth of Islas usetis Division of Regist" ti Board of Electri \ 1: MICHAE S. �= 9 WAVE M 4 NORTH A� Master Elec 21705-A 07131!2016 y 008772 i No. License A Expiration Date. Serial ✓ O. ; I�r Date ...... TOWN OF NORTH ANDOVER This certifies that ... ......... PERMIT FOR WIRING has permission to perform ............. . .. . . ............................................. wiring in the building of .................. PJ4/.?.<WnE ................................................. at 2-0 (P North Andover, Mass. ................ &,Z, ......................................... ......... ........... .. �Z,4.14elir Lic. No. Fee .. .. ........ .... M-7 ............. . .......... ... ............. R LECTRICAL INSVECTO Check it 12- 9 A /It C,ommonwealfh o1 kamachajeffs eLJePartmenf o� ire �ervice� BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 12 Y, Occupancy and Fee Checked [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 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: E City or Town of: A16 ( A ph Aa e r— To the Inspe for o fres: By this application the undersigned gives notice of bis or her intention to perform the electrical work described below. Location (Street & Number) e 1 ko e d Owner or Tenant c J- Telephone No. Owner's Address ,:S Cl y14 e 7fl' b kJ F%J 3 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building t2 Ns Jet, G2 d 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:V j ire e, e-, ru na(--e, Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Swimming Pool Above El rnd. rnd. E:1 o. o mergency ig ing BateUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches o. of Gas Burners of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number . Tons . . KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Municipal EI El Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: INo. 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 Electrical Work: (When required by municipal policy.) Work to Start: ep Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COV GE: 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: INSURANCErn—al—des BOND ❑ OTHER ❑ (Specify:) Jc' `, rot; I certify, under the pains and p of perjury, that the information n this application is true nd complete. FIRM NAME. Al p5 L. E p rl 7LIC. NO.: F-3 Licensee: Signature _ LIC. NO.: (If applicable, enter "exempt" n the license number line.) Bus. Tel. No.• Address: _12e K / cJ c'y f ti (� /� y� Alt. Tel. No.: Z5 Z3 *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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ �z Date... ....................... . . ......... ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... ........... .............. ...... *1'** ................................ has permission for gas, tall tion .... ..................................... inthe buildings of . . ............................................................................ at ......... 2 -up ... v,.aa,�Px U: ........... . North Andover, Mass. ................................................... Fee ..... �).� ....... Lic. No. J2 . ........ GASINSPECTOR Check # 9660 " = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA MA DATE f% /— p�9Y� PERMIT # JOBSITE ADDRESS�lii j'�'�"C� tri i OWNER'S NAME �j G` �� OWNER ADDRESS TEL�"�j� FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT :1x PLANS SUBMITTED: YES N0O< APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES }(NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �' ` LIABILITY INSURANCE POLICY / OTHER TYPE INDEMNITY : BOND i 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 AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true an ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia ith& all Pertinent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - /Z., PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 IGNATUR _ MP K MGF JP JGF LPGI . CORPORATIONA# 3631 C PARTNERSHIP #: LLC # COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3 CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com h v •0� The Commonwealth ofMassacheasetts Y i - Department of dntlatstrial Accidents 1, Office of Investigations 600 Washington Street Boston, AM 02111 www. mass.gov/ilia Workers' Compensation Insurance Affidavit: Build e>rs/Co>r;t>tractorr°s/Electricians/Plumbe>rs Name (Business/Organization/Individual): Address: City/State/Zip:'%��'Ce�'/'%�%JY/W Phone #: Are you an employer? Check the appropriate box: I. I am a employer with / 4. 0 I am a general contractor and I JX employees (full and/or part-time).' have hired the sub -contractors 2. ❑ 1 am a sole proprietor- or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for mein any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.+ required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] c. 152, §1(4), and we have no employees. [No workers' insurance Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or- additions 1 l .❑ Plumbing repairs or additions 12.❑ Roof rep ' s 13.D60ther lag, , *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. prem an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. a Insurance Company Name: , Policy # or Self -ins. Lic. #: r `,4 Az '16�/ 3 Expiration Date: Job Site Address:"v��C7.� /-� `7r• City/State/Zipe&3 e &;7 r' 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ve^ation. ,A I do hereby that the information provided a ove its trite and correct. '� _ _ //atmate �I /r /_/ Official use only. Do not write in this area, to be completer) by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building (Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: .BOARD PLUM$ER$" AWD GASP i'TT-ERS . ISSUES THE FOLLOWING LICENSE... L I DENSE 3' AS A J0UR.Nf YMAN PLUMBER` j PETER G VI ENS w 9 BLUEBIRD LANE All ATE I r J ATEINSiN NH 03811-2362 216.:35:: 05/0.,I /'Ik :—. 213586 azawol o o• fA 1*i caA6tE16MIm8& tic KMzV*WMXft Dmailund off Pwibft Said Hoisting Engineer j Limmez HE -110323 I PETER G VIENS + " 9 BLUEBIRD LA s t 3 'r N ,ATKINSON NIT 03$11 ! a �y --51. !! flit, as G ittimor €1/13/ 015 ' 11 /13/2015 State of Nei Hampshire GAS FITTER&LIC-IIISE NAME: PETER VIENS L � ENDORSEMENTSI STNj -TP DATE ISSUED: 10/15/2013 DATE EXPIRES: 11/30/2015 LICENSE #: GFE0700587 I certify that 1 have examined in accordance with the Federa o or arrier Safetyul ions (49 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified; and, if applicable, only when: ❑ wearing corrective lenses ❑ driving within an exempt intracity zone (49 CFR 391.62) ❑ wearing hearing aid ❑ accompanied by a Skill Performance Evaluation Certificate (SPE) ❑ accompanied by a ❑ qualified by operation of 49 CFR 391.64 waivertexemption The information I have provided regarding this physicaf examination is true and ppmplptp. A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office. SIGNATURE OF MEDICAL EXAMINER T EPR 1E DAT MEdiCAL EXAMINER'S NAME (PRINT) ❑ MD E] Chiropractor ❑ DO Advanced Practice Nurse MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO. STATE rSSUING �� !Q ❑ Physician ❑ Other Assistant Practitioner NATIONAL REGISTRY NO. SIGNATOR OF IVER INTRASTATE CDL ONLY ❑ YES NO ❑ YES 4ZINO DRIVER'S LICENSE NO. STATE ADDRESS OF DRIVER b/ MEDICAL CERTIFICATION EXPIRATION DAT 09A� PLY 1 DRIVER PLY 2 MOTdR CARRIER 26520 (5/13) "�-bRm7,� lHia'.1v�'P�do/:m�s�e��71.mAA/AVaPS�AgId9_At�]mletaf"°4 - PLUMBE:RS AND GASFITTERS . ISSUES THE FOLLOWfNG LI CEN L I LENSED AS A MASTER PLUMBER �� RETE:R G VIENS 9 BLUEBI'Rb LANE ATKIN50N tH 03811-230.2 1211.::.. 05/4.1:/16 213585 0 0 i r �41TtfXdl�nR.r�I8fl7 ®� �{3:F>i�1(t DwartT it 0 Fuwft Sew Pipefitter Journeyman �. LkzA w: PJ -028388 J ? PETER G VIENS 9 BLUEBIRD Ll 1 .ATKINSON, pG �\ 1111312015 STATE OF NEVA HAMPSHIRE BUREAU OF BUILDING SAFETY & CONSTRUCTION PLUMBING SAFETY SECTION . NAME: PETER G VIENS ,1 LIC #: 3249 M EXPIRES: 11/30/2014 EE F�=011 .rvs-".� ;; Peter VienS Cert # 1023121001-12 Expires: 10/23/2015 I I Certification N. F. P.A. 99-2012 ed. ASSE 6010 Installer 8 ASME IX Brazer OSHA 600316337 itYS. Srr�ntcal La61or YWC[;OtVXHS%8bty-m5 P9sattA �t�a Yetei-Yievs ts�saitfgy�artgAelatla SD.'�urci�c�aliotsai�di�y�r173eaun 3?21T11f}D`fabltf@9 �Ba'�1y�0�E21th Date.. /.0.- 1.3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certi fies that .... ............ has permission to perform .... ............................ wiring in the buildin of ..... M.)%Co.7" 9 Tr ................. at .... ...... rth Andover, Mass. r_�' 02-0- 51 If ee ......... Lic. No.. )4(�63 ...... l0i��'//-w ........ ... ..... ......... 7 ELECTRICAL INSPECT6R �heck 4 37'11Y 11349 S\— - � c7 a oxww use Gaty FetmitNo_ OcmvaBzy BOARD OF FIRE PREVEWnON REGULATIONS and Fee Checked (ImmbbaQ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Aft�kmt�ie.�� ����� (l'iEASEPRlNi'Ihi OR TgPE 1NFQR�%iTit?N) Bate: / it e1/3 Cii+iy or Tows eft To theme of By this applihe g� � of bis orlon. Wu-w.the o csi work &mmbW below. r-ocat%a (meet & Pfumber) 2�DA .sem ter' Owner OrTeaant Owner's Adam Tetephose No. Is tans permit in conjumcum wfth a bunftg p0mv. Yrs ❑ ?to ❑ (Check hPP B� e Utility Anthorhmaoa N. i& sting Se"ice Amps / Yoitt Overhead Untigrd ❑ Na_of Mete3rs New service Amps I Volts Ovwtmd ❑ ' Undgrd ❑ ' No. of Meters Number ofFeeders and Ampacity Location and NatnrE of Proposed Electrical Work- -/ ork: No. of Recessed L ++� of Cwt. -sem (Pam}gads aaale be waived me r Of f9rre� - of T KVA No. of Lnnihaire Outlets N416 of Hut Tubs GeneratorsiCVA No. ofLulubmires EZu4vS7- Mw 8whuming Pod ❑ NE -4 MCY U�miRs l o.9f C1e Oamds QlSr7Lf 0. of l[ Bmwe s ALARm 6. QtztInCS No. of Swjh*n 2 - mmufGasBumers of No. ofRangesof " Air Coad. Tofaf Tens QfA Ueviees No. of Waste Disposers -pum-p E KW _ Dem ❑ ❑ Othce _ Na of Diffissashers No. of Dryers Appliances KW Ni. of Water Heaters KW . o€ _No.of or eat l� ofDevices or t Na- Hydromassage Bathtubs No: of motors Total HP ns l� of Deviefs or . OTHER: Estiata#ed Verb o€ t Wed-,•` •"•B� ` ortup�eptry L& Laga[or of frff s. bynumicipd PoficY3 Work to Stam I (0 beim in =mdmm vft MRC pzWc 10. and upon comp& rs L II+ISUR"CfC— YEBA.6R: ihJess vWw d by lite oma. no pmt farthe of ekcftk t work may issue unless ftd s cuvamp or its sabstwW equivalent" The that such ammVe is in f+wc6 and bw offirbied pmofaf=mwto &V permh ksuWg ggf. CHECK ONf= DMURANC.E jh BOND ❑ 0T7IF.R ❑ [S�C#i3►-) i ,afp, mrder thep�ram�dp of jam, im c arr tMs f FIItM NAME: VJW i 1> tr L i; i.T2i CAS CST $Z 1:, i4 IAC NO.: Licensee: VRV ID i#A t. &. rte Stere --I,IC. NOs f' 1 & 3 Address:�rLf*a--r S"f 1 MmTeL No.; *Per?&G"I.. c 147, s. 5k61, sw aftwork ofp&iic�Y� A[t. Tei. D.`�7&- .. Lk- MD.' 0-vVNER'S WURANt9 WAIYi : i wn aww that ltie dagxiro#lm.the liabth"ty ie&etrance eovemgC =May requiredby law W mys;pa� below, I hereby %uive this . Iaatibe (CfAck one ❑ oevau ❑ owata's t OwnedAgmt Signatmrs TetephoneRm PBRAUT'IWE: $ 09751 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certi fies that .... 0.(ki\ V 9&1 j has permission to perform ...................... Ate 6f plumbing in the buildings 'of. tv e ... at .... 2-0 (o. �� .4% ..... , North Andover, Mass. ..... .. . . A 0A At -119 Fee.4.16Q.'.Lic.No..A.�q.�.. ...MO ................. ... PLUMBING INSPECTOR Check MASSA HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , i e.� / 9 PERMIT # CITY MA. DATE JOBSITE ADDRESS O bJ S U P I- JY e-'� OWNER'S NAME -F6 ✓`� ��' c o �� OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ CLEARLY FIXTURES Z FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY / ROOF DRAIN SHOWER STALL / SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes [�, No ❑ d IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent 1 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. PLUMBER NAME rh 9 V- !--1 6 L' V- 5 le C f SIGNATURE LIC # MP [A JP ❑ CORPORATION PARTNERSHIP ❑ # LLC ❑ # p J� Dec /s `/ X 0 � � �.S S S 1 v 1g K.3 A � 17�ADDRESS: Old J I e � o'e COMPANY NAME � Y � t � /� CITY 1 �IJ[ �' I�C �! 0 STATE /� % ZIP C EMAIL 16u,13$ QJS j�,,, �',t dP✓,' LQ� b'r7t TEL 0 CELL 9 7 S-'' S/S - %S FAX _ �/ ? 0'` �i YJ .S Q7 d t/ The Commonwealth of Massachusetts aft 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 Le0bly Name (Business/Organization/Individual): S S f, , vs, -,y A __-X C� Q Address: (S) /�t,J r (( 1_�.-/ City/State/Zip: I- -/ -L 3 S L9e t.- c v"t ) Phone #: � ) ?- - & Y S - ;)-/ / 0 Are you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors a[ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §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. ❑ Demolition 9. ❑ Building addition 10. FJ Electrical repairs or additions 11.®,Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other .ny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. rm an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation. p /� surance Company Name: dicy # or Self -ins. Lid. GJ 2 0 % (3 G / O Expiration Date: 3 / Y - / 3 b Site Address:- a a Ce C,. r G e, /;,, Ka City/State/Zip: IAJ'A- :tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a LC 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ✓estigations of the DIA for insurance coverage verification. !o hereby certify under thepains and penalties ofperjuty that the information provided above is trite and correct. mature: �''"-- — Date: one #: Official ttse 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 #: Informati®n 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 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 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 COMMONWEALTH OF MASSACHUSETTS, PLUMBER -3) AND QASFITTERS . LICENSED AS h. JOURNEYMAN PLUMBE "ISSUES THE ABOVE LICENSE TO: `MARK `W BURGI*.,-.,S cli o6 OLD—KENDALL- RD TYNGSBORO MA 01879-1023 9-1023 �-22900 05/151/14 .1646.45 COMMONWEALTH OF MASSACHUSETTS. FEW; i I PLUMBERS AND GASFITTERS L W ED AS A MASTER PLUMBER, IC N ISSUES THE ABOVE LICENSE TO: Mi ,f,? K W BURGESS 6: UD KENDALL RD TYNGSBORO MA 01879-1023 1,1894 05/01/14 164644 COMMONWEALTH OMMONWEALTH OF'MASSACHUSETTS, E 0 1 1 PLUMBERS AND GASFITTERS. REGISTERED AS A PLUMBING CORP. f. ISSUES THE ABOVE LICENSE TO: 1. MARK W BURGESS BURGESS PLUMBING & HEATING INC. Ild 6 OLD KENDALL RD TYNGSBbRD MA 01879-1023 2986 05/01/14 1646.413 1. I N2 2053 0 1�1 Date.., - 2',f—,571 ... .......... TOWN OF NORTH ANDOVE PERMIT FOR WIRING This certifies that ..... .................... has permission to perform .... ..................... wiring in the building of . ...... . . .. ................................ f at .... -4--/ ...... 6 ............................... . North Andover, Mass. ...... Lic. NoQ.62-11 .............................................................. 00� ELECrRICAL INSPECMR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .......................... N2 2 J 5 2- VORTN E TOWN OF NORTH ANDOV R 04 0 11.1 PERMIT FOR WIRING 4L o This certifies that ....................................................... has permission to perform ..... ...................................................... ............. . wiring in the building of ..... tr::�e ... ......................................... at< ..L, ..... ........ ........ .. ......................... . NorthAndover, Mass. ..... Lic. No/�.�� ................ I*C*A"L* *I* N**s'P'*E* c*'r'O**R'* 09/25/98 10:17 WHITE: Applicant CANARY: �PAnl;IBOIP PINK: Treasurer 7w"g eMminro"IW91 117w� 61;7 75 Deis. w—e 14 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only -�7 Permit No__ � C2_ Occupancl S Fee Checked_ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical worts described below. E!e=cal Code 527 CMR 12:00 _ C Date To the Inspector of Wires: Location (Street & Number �?,L1 (��_c Owner or Tenant gOY1, E I ycy%N 1C' iA mA0,CO_7e Owners Address '30L, LJ 09 J I- P -L t=`i R � . � /J&- 14r-�Q U t/iX, . �`1A l� I W -5 - Is this permit in conjunction with a buildingpermitYes No El (Check Appropriate Box) t Purpose of Building f"1-l� ht t_�f iRC_)oV. )A -W k -M CA_;. Utility Author¢ation o 8 p(@ ? C0-1 I L Existing Service ,00 Amps /jam Z O Vats Overhead L�-- Undgmd G No. of Meters New Service & 0 Amps % Z Vohs Overhead C�-- Undgmd ❑ No. of Meters Number of Feeders and Ampac,ty 3/ Location and Nature of Proposed E! cai Work ,VrE j:Q�tfS f n.P 7'9 W, 12"p, OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a astern Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = ave s fled valid proof of same to Me.CtRce YES = No = If you have ecked YES please indicate the type of verage by checking the appropriate box I SURANC = BOND = OTHER = (Please Sperafy) %�L,,QT- 9�-1G� 1,VV Estimated Value of Elect 'cal Work$ sefi 0. �" / (Expiration Date( Work to Start Inspection Data Resqueated W i%/ 6"O1I Rough Final Signed under th Pen ttles of periury: FIRM NAME UC. NO. �c Bus. Tel No. , Address& 13o&o k IVA DIl%t'pAlt Tel. No. i9% /,!!r'7- 53 JI OWNER'S INSURANCE WAIVER: I am aware that the LIcansefi does not have the insurance coverage or its substantial equivalent as required by Mas3achu3QM3 General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) .Va Telephone No. PERMIT FEE 5 ------— (Signature of Owner or Agent) Total No. Lignteng LightenOutlets No. of Hot fuse No. of Transformers KVA . Above ❑ In C No. o' Lighting Fixtures Swimminq Pool qmd C qmd C Generators KVA No, of Emergency Lignbng No. of Receptacles Outlet No. of Oil Burners Sattery Units No. of Switcti Outlet No of Gas Burners FIRE ALARMS No. of Zone No. of Oet antl -----TTTT Total Ng. of Ranoes No of Air Cond Tons Initialing Deviceevice s Heat Total Total No. of Dioosal No. Pumas Tons KW No. of Sounding Devices No.1 of Self Contained No.Vf Disttwashers I SoaceiArea Heating - �� DetectiorvSounding Devices C Muniapal C Other No. of Orvers Heating Devices KW Local Connection No, of No. of Low Voltage No. of Water Heaters KW Signs Bailases I Winn No. Hvdro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a astern Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = ave s fled valid proof of same to Me.CtRce YES = No = If you have ecked YES please indicate the type of verage by checking the appropriate box I SURANC = BOND = OTHER = (Please Sperafy) %�L,,QT- 9�-1G� 1,VV Estimated Value of Elect 'cal Work$ sefi 0. �" / (Expiration Date( Work to Start Inspection Data Resqueated W i%/ 6"O1I Rough Final Signed under th Pen ttles of periury: FIRM NAME UC. NO. �c Bus. Tel No. , Address& 13o&o k IVA DIl%t'pAlt Tel. No. i9% /,!!r'7- 53 JI OWNER'S INSURANCE WAIVER: I am aware that the LIcansefi does not have the insurance coverage or its substantial equivalent as required by Mas3achu3QM3 General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) .Va Telephone No. PERMIT FEE 5 ------— (Signature of Owner or Agent) �Location No. Date Tiq TOWN OF NORTH ANDOVER 0. jillijagilfI& 0 Certificate of Occupancy $ CH Building/Frame Permit Fee s Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 13775 /--Building Inspeqf6r ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING w - BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: .-.- B 1��i1n-Convm'issioner/I or of Buildings Date p JE' L 11VPt 1-bX!,F MrLKMA111LKV 1.1 Property Address: 112d6 6L/AVERL6Y R/A 1.2 Assessors Map and Parcel Number: /,S, Map Number Parcel Number .UO /4N,0t) lip --IA U/�'f�.5' 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 Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service Signature Telephone 2,.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor. Address r Signature Telephone r Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ , Company Name Registration Number Address Expiration Date Signature Telephone T rn X z O 5 SECTION 4 - WORKERS COMPENSATION (M G.L C 152 S 2506) 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) ZIC Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ��- v SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant licant1. OFFICIAL, USE ONLY 1. Building - �� O (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) o2 _�- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in. all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMMERS 1 ST2ND 3 RJD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE d. 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. m now �O APPLICANT d�4-07 HONE (�/-�/,(� }ASSESSORS MAP NUMBER %% OT NUMBER ,� Z SUBDIVISION LOT NUMBER STREET 4�WtW>Le ..: fQ:...:r:G � A649SSTREET��NUMBER � �c;V,9i ............. �...............OFFICIAL USE �ONLY ..L:�h: a -e ZeIOIA(f L ........... RECOMMENDATIONS OF TOWN AGENTS 4 f,Su m �,o � ���►��� �^Zf — ..................... s..,.....�............ � . DATE APPROVED .......... �....... C0I49ERVATION ADMINISTRATOR DATE REJECTED COMMENTS &)C� 4 ,J ( •-, DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE 11 Town of North Andover o� NORTH o Building Department ti y—~ 27 Charles Street North Andover, Massachusetts 01845 z " �► �A�09 <ociiwwu• e � (978) 688-9545 Fax (978) 688-9542 7 �OR�TEO PPa` tG� 9SSACHU5!t 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 ell, sl 50a. The debris will be disposed of(('�i'n /at: 4�-vAC, 67 A57716alV #A Facility location - ��';'� a ��- & L Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this r project through the Office of the Building Inspector. n V I O qb O z W W4 o O u o° w Cf)5� a cn o z OA z w o cG v_ U cd w 0 a a to o cG c w a o w U w Wcw ao' cn w a o U a z z w z d w w G rA z v o o cn J c o CD m c c i3 ; o ` C h ' � C ' � O V V Q aC A A CO , .CD cc O c- : N rO Ea o mA � U := v .r o c. U, j•WN�..� N 1� z O m W O U O O V CM Q me r-� N R mm I3CO) o m C C � : � N ECD CD O CL N O O cm �a N CL mor Q'Z m `o S m mp S H CD WC N Or=...•O D •N W .E � o C2 CD ® O ODje C COO d m ' o �w cob S co 0�go = � aim J bQw- 9' co O CD L O Z CD CL O y G C IGD pm C C CO) CD •ff m m CD 0 CD CD O � � 0 O L M O d CL O� Q y C O +0-0 C ccc v J .O •d O co CO2 Z co V CO)CL O C C cc CL _02 LLJ 0 LLI w W CcW Lli CO O U Q rO � U U, j•WN�..� 1� z W O U r-� bQw- 9' co O CD L O Z CD CL O y G C IGD pm C C CO) CD •ff m m CD 0 CD CD O � � 0 O L M O d CL O� Q y C O +0-0 C ccc v J .O •d O co CO2 Z co V CO)CL O C C cc CL _02 LLJ 0 LLI w W CcW Lli CO tocation A0 r,, No. -3 9� Date v 'joRT01 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ro Foundation Permit Fee $ CH Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee TOTAL /'I"'luilding (nspector 1 279 �0,9/15/98 15:39 65.00 M Div. Public Works tocation— No. Date 14ORTAI TOWN OF NORTH ANDOVER Certificate of occupancy $ Building/Frame Permit Fee $ SS CHUS Foundation Permit Fee Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 61 Building Inspector ­�)/15/98 15:39 65. 00 PA I D 0 , . Div. Public Works J Z �c _ C 9 n w Z I� O i z LJ LJ z z LL N LL - z N j y a I w 7 n ` H z w LLI w w I— _ ci� Z s Z 7e ZC- a n X + w _ N F- _2 C � n � N N Q Z � ..+ _ �i vr ^ _ LL I z w - - I� A N Z N � � J L S U OC } z ay w .3 L z Q f lU £ L L •V Q I.� Q Z �.. Q w N w lJ W z J C ( 7 .Tr. ~ 1••• W 2 z Ln uj 3 Z U J Z �c _ C 9 n w Z I� O i z W z z LL N J Z �c _ C 9 n w Z i z W z z LL N LL - N j y a I w 7 n ` H z w LLI w w I— _ ci� Z s Z 7e ZC- a n H + w Z _2 C � n � N i z W LL N LL - N j y a I w 7 n ` H z w I— _ ci� Z s Registry of Deeds Northern District of Essex County Lawrence, MA 01840 09%Q;Q/98 MARCOTTE :`':;'' JC c # 19 Rec : Type ,FIiN ;ar, r, 16.00 Inst 30446 Coa;i Rs' `. 1.50 # 20 Rec: Type 'NOTC 10.00 Inst 30447 Postage 0.32 Total 27.821 # '41 Payment Check 27.82 THANK YOU! Thomas J. Burke Register of Deeds 01 r TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units ... or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: 1'c=cr��us�z��n vw Est. Cost /,0 000, Address of Work JQ& 1_.,)9V6RLC—V Rb Owner Name: '14 Date of Permit Application: /9 Z� I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Job under $1,000 Building not owner -occupied v1 Owner pulling own permit Other (specify) Notice is hereby given that: Pemit No. Date OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL C. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the'above property: Date Owner Name 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 INmr�S r PRTR\Ck(-) MPSPC.0,-7v PHONE job1-911-3 LOCATION: Assessors Map Number l5 PARCEL_,57 SUBDIVISION LOT (S) STREET W,�)yCRLL� 86 ST. NUMBER RECOMM5NDAT ►r�� � 0 LOIN J COMMENTS _ r TOWN PLANNER COMMENTS **************OFFICIAL USE ONLY*** TOWN AGENTS: MINIaTRATOR FOOD INSPECTOR -HEALTH DATE APPROVED iv DATE REJECTED YxiwQ M -toj\ DATE APPROVED DATE REJECTED - DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS ,q PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Any appeal shall be flied within (201 days after the date of filing of this Notice in the Office of the Town Clerk. TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Property: 206 Waverly Rd. NAME: Thomas G. & Patricia A. Marcotte DATE: 8/12/98 ADDRESS: 206 Waverly Rd. PETITION: 029-98 North Andover, MA 01845 HEARING: 8/11/98 r�.EG7i/ JOYCE VIA3; iAWl TOWN OLE!_ --,K NORTH ANDOYCR AUG I1 1144 P� `yd The Board of Appeals held a regular meeting on Tuesday evening, August 11, 1998 upon the application of Thomas G. & Patricia A. Marcotte, 206 Waverly Rd., North Andover, MA, requesting a Variance from the requirements of Section 7, Paragraph 7.1, 7.2 & 7.3, of Table 2, for relief of lot area, street frontage, front setback, side setback, and rear setback, and for a Special Permit from Section 9, Paragraph 9.2, to take down a three season room and reconstruct a year round room on the existing foundation, on a non -conforming lot, within the R-4 Zoning District. The following members were present: William J. Sullivan, Walter F. Soule, Raymond Vivenzio, Robert Ford, John Pallone. The hearing was advertised in the Lawrence Tribune on 7/28/98 & 8/4/98, all abutters were notified by regular mail. Upon a motion made by Walter F. Soule and seconded by Raymond Vivenzio, the Board of Appeals voted to GRANT a Variance requested from the requirements of Section 7, Paragraph 7.1, 7.2 & 7.3 for relief of lot area of 6,945 sq. ft.; street frontage of 32.66 sq. ft.; front setback of 11.5'; side setback on I North side of lot of 9 ft.; rear setback of 1 foot, and to GRANT a Special Permit from the requirements of Section 9, Paragraph 9.2 to construct a year round room on the existing foundation on a non- conforming lot, and that a gutter be added to the roof line to control the water situation to protect the adjacent lot on North side of 206 Waverly Rd. Voting in favor: William J.' Sullivan, Walter F. Soule, Raymond Vivenzio, Robert Forel, John Pallone. The petitioner has satisfied the provision of Section 10, paragraph 10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. Note: The granting of the Variance and/or Special Permit as requested by the applicant does not necessarily ensure the granting of a Building permit as the applicant must abide by all applicable local, state and federal and building codes and regulations, prior to the issuance of a building permit as requested by the Building Commission. BOARD OF APPEALS William J. Sullivan, Chairman Zoning Board of Appeals W 905 Great Pond Road North Andover, MA 01845 Tel. No. (978)-685-6161 June 10, 1998 Thomas & Patricia Marcotte 206 Waverley Road North Andover, MA 01845 Reference: Proposed Addition to Residence over existing Garage. Dear Mr. & Mrs. Marcotte: After inspecting your residence on May 23, 1998 at 206 Waverley Road, I am confident that you can extend and reconstruct the existing room above the garage so as to enclose the exterior concrete slab. The slab exposed is the rear section of your 8" thick reinforced concrete garage ceiling. This slab appears to be structurally adequate to sustain the added residential live and dead loads associated with the addition. Although the slab does not appear to require any support in the vicinity of the new proposed living space above, a 6"x6" wood beam and jack -post slab support, as we discussed, may be used if you choose. Respe gully, Louis C. T rta one, P.E. C