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HomeMy WebLinkAboutMiscellaneous - 21 FRENCH FARM ROAD 4/30/2018 (2)Date........................ I ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... 4 ...../... has permission to perform .......................................................... wiring in the building of .... ..... 6.,,.jj� .1 ....................................... at ... ..................... ............................ .. North Andover, Mass. Feel 715 .. . ....... Lic. No. L11 C . ......... ........... ............. .......... ...... ..... ELECTRICAL INSPECTOR Check # r , Li Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 CM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: O City or Town of: NORTH ANDOVER To the Insp ctor o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) o:� / , Ze--"'A Owner or Tenant ,�,�ZA/V G011;;' Telephone No. Owner's Address jp M A Is this permit in conju'on with a ' ding permit? Yes Purpose of Building t,tJg n/ Existing Service Amps / Volts Overhead ❑ No ❑ (Check Appropriate Box) ity Authorization No. Undgrd ❑ No. of Meters New Service Amps / Volts Overhead [:1 Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Co- letion nfih, f /111.1;1, . f-hL, . , 1,,.... 1 t.. a__ �_____.__ _-- No, of Recessed Luminaires -.. ..-11 No. of Ceil: Susp. (Paddle) Fans .—t:11 r ✓e rvutveu by the iris eciur q/ wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El E:] rnd. rnd. o. o mergency 1-g g Battery Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No, of Detection and Initiating Devices No. of Ranges Z No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals ..... ...... Number .Tons.._ KW ••••••••••••••• No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water KW Heaters Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Tel Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of ec 'cal Work: (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 painssand penalties of per'ury, th the information o th' application is true and complete. FIRM NAME: N�'% LIC. NO.: Licensee: Signature LIC. NO.: (If tipplicable, enter "exempt " ii he license number line.) q . Bus. Tel. No.: Address: �t iC7 �G''!y� 1-011•/ .4f��j ; �--j'7 6 Alt. Tel. No.: / ^Xf (,ag *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: $ The Commonwealth of Massachusetts Department of Industria! Accidents .. Office of Investigations 600 Washington Street 1 i Boston, MA 02111 c� www.nsass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Alaylicant Information Please Print Legibly Name (Business/Organization/Individual): Address: C1 City/State/Zip: % ,, X1.5 (" /)'IV CAv-ll�hone #:. �f' C! 6 Are you an employer? Check the appropriate box: I . ❑ I am a employer with 4. ❑ 1 am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I am asole proprietor or partner- listed on the attached sheet t hip and have no employees These sub -contractors have working for me .in 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. El New construction 7. Remodeling S. Q Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -Any applicant that checks bortif l must also fill out the section below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for in suranc9p coverage verification. 1 do hereby of perjury that the information provided above!$ true Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # lam./.k /1) correct. 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 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), ad.dress(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 permittlicense 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 42111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Date . __ 01 ".� '. TOWN OF NORTH ANDOVER PERMIT OR PLUMBING r ,SSACMUSi4 This certifies that ........... ....:.'....-.. `.�' �..... '-.... .... . has permission to perform .._. v._.-:.. -�� ✓. I ....6' ..!..... plumbing in the buildings of 1r:'. 1:- at. !.. '.%'. r.... ..:.. , _ ........ , North Andover, Mass. Fee .-.%-. ..Lic. No.:.'.�fir'.. ..�."' �,�- ...... . ,r PLUMBING INSPECTOR Check !t 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS j Building Location cJ "Ce—"C1n - Date Permit 1 Owners Name AT &8 Permit # Amount or, Type of Occupancy11 New U Renovation J7 Replacement Plans Submitted Yes a ❑ }c�+ No li'IYTT TT) TT r (Print or type) _ Installing Company Name : o L m J yzp Vk` . W h � t "A Address Its J em�1e 6 ) \V 191 Check one: Certificate ❑ Corp. ❑ Partner. Firm/Co,. Name of Licensed Plumber: :Lose -91') {.: mi R Qti A Insurance Coverage• Indicate the type of insurance coverage by checking th ppropriate box: Liability insurance policy ® Other type of indemnity ❑ 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 ❑ I hereby certify that all of the details and information I have submitted (or best of my knowledge and that all plumbing work and installations perf compliance with all pertinent provisions of the Massachusetts S By' APPROVED (OFFICE USE ONLY Agent ❑ ive application are true and accurate to the ernnt Issued for this application will be in and Cha ter 142 of t4Sfj"eral Laws. Type of Pltmbing License 'enseINUMer Master �b�) 0 Journeyman ❑ r 1, 47 4, The ( tIftoittatlUt>ath ill I/.6 880811:4ujolptts Office Use Only bepdrfr)lerif of PrAlfc Safely Permit No. i 90ARD OP PIRI= f'kf`VtNtiON REGULATIONS 527 CMR 12:00 Occupancy & ree Checked 3/90 (leave bank) 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 INI CINAtION) Date %( Z%/p S— _ City or town of Q,r_7 �.v do V e p To the Inspector of Wires: The Undersigned applies for a permit to perform the electrical work described below. Lbcation (Street & Number) L- /�Dr e y c, F, P- P" X d, Owner or tenant __ R �. Z t /" lit. 7 -64 r, e) S S Owner's Address is this permit In conjunction with a bullding permit: Yes No P t Id <,I '?- / /9 0� (Check Appropriate Box) urpose o But Ing 9 e Q ."f y e Si e IL -11c C • Utility Authorization No. _ 61151168 $ervite Amps / Volts Overhead L] Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work —A&Z"J�.rry © m - /i O"q No. of Meters No. of Meters No, of LI htln Outlets No. of Hot Tubs TOTAL No. o` Transformers KVA No. of Lighting tinFixtures AbI(—� n - SwimmingPool ❑ md. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of'Emergency ig ting Battery Units No. of Switch Outlets S No. of Gas burners 1 FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. �' Sounding Devices. No. o: Self Contained Detection/Sounding Devices Munic!pal Local❑, Connecth` ❑Other No. of Ranges Tota No. of Air Conditioners Tons No. of Dis sats Heat, Total Total No. of -Pumps Tons KW No. of Dishwashers S ace/Area Heating KW No. of Dryers Healin Devices kW No. of Water Heaters kW o. o No. of Signs Ballasts Low Voltage Wiling Mo. Hydro Massage Tubs . No. of Motors total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusites General Laws have 6 current Liability insurance Policy including Completed Operations Coverage or Its substantial equlvaler,t. Y_S j?� NO O t have sr_u-n:tied valid proof of same to this office. YES gNO ❑ It Vol) have checked YES, please Indicate the type of Coverage by checking the appropriate box. INSURANCE 9 BOND ❑ OTHER❑ (Please Specify) Estimated Value of Electrical Work $ =S (Expiration Date) Wok to start _ 71z/A9 S- Inspection Date Requested: !lough 4A111 in OW Final Signed Under the penalties of perjury: FIRM N, Licensee Address _ LIC NO.?ZZ ;P, _ _ LIC. NO. CLQ 3 SO? Tel. No. SOF-3S 6-Y A%. Tel. No. _ OWNER'S INSURANCE WAIVER: i am aware that the Licensee Jok4 ttol have the Insurance coverage or Its substantial equivalent as required by Massachusetts .General Laws, and that my signAture bh this Ormit application waives this reJUirement.. Owner Agent (Please check one) telephone (Signature of Owner or Agent) Date.................................. NORTH ..... ... "o TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING 4 _ • • N ,SSAc"US� This certifies that.. .......... 4 ...E............ ................. ............... has permission to perform..............................^.............................................. wiring in the building of......................................... ,........ ..................................... at................. ............................................................... , North Andover, Mass. Fee,._ '::.. ......... Lic. No.".'....-..'. J............................................................... ELECTRICAL INSPECTOR WHITE: Applicant p 7 CANARY: Building Dept. PINK: Treasurer GOLD: File Location '+ E , q, �- No. 1�2? Date y Y O: H , ORT1y TOWN OF NORTH ANDOVER �«•o :'h•00 9 a ; ; Certificate of Occupancy $ CNU,E<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �� U Check # d-021- 17 7 5 j I ' `� � Building Inspector r- t TOwN OF •NORTH ANDOVER Tj�/( ILDING DEPAR►VER \PPLICATION TO ' • iEN 1 BUILDING PERMIT NUMBER: 71 -------------------------- SIG—ATURE: / --+--- Bulldtn Com / �I� r SECTION I- SITE MO �ssloner/I ' r of 1.1 RMATION �P�r mess: 1.3 Zoning Wbrmatiou: 6�d Provo d seC 6 BUILDING SETBACKS }t Front Yard R�red Provide Side Yard DATE ISS D Da� 1.2 and 'Kap Number 1.4 .... %4& Provi 1.7 Wats SOPOY M.G.L.C.4o. 34) L3. Patl;e ❑ ° Prn,� Zane F7ooa Zone Inf°�on: SECTION 2 - PROPERTY OW, °it� Flood zone 2.1 Owner of Record RSHIP/AUTiIOR17�D AGENT Nam —f( A Diw cns: e (1'nnt) Z Address for Service : signature 2.2 Owner Name Print Address for S aaf- 110N 3 -CONSTRUCTION SE Tel hone 3.1 Licensed Construction Su RACES Pervisor: ������� Licensed Construction Supervisor. Address Signatwu Telephone tered Home Improvement Contras for 611 J?7�/- a�z Name M Numb _c Not Appucab p 905 '5�" ParebrNam Rear Yard Provided system: On Site Disposal SyBkm ❑ 00 /2o License Number --- Expiration Date Not A Phle c —3t7 o 'S_,� Registration Number 1t.'�/2/(' 6 Expiration Date E r t i C C R I C Z R 9 C M r V) SECTION 4 - WORKERS COMPENSATION (N.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with in the denial of the issuance of the building permit. Sistned affidavit Attached Yes .......❑ No ....... C SECTION 5 Description of Propmd Work check all ap ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Failure to provide this Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 1! Cir% �T7A1►i L CCTiM AT1CT !`l1NCTDfT!'Ti!)N ('l1CTC 1 r � will result Item Estimated Cost (Dollar) to be Completed by permit applicant 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) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO HE COMPLETED Wtt> N OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Herebv authorize to act on My behalf, in all matters relati-ve to work authorized by this building permit application. Signature of Owner Date- — — �SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION_ - 1, as Owner/Authorized Agent of subject e property Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/ Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMIBERS 1ST2 NU 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 i v PI -177X, je Licensed & Insured • Roof Leak Experts • (978) 794-3883 • 1 -800 -WAIT -4 -US proposal bolded To Phot�rye' �) � / 7 Street lab Name City. State & Zip Code lob Location lob Phone We Propose hereby to furnish and labor in accordance with specifications below, for the sum of: �rrte+'' n T / !=�G� c S';,wT 3 vm,n,?C�=I-,-v4/��ii', Dollars (S 'S ). All material is guaranteed to be as specified. All work to be complewl in a workmanlike Authorized mariner according to standard practices. Any alteration or deviation from specifications be- Signature: ✓� �_ low involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This proposal may be or delays beyond our control, (hurter to carry fire, tornado and other necessary insurance. a withdrawn by us if not accepted within idea. Out workers are fully covered by Workmen's Compensation Insurance. We hereby submit specifications and estimates for: S , ���, f C-7V41u=-C 4 eL (-A-1 j 77`/J y Lf f /?i'r+. a� J i �L �.v r7 S , C j1lCc— S T -S Fes e- c—,5 Cir. n fAn() L I t -Z! L L f� S � C_ .� ':7 / 4 ' ✓r►1 4 ,� c •'Z �� 17 'sTitrrT L��.�� sS <<J 02,rr3 Uj= Sl -IJ 1TcyLJ is /�cJ3c" L��•!/� >- - c, tTl 4. -71-1 L: 2j S��'<�i�c'_✓1 r] �rrL� f)G S / �-�- /�t�,: �-�T%G- J�,ln,' sl--le7-3 C3 ,-1 is., < C3 3 2 S c Yf ,.-r G c s + L -J,1119 1 �J ; IVY? /9 3-i4 .i T L 0,4-,, CiA c»s i "" 1 ----- it L L /� G' 5 % -� f r, T To .-s-r G �' r'l r� :1 . � SiI/J� ri/ �'/ �� Z c S SCS: C, Z' J /�!J tJ•+TQ��»! �- lac= / trd� G' i C c T f Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified_ Payment Signature: _ will be made as outlined above. 7 Date of Acceptance: 2 Signature. The Commonwealth of Massachusetts Departinent ofIndustrial Accidents Office alinifestigations 600 Washington Street, 7 1h F1001 C�%Boston, Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors Applicant inf6rhiation, Please PRINT Ieaibly name: (-q K? address: all city 1414 state: ow 4- ip:(30�Y Dhone# work site location (full address): H I am a homeowner performing all work myself Project Type: E] New ConstructionFIRernode ❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition I am an employer providing workers' compensation for 'my employees working. I on I this job. company name: 4 CC U 7 � C- YJ 6 /1 t� /?6o address: city: .5-5 phone#: 94,? -917J- 175 -IJ insurance co. r4t* - Policv# A LJ e— — -1 F❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: city: phone #: insurance co. 7 policy7. company name: city: phone #: insurance co. Dolicv # Attach additionafsh"t if,necessary,.! , Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 a . nd/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the a sand penalties of perjury that the information provided above is trite and correct. Sig -nature a_e, = — Date 4:1 41 , 54 OV 4f Print name. 2A —Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # ElBuilding Department [:]Licensing Board El check if immediate response is required Elselectmen's office E)Health Department contact person: phone #; ElOther (revised Sept. 2003) '77 CPI Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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,7t" Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 M North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: if, - A-1 (Location of Facility) signature(/of/permit Applicant I�L7C/0Y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector E CO3 10 CD az CD CL Ar CL Im COD E CO3 10 CD az CD CL Ar CL Im Location .-,; / No. Date > ' C% O `/ TOWN OF NORTH ANDOVER i� r °t ` Certificate of Occupancy $ �'�s' • E<� Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # it Building Inspecto �* TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Sectm for Of%i use DSI _baa BUILDING PERMIT NUMBER: 623 DATE ISSUED: SIGNATURE: 13611drig Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: ^mac= i Fc- 1.2 Assessors Map and Parcel Number: Map Number Parcel Number /j p, �� �� n /j 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 ReqWred Provided R 'red Provided w: 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: V\ d Licensed Construction Supervisor: 3 J "C._ D /% Address Signature Telephone Not Applicable ❑ G / O L ( ( 2_ C) License Number J Expiratin Dat 3.2 Registebb Home Improvement Contractor A-(- Un ✓o ,k/z pn-c ��6�c Not Applicable ❑ Company Name -c>-i-/���� 1,55;711`M& �1L f0 ,W,//SJ ( / - umber Registration /z - J J U Address %"� Expiration Date Si naturI V Telephone M M O z M go O mn ic r v M r ^Z d) SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Xxisti g,Buildir# ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify t} Brief Description of Proposed Work: V. I SECTION 6 - FSTIMATRD CONSTRUCTION CCISTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building(a) �-->, u� Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 5Y 4 Mechanical (HVAC)w 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGEN R CON RACTOR APPLIES FOR BUILDING PERMIT I, Vas Owner/Authorized Agent of subject property HereGatfhorize to act on Mybe, 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 n µ NW— NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TUMBERS 1 2 3RD 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 • North Andover Building Department Tel: 978-688-9545 6 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that.the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: ,Yq-11 (Location of Facility) Signature of rmit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector M Ci LD I C�nn>srrnaa�ys Residential & Commercial Roofing All Types Of Siding CHIMNEYS POINTED -REBUILT -CAPPED - Expert Masonry Work { �d Roof Leaks Experts Mass Toll Free Licensed & Insured I_orally Owned do Operated Since J976 � ! 1 -800 -WAIT -4 -US -� License #034200 (924-8487) IKOw G�ixP� ?Zoarrs or'90AV We- Work Year Round u •' S Proposal Submits d 10 Phone- wT� Date fit. a >_ Q�7 l'��'As succi Joh Name Cm, State & ZIP t ode Job Location Job Phone We Propose hereby to furnish and labor in accordance with specifications below, for the sum of: Yr.,/( �d iykl�z 7- /ir. Dollars (S All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized r manner according io standard practices. Any alteration or deviation from specifications be- Signature: —✓� low involving extra costs will he executed only upon written orders, and will become an 1 --- -- ---- extra charge oxer and above the estimate. All agreements contingent upon strikes, accidents NOTE Fhis proposal may be Or dedatis beyond Our control, thtiner to cam fire, tornado and other necessary insurance Fully by Workmen's Compensation Insurance. withdrawn by us if not accepted ()or workcn are cox cred within ` c �•�— kkQ hGreb} �uhtntt :puctt3uatlun.S and C;ttniates tor: The Commonwealth of Massachusetts Department of Industrial Accidents office ollmtesuffadefis 600 Washington Street, 7`s Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit: BuildinQ/Plumbinp/El U'""iiftruc.fiY lMfinr, stt n,d� AlaaseRRO 'f 1' rilxi� address: 3,c> (_ C(tOLL Z%W' c: city � state: Ato/4 gi :oj�R Dhone# 9Y)Y Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cord y under the pains and penalties of perjury that the information provided above is true and correct „ u" Print name �� lz��N t�'n 2�! Phone # %� 917)7-" `� S I official use only do not write in this area to be completed by city or town official city or town: permit/license # []Building Department Licensing Board ❑ check if immediate response is required ❑Selectmen's Office OHealth Department contact person: phone #; ❑Other (mvircd Sept 2003) i L Jle "Uom�rco�zurP,aGux �✓�oaaclutdeaa Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 137057 Expiration: 10/2/2004 iTy�ae: DBA ALL LINDER ONE ROOF FOHN LANZAFAME 166 A MERRIMACK ST. METHEUN, MA 01844 Administrator ��ie Uaa�nnamwva� o�..�/�aaaaciuc6eiZ6 BOARD OF BUILDIN6G REGULATIONS f License: CONSTRUCTION SUPERVISOR ;`. Number: CS 069120 Birthdate: 04/03/1959 Expires: 04/03/2005 Tr. no: 10040 Restricted: 00 JOHN W LANZAFAME 30 TEMPLE DRQ METHUEN, MA 01844 Administrator E9 * )� ., M -1 O O v Z O O y O cm I O CD h O O O CD ® L M O M. CM ca O *-,� C C o O v -J CD ca ts .0 coCD � C c— � C cc CA N 0 OC W W C9 w 0 x o N u a 04 o U a acn -o x °�° w�' v C U x C4 U '� Rr w2' w OG w a W x U 5� cn m w x 0 °�° w z w m cn Q o cn ., M -1 O O v Z O O y O cm I O CD h O O O CD ® L M O M. CM ca O *-,� C C o O v -J CD ca ts .0 coCD � C c— � C cc CA N 0 OC W W C9 w 0 O O CD fti mcm c C. + L mm j = LU y m3 s o� NG P ., M -1 O O v Z O O y O cm I O CD h O O O CD ® L M O M. CM ca O *-,� C C o O v -J CD ca ts .0 coCD � C c— � C cc CA N 0 OC W W C9 w 0 O O CD fti mcm c C. + L mm y m3 s C" m N C C � •� C O zip R = C H C H A O `" E :oo : CLU o y m Z = C: O cm COQ y •� ;m p C� v y O cc z G ++ C L O CL cm C ID H m C •O ® p N a4 m w~ C m _ .y CD •O.t 6d .E C .y Z L a-- V m F O: o CD 0 A ` H •� 0 O C, m :IM ., M -1 O O v Z O O y O cm I O CD h O O O CD ® L M O M. CM ca O *-,� C C o O v -J CD ca ts .0 coCD � C c— � C cc CA N 0 OC W W C9 w 0 �D A N S S Location No. T Date L. Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL � Z, # $ Z-Y)Q- Building Inspector Div. Public Works TOWN OF NORTH ANDOVER L p � Certificate of Occupancy $ Building/Frame Permit Fee $ �s•�,.usEt� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL � Z, # $ Z-Y)Q- Building Inspector Div. Public Works PERMIT NO. v APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40. LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. F LOCATION ., ` n. L.— e ( �A�tw V�i'0 r�� A ,C17��.- PURPOSE OF BUILDING r� V�I l _G OWNER'S NAME R t e� I C„yq tv NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB Q-A LA, 1, ` J?A r Js` Ir, ARCHITECT'S NAME _.l _ �C li-� - SIZE OF FLOOR TIMBERS IST ,�[J+, 2ND -- _ 3RD • BUILDER'S NAME 1� t-V1V v _/vI vn p SPAN � 1 I DISTANCE TO NEAREST BUILDING .,I �.¢�.a cc lit 4 A4 A DIMENSIONS OF SILLS "' POSTS DISTANCE FROM STREET ►` DISTANCE FROM LOT LINES - SIDES / ` REAR I ` " '" GIRDERS AREA OF LOT / L FRONTAGE I L HEIGHT OF FOUNDATION t i THICKNESS t D 11 IS BUILDING NEW N V SIZE OF FOOTING X IS BUILDING ADDITION `[/may- �+ MATERIAL OF CHIMNEY _ IS BUILDING ALTERATION ♦ ]1� IS BUILDING ON SOLID OR FILLED LAND �� •I WILL BUILDING CONFORM TO REQUIREMENTS OF CODE L L IS BUILDING CONNECTED TO TOWN WATER s BOARD OF APPEALS ACTION, IF ANY D� IS BUILDING CONNECTED TO TOWN SEWER „0 IS BUILDING CONNECTED TO NATURAL GAS LINE 1V INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED-� ct SIGNATURE OF OWNER OR AUTHORIZED AGENT F E E 3o 62) - PERMIT GRANT 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST � �I EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY i -- NU ILMING OWNER TEL. i/ CONTR. TEL. # �� ✓ 3 3 S'' CONTR. LIC. #� H.I.C. # L L � `Z L 1 OCCUPANCY WOOD JOIST INGLE FAMILY �J I l STORIES MULTI. FAMILY ATTIC STRS. E FLOOR _ OFFICES WIRING STONE ON MASONRY APARTMENTS STONE ON FRAME WOOD RAFTERS SUPERIOR I� POOR ADEQUATE NONE _ 5 ROOF CONSTRUCTION GABLELj 2 FOUNDATION HIP 8 INTERIOR FINISH CONCRETE GAS OIL GAMBRELI 3 I 2 13 CONCRETE BL K. FLAT PINE WATER CLOSET _ BRICK OR STONE LAVATORY HARDW D WOOD SHINGES KITCHEN SINK PIERS SLATE PLASTER DRY WALL — — — STALL SHOWER UNFIN. 3 BASEMENT AREA FULL FIN. B M T' AREA _ '/. 1/1 1/1 L FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS CLAPBOARDS I 9 FLOORS B I 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D ASBESTOS SIDING _ COMI,AGN _ STUCCO ON MASONRY STUCCO ON FRAME I 11 HEATING WOOD JOIST I �J �J I l BRICK ON M N Y BRICK ON FRAME ATTIC STRS. E FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY _ STONE ON FRAME WOOD RAFTERS SUPERIOR I� POOR ADEQUATE NONE AIR CONDITIONING 5 ROOF 10 PLUMBING GABLELj HIP UNIT HEATERS BATH 13 FIX.) GAS OIL GAMBRELI MANSARD TOILET RM. 12 FIX.) FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. d COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF RO MS GAS OIL B'M'T 2nd _ 1st ( 13rd ELECTRIC NO HEATING BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM s LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. v cn D m T Z D r m .v, y d C •C O CA Cl) 10 0 Q O �. r im S o CL = y CD o � fl.� o c Q wwc,, =r = CD CD O CD O CDCD y CZ O y 1. C=D � v CO) O � Z CD O O CD C CD 0 `J Cn lJ O V � 0 C Ip c ?'a o m 2 O — N o Q cA EL- 0sm ,0 Ns mangy m _ CD m .- ae = °:m o T =r• =rm co m .. 0 0 �� ; o o i?c _ o�Icn,x 00 c S� a �m � 9 m m 00 al C ' dm . 40 as m � CL o ,C13CL � a �• = -- Cap Go CA Q CD 1 A ` m m N 0 C r =r m o C CD o: RCD: Wim: COS sem: mm a'g n� o c o' �o (p Ow � o W �. °c b d C m C Z m x OC C C ^• z (n C/I b cn S toO d O x O -A z eo I )Nq 0 9 0 c FORM U - IAT 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** � C r''r PLICANT: Phone L 5a - S-33 LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) r-- r- �reet -1 (2,-2 v. c `'AVIL,_"oU � St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWu AGENTS: A 7 Date Approved Conservation, Administrator Date Rejected Comments V&P l lYi7, lywT !/eft % 4.� Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected - driveway permit /,_P re Department.17 �j�ti6�Q6 Received by Building Inspector 1995 Date 1 The Commonwealth of Massachusetts Department of IndustrialAccidents &MV811adios 600 Washington Street Boston, Mass 02111 Workers' Compensation Insurance Affidavit I am a homeowner ming all work myself my employees working on this job. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do hereby c rd under t e padnuthe in o on ided above is true an correct Signature Date b Print name N tn Phone # official use only do not write in this area to be completed by city or town official city or town: permit/Gcense # OBuilding Department Licensing Board check if immediate response is required oSelectmen's Office ❑Health Department contact person: phone #; — riOther (revised 3/95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, neither the commonwealth nor any of its political subdivisions shall enter into anv 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. i _ ',,iiz G, > , r^ ¢max„ .� , % i ✓ a, e: ,✓� .( z' Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. x 7-777 '` c , �. < `; x City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. . a r*o.s.sr4ty �' r-rz r^�,�'T ^« d 4.' The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents afice of Invesugadons 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 Lor 54A LOT PSN OF. ����� �c� c �� �'� arc �.o�,v, ,. RTH ANDOVEP, �VASsl E D L P H _D, �.PATRtC( A.A.N. 'GPLAN "rO STY. ADO 'M " 44 i nq� -J u_N_ , >.5 \� I rs C), o o I --am G. GoopmNA Of - E loom Q000 CEMTIZALSTREEr vm W DOV E P, MAGZ V- 1-2- t2- z 0 a z 0 k LU 0 0 w z a l Q) z LLI Lu ZQo 6-� 11 Z Q) Lijz wuLli Q�Lli w Z I— U W Q w z z�0 a—� �sW~ W ui XL1zQ / OO Q mnkDF- z zz l Q) z LLI Lu ZQo 6-� 11 Z Q) � U (O L� Q�Lli w Z I— OQ W Q w z z�0 a—� �sW~ W ui XL1zQ / OO Q mnkDF- z LlLliQ Z ui aZ���N w:i U 1L10 flz s w O:2fl:iO Q �[Li z00 azv�LLLL wiz >O— / :5zW ��O 0 L Z W I -- z s, x:::s wm m� z Z 0 .g -,z I I z zz l z Lu ZQo oL � U (O L� Q�Lli w Z I— OQ z LlLliQ Z ui aZ���N w:i U 1L10 flz s w O:2fl:iO Q �[Li z00 azv�LLLL wiz >O— / :5zW ��O 0 L Z W I -- z s, x:::s wm m� z Z 0 .g -,z I I z z oL _---s Q� XZv u z Ov uw w� U 6zLL >fl�Z ZOLLJ w -mow nz ��w0 w Q �o z LlLliQ Z ui aZ���N w:i U 1L10 flz s w O:2fl:iO Q �[Li z00 azv�LLLL wiz >O— / :5zW ��O 0 L Z W I -- z s, x:::s wm m� z Z 0 .g -,z I I 0 z z z T o F-- F- Q a s Q _ w -A w � XQLL 0 S S9c WI)z ZW LL Z O_ T�z v �ZOOQQ WLLJ �119 C3 XQ X ��� O W W w z �� ~nC,<-<� N� X F- SF--N�CfL- IO N � - 0 ZO z z� T Q � W S W T- WF S -W N U-~ Q - O o Q fl X oz z N z W W ... ....... ... ....... ........................... 0 z ZX O W > =w = LU ST u - F F Lli T : Q Q s b N SN z Q F- — X — W N Q> Q ui - Q F OL Q Z) LLJ� a z -'s w v vQ fl } azo A 1- z LU � F-zo - fl _ lzw a 10 \np� W X N N w v Q W S` W �LU Q u= T w d `� �w z m� LL O> w IVo z F - Oz W :� <uLL0 � fl za az � F- DO 00 ti- LL C3 W 0 4c �z LL - Iz 4 W W 0 W I�z Z L1 W ON �z LL - Q X � U LZ 0 ��P Q v > 00 � 0 'NIW ., W Q IN Date ........ ......... HORTM lo TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING o CHU This certifies that .......... .............................. I ..................................... I ....... . ..... has permission to perfo/rm .... ........................ ........................................... wiring in the building of .......... ........................................................................ at................................................................................ . North Andover, Mass. Fee..................... Lic. No . ............. ..... I ......................................................... ELECTRICAL INSPECTOR Check # V14��3",j F3C�ARC7 OF �lRC PREVENTION f Occupancy antic Fe.c Cliecke FGIJI AZ IC d (Rc'v 11/99) APPLICATION FOR PERMIT TO .PERa �������('Allwmktotic:periArmrjInaccowal,i:L W�O-R�K f'HINT I ? 's�..,tl„Isclts C: l,:rtrrcat r I,,t S�CI,IR 1? f)t) � V /NK C)/t Y'YI• !�- �f!- ,Vl, (�l l 1. f 17 `ti) ,U a l c; .,.�- �- r^' City or A,o,vl, of: __ _ _ 1'v JI1c Insp ctor tai fl'i, es. � �-`- Ily Ihls apl}IiC ltictn the undCr.;iIlr:rj t!tv s rt cI; c c:( r icr illl'nlo0l crCorm the elcctttcal work described below, f.acatiu,t (SlrCct �C• r4urrtl)cr)� ........ �1'Ir^ � Owner or Tenant � Owner's twclress -_---- /�j� _.._..__.__�.-•- � �� Tcic�(1ltpne No. ._....._.__._._.-_�;•,-._�. � f cif- � .�__-_____ ��.: - -��'� C ES this pCrltrtt in f.ANfrlrtCttUtl }Y 1111 :1 (Jlldtllr,Q t'urlu,sc of Uui3dinl; 9C1)c�'Ic J\1TrAj)rIato 110..j) FOStittrp ,\ u. Set vitlt \ ('` ••^^-- "r,)!)s Voll } <)�: 121cat! L_� UHLi,M,rlf t 1 No. ur,Motors rvc,v Scr,irc — Ant!)s 1 1 ulls""'--- _..._._. ...__ 0% el head itnr)nrtl iVq, Af . Number of Feeders altd Ampicity :�fercrs___ _ LPC;11iUlk and INiturc u ailosctl _Ictlrical ��'ork: 41_q ,bn ul!lr v!l.�,ril krbfe Isla, ,..,....._—_.,._-_ �__..__o-..o-._-_�-_cl.i_`•......___.___._�_..T___f ry rc y)r Cftnr p'r_V (rt�,of Recessed irtaes _lmp (i'aile) Falls IN Y be .__._..tr No. of liglrring OIItIQI$ No. or tlul TU1.3 -- - _ Generators KVA 'No, of L,ighlit►; 1,ictttt't'S E3atcer Uctils No. of Receptacle outlets No, of o)it Uurners No, Of SivilCltes ----•_--._....._._...___._._,-_.,_ I n. of Cas Burnersmoll �ett:t:tiou antt 11'u. of Ranges !tont f Aiil� �lun,ber i o -- tYo. of Co+IJ. lyi1, o(-"---'�." Tons Alming Devices �o. of Waste Disposers T ~~ - Totats: its 1 1V_ - rho )c Spaeila Il'Iting f<1Local li❑oltJ�lf n n\o. of Dryerz _Coll .ctiao1fr:)tnRAppiiamc's vs"- i;'uK\y Tc ms ic csOtfl�r � f}c4'ic / t�'A. 01^ _.._.. mom, _ cs or EtgY:1)t?IlE 1 l c a t c r s RIX I a. o f --_ -_._-- ._--,-----•----.---- _ tii'�ns liaf3asts f3nt^ 11'iri)tS: - No. of Devices ar uif alettt IYa. r+.lrotill ssage lllatfttubs ria. of allo(nt'S Tofa1)(� c econlrnunicalionS ! ritIlg: OTHER: ---- - ---- -- _ __ V�. of De,^ices Ar � urs'Alent . �..L_.. I or as roqtrjrd E,\5E1}t-\}viC(U\rFlt \GE:; lJr4i�:ss �vaivcd by the a„stertlrlo(pc�n l�tl fc,rrtl crpe forrnance of cler.trica brl,e IrItJ13c1Q� of Wires. the lircnsce provides proof o{It,,brlity idsurartce inc!ucri(tet "con, le i' ( ori: may issue Unless undersignr,A c:enifies Ilial st,cl� eovera s in i'orcc, and l,ae r.clri(,ited prnaf ctFstan to tft' a 01 'IS Lss rrngtofliccuivaletll. Tftc C%! EEK Ci �tE I\' R.ANCf I30mo !' � �] curl! .a C.J (speciry } Csliutaled Valllc(-QjFlcclrical lVctlf,—��----__.__ fE�plralloll D.)rc) -3-M -” i','v!_Icn rc•quircd by fllunlcipa} pGIrC) ) Wolk to Curr �n ,- S Glspccl,t?I,s b Qto e ri uer,lc,! u? u; - d r,!auec +ill ,�tEC RI!Ir IQ t'tY1JJ''I', flJhJc'J' 1�u1�rlj,rr�• ad upoIllf' f7rt.:rplrtio1 rh�,r lr�;� ;- J;�, rrrRlf,�,t rill.S R/rllll(•Q(!(!,I !t rrlfPQ!!rJCO117p1C'i('. �, I • f ! L\ f \ : \Aft• : r^.^'.,r--•� � t17_ ...__., .. - .. _. _ -Wore 11: �f Bus. Tel. j\, o. (ilk 1:V('h 1YAl�"l I2 Ian',;,t,lre III:II tllc l i - All, Td. Ilf).:_��751 rectuirrJ by la-, /nrs,r )Ilrn,e Ilre i,abilit) insurance CC't,ctsl+r nOrn,ally 1.3> n,y srtallaltuc holo '., I lbp ' IIID rrr vIn :. On rtcrlll,^cul 1 I lul tll� (i lice nnc) �� iJ tt llt'r SIUrl' n it r S a"CiH. _s