HomeMy WebLinkAboutMiscellaneous - 21 WOODBRIDGE ROAD 4/30/2018AORTN
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Date.... ..............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... t' 'I, �
...............%.... ) ................. ......... ...............................
has permission to perform � ................. ..
wiring in the building o f ................................................
....... A�....... North Andover Mass.
Fee ..R5.-..'... Lic. NkY45� .............. ...... . . .........
. ..... .. .. * ........
ELF Rl A IN PE R
Check #
87L5
I
Commonwealth of Massachusettsofficial use only
Department of Fire Services FOccupancy
mit No. -- �-'
and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] ✓
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical C4ecto
27 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:�City or Town of:NORTH ANDOVER To theIf Wires:
By this application the undersigned gives notice o is or,er intention to perform the electrical work described below.
Location (Street & Number) ri
Owner or Tenant Telephone No. ®V76 93 �
Owner's Address
Is this permit in conjunction Ivith a buildinM-4—
mi . Yes No ❑ (Check Appropriate Box)
Purpose of Building . p U �, 1 Utility Authorization No.
Existing Service 0'&® Amps 1 /d 7-A7olts Overhead Undgrd ❑ No. of Meters L_
New Service Amps / Volts Overhead ❑ Undgrd
❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature ofyr?posed Electrical Work:
.e 1 n -
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water Imo'
Heaters
No. Hydromassage Bathtubs
OTHER:
No. of CeiL-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑ In-
nd. �rnd ❑
No. of Oil Burners
No. of ;as Burners
No. of Air Cond. Total
T__ -
Space/Area Heating KW
Heating Appliances KW
No. of o. of
Sims Ballasts
o. of Motors Total HP
table may be waived by the
Generators KVA
o.
Units `�
ALARMS No. of Zones
Alerting Devices
❑ iviulucipai El other
Conneet an
No. of Devices or
Data Wiring:
No. of Devices or
Telecommunications
No. of Devices or
Wires.
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value o Elm 'ca Work: �Q®.' (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 liabilityw&surance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such covp&ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:)
I certify, under the in d pen s of perjury,}hat the ' orm ' n on this p !i n is true and complete.
FIRM NAM % 1J'✓l GRA U C . b t e f LIC. NO.: O3,ts %}
Licensee. Signature LIC. NO..
(If applicable, en
t "ze ept in th license tuber line.
Address: -�@ U l Bus. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of ublic Safety "S" License: Alt Lic. No. 5 7
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. �
1,3 J�.
I
.d+
kr 1
tl��t
>a ;
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
i www mass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
Name
Address:
City/State/Zip: L2 U� M Dl� � �- Phone #:. 91,�e ro o �% S
Are you an employer? Cheek.the appropriate box:
t • ❑ I' am a employer with 4, ❑ I am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
2. ❑ I am asole
have hired the sub -contractors
listed t
6. ❑ Ne nstructton
7.
proprietor or partner_
on the attached sheet
emodeling
ship and have no employees
These sub -contractors have
8. ❑ De n
working for mein any capacity.
[No workers' comp, insurance
workers' comp. insurance.g
5. ❑ We are a corporation and its
ding addition
required.]
3. ❑ I am a homeowner doing
officers have exercised their
10. $IectriCal repairs or additions
all work
right of exemption per MGL
11.7 Plumbing repairs or additions
myself [No -workers' comp.
insurance
c. 1.52, § 1(4); and we have no
12. Roof .
❑ repairs
r uired. t
eq ]
employees. [Afa workers'
13.❑.Other
Y d....
comp. insurance required.]
•• +++>u arso nu 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.
Zimietors that check this box mustattached an additional sheer showing. the name of the sub -contractors and their et er! mss' c rr"• ;.clicy information.
'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 $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 g9M1ce coverage verification.
In
- I do hereby
and penalties of perjury that the information prop' abo true and correct
-� Date. I ! ' e,�
Of ickd use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
a
Information and Instructions °
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore
of the'foregoing engaged in a}oint 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not'the Department of
Industrial Acdidents. 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 lnvestigations has to contact you regarding the applicant.
Please be sure to fill in the per-mit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense 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 f sture permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax # 617-727-774
Revised 5 -26 -QS www_mass.gov/dia
Date . . - (2( . v!
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING/
c ✓'��qh
SACNuS _
This certifies that...... ✓..PGj.tt.�./..r�Ac�'.•
has permission to perform .GI.?. ........................
plumbing in the bu'Idings of .� �?! `�..................... .
a i l�Od�6�
at ......... ....... !G�'......... ,North Andover, Mass.
Fee. r Lic. No.//.;. ......................... . r
PLUMBING INSPECTOR
Check #
8048
K
MASSA CHUSETTS UNIFORM .APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location �-/ C✓GPJ%1�2�1
New Renovation
TYPe of Occupancy
Replacement '4
EP TURES
Date
Permit #
Amount
Plans Submitted yesNo
. El❑.
G
/(Q� �^ Check one: Certificate
ElCorp.
L J Partner.
Name of Licensed Plumber. FUM/Co.
Insurance Coveraze: Indicate the type of insurance coverage b c
Liability insurance policy g y heci inggthe appropriate box:
P y Other type of indemtii
Bond
made aware El
Insurance Waiver I the undersigned have been e that the licensee of this application does not have any one of the above
three insurance �.
Signature Owner y
Agent ❑
I hereby certify that all of the details and information I have submits
ed
best of my lmowledge and that all plumbing work and ins tions(or entered) m Wove application are true and accurate to the
P
compliance with all pertinent provisions of the Mass setts ormed under Permit Issued for this application will be in
Plumbing Code and Chapter 142
=A-PPROVED7F,icE
P of the General Laws.
M gnaLure of Lrc ea Win
Type of Plumbing License
Ly License 1 &M er Master {-� —
ourneyman ❑
0
T;i \
he Commonwealth of Mtrssachusetts
Department of Industrial Accidents.
Office of 1nverd a jo
600 Washinns
e ton Street
Boston, Mr4 02111
��''. m4SS.o Ols�diq
Workers' Compensation Insurance. davit: guilders/Contractors/Eleetricinns/Piitmbers
3iicant Information
Namt- (Business/Organization/Individual):
Address: 5.
City/State/Zip:
Are an empioyer? Check th
e appropriate box:
1 I an a employer with 4. ❑ I am a s mll
..m to ees full and/or art -time .
"PY-�( p )�
2, ❑ f am a sole
have hired sub- contractorand I
proprietor or panlogit-
ship and have employees
listed on the attached sheet #
.no
working forme in any capacity.
These subcontractors have
workers' comp. insurance,
[No workers' comp. insurance
5. ❑ We are a corporation
required_]
3. ❑ I am a homeowner doing all
and its
officers have exercised.theirright
work
myself. [No worker's' comp,
insm'ance
of exemption per MGL
c. 152 and we have
required.] T'(4),
no
eiPloYees. [No .workers'
comp ins
Type of prOjrvt (required):
6• ❑New construction
7• ❑ Remodeling
g• ❑ Demolition
9. ❑ Building addition
10:❑ Electrical repairs or additions
I l .❑ furnbing repairs or additions
12,11 Roof repairs
13 ❑
"Any appiicant.that checks box # 1 .must also -fill out the section below showi tsranee required ] I Other I
Y Homeowners wlw submit,utis afudevit itidicanrfg uley au_ dainr ;r' 4:c=..; ng tteeir workers' compensation oil
1Conmictors that check this box.rnust armched an addiYionat sheet showi tin Er_n hire outsi cuniraeiurs us yu�i new, atnriav
the name of the sus ccr Mors and their woricers' rAm it rndi eting s h.
I am an. emolover that is Prov dine work P poiic} inrannation.
e = comperrsatiori insurance or
information. // f ng'employees Below is the poliCO, and job site
Insurance Company Name: C.✓. ea�f
Policy # 07 Self -.ins. Lid.
Expiration Date: / �d
Job Site Address: 2 �/dx ��
Attach a copy of the workers' compensation policy deciaration
Fe
Crty�Stat.IZrp.
.Failure to secure coverage as required under Section 25A of pab(r. 152 car Iza ;the policy number and expiration date).
fungi up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in � to
imposition of of a STOP WORK
penalties of a �1>'
of up to .5250.00 a day against the violator. Be advised that a eo ORDER and a fine
Investigations of the DIA for insurance coverage verification. p) of this statement may be forwarded. to the Office of
I do herebyce u the pains and penalties o er u ,
%P 1 rJ that the inforrrra6on provided above is true and correct
Si�rua
Phone #:Qat:
� OS��
1
EOf
orzlp. Do trot write in. this area, to be corrrpleted by city or town ociaL
r
a�
hority (circle one):
Permit/License ;r
Health 2. Building pDe artmeut 3. Crt3�own.Clerk 4. Electrical Inspector $. Piumbino binspectorson:
Phone R:
Date....
... .....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ .......... .....................................................
.
has permission to perform .................................................
wiring in the building of ....... ............. e-1-1
%
...........
at .. ....... ............. . North Andover, Mass.
.. ........
Fee..................... Lic. N.�........ ................................ . .............................
ELEMI&ALIkSPECTOR
Check #
46%'I
77 COAMONWE4LTHOFM4 SAL'H%,jE 5 Office Use
se onlyy
DEPARTAILVTOFPUBLICS4FETY permit No. e
BOARDOFFREPREVE MONREGULAHONS527 2:00
Occupancy & Fees Checked
APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street A
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes
Purpose of Building
Existing Service Amps LVVolts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No (Check Appropriate Box)
Utility Authorization No. _
Overhead Underground
Overhead =1 Underground
No. of Meters
No. of Meters
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
J
ground
round r7
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
�a
No. of Self Contained
��•
Detection/Sounding Devices
Local Municipal
_
Othe
No. of Dryers
Heating Devices KW
� Connections
No. of Water Heaters KW
No. of No. of
Signs Bailasis
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER•
VR=1MCo1Uaga Rrm ttothete#MT0ltsofMas XhusEtsGerleralLam
ibaxeaamaiLA)khurancePbheynrkxlingCoir,nplee CovetageoritsmbstatWeg ivabt YESEJ NO E
Ihav %kmitedvalidpmofofsametoffrOffim YES ri ? F3uuhavccbodwdYES, pleases>dic&drVArofcovaageby
dradng
INSURANCE ' �' BOND F-1MIER F-1m1eawSpe*) e 31a�-1�
WodctoStatt
kq)0C lon D&Regtlesmd
Lia�ce (iV jj' AAdo Signature
OWNER'SINSURANCE WAIVKlamawarethatdELlwdoesnotha1
and that my signatm on this pemrit apphcabm waivfs tins regtmar-oIt
(Please check one) Owner M Agent
Igna ure of Uwner or Agent
r4TdUML)=
EstinatedVah&of ADctncdWodc $
Ro* FRral
fcll,(ALimmNo. 17 �d�y/�.lwe -5--&&f �-� �_
LioffwNo O �--
��O✓�G r '� BusillessTel No. I�,� /„Sf s ^ 55
At Tel No. � Ya.3
enar&-imoDNengeorit3subst<a�ecuival2itasmgtmedbyMw,achusettsGff)cdLaws
f - O.a
Telephone No. PERMIT FEE $., c 4 .1/
Locationf �/d�- (!aG p
I No. -71 t0 7 Dater
H01RTp TOWN OF NORTH ANDOVER
Certificate of Occupancy
# '
$
Building/Frame Permit Fee
$
'�� �CHU t� Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
o Water Connection Fee
$
TOTAL
$
� ,�^ Building Inspector
U
46/20/96 13:21
• - 9 8 AOO PAID Div. Public Works
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Office Use Only ACPC
044 Lfam I unnitaith of gus#uslffs Permit No.
'gepar11 art of 11ahlic —Aufztg Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3194 peeve blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527�CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date -�' / b? r QL',
(Xw or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) r-Yz 4&:1h12,ge/6Y4 S2,
Owner or Tenant 2?zyn I :5'eze';,
Owner's Address <'Qm-
Is this permit in conjunction with a building permit: Yes /K. No C (Check Appropriate Box)
Purpose of Building S'i:e/oto r_�/�/�7�Lc. Utility Authorization No,
Existing Service Amps _J Volts Overhead '—I Undgrnd r
r
New Service Amps _J Voits Overhead L–. Uncgrna
Number of Feeders ana Ampacity
No. of Meters
No. of Meters
Location and Nature of Prcoosed Electrical INerk
Toiai
No. of Lignnng Outlets No. of Hdt -;os � No. at -ansformers KVA
it
No. of Lighting Fixtures /' i Swimming Pool 9 ro e— erne. _ ! Generators KVA
C� No. of Emergency Lighting
No at gecectaCe Cutlets I No. of Oil Burners I Battery Units
No. of Switch Outlets I No. of Gas Burners FiR.E ALARMS No. of Zones
Total No. of. Cetection and
No. ct Air Conic. No. of Ranges I tens Initiating Devices
Heat Total Total
I No. of Disposals No.of "
?arcs Tons KW No. of Sounding Devices
Vo. Seif Contained
No. of Dishwashers ! I SoaceiArea I-!eatird KVV Oelacc;oniSounetng Devices
Municioai
No. of Dryers Heating Devices KW Local Connect;on _Other
No. of No. at Low Voltage
No. of Water Heaters KW i Signs Ballasts I Wiring
No Hydro Massage Tu^s No of Motcrs Total HP
OTHER:
INSURANCE COVERAGE: Pursuant ;o the redu,rements at '.Iassac::usa7,s General Laws _
I have a current Liaoiiity Insurance Policy including Camo!eted Crerations Coverage or its suostanual eauvaient. YES < NO — 1
have suomirteo valid proof of same to the Office. YES JZ NO - It you have checxed YES. -lease noicate the type of coverage cy
checking the approcriate oox.
INSURANCE ,- BONO = OTHER = (Please Scec:fy)
(Exoiraoon Date)
Estimated Value off E!ectrlcal Work S 2L• o
Worx to Start lj "�8 �� Inscec!ion Date Racuestec: Rough r+nal
Signed under the Penalties of perjury
FIRM NAME
A LIC. NO. •C 3.i Ems_ `?
LIC.NO.
Licensee fYJi47^r �?/��n{t^�� Sig^atcre �--
Bus. Tel. No. S� ^ % %S~ � S
Address �� sf A'►.C'Y.t✓uE+'�✓ �� C,/�5'�' Alt. Tel. No.
OWNER'S INSURANCE I am aware that the Licensee Goes not nave the insurance coverage or Its suosiantial eduivalent as re-
ouireo oy Massachusetts General Laws. and that my -signature on :nis -ermit application waives this reduirement. Owne Agent
(Please cnecx one) w
:eteonone No. PERMIT FEE 3 v
Signature of Owner or Agent) <�SaS
This certifies that ... �%!ti QC , , !% ��G ? ca 1. �J� IrE'
VV I Ki AJ
has permission f6riinstallation ../r34/ ry .l�m�>?9. ...
in the buildings of j� . -:r6k..%... .2. ,(f . . . . ................ .
at A.V. w..o.J. �l�j.cc� , , $t - , North Andover, Mass.
F C No.. = ..�
�1 �9 I�IU �6INSPECTOR
��
WHITE: Applicant CANARY: Bui ding Dept. PINK: Treasurer GOLD: File
TO 2696
Date...... ..
TOWN OF NORTH ANDOVER
_
Op
WWO—T(U CAL
F?Oy
PERMIT FOR MB INSTALLATION
9v
'rs,9SSAC'HUSE5
This certifies that ... �%!ti QC , , !% ��G ? ca 1. �J� IrE'
VV I Ki AJ
has permission f6riinstallation ../r34/ ry .l�m�>?9. ...
in the buildings of j� . -:r6k..%... .2. ,(f . . . . ................ .
at A.V. w..o.J. �l�j.cc� , , $t - , North Andover, Mass.
F C No.. = ..�
�1 �9 I�IU �6INSPECTOR
��
WHITE: Applicant CANARY: Bui ding Dept. PINK: Treasurer GOLD: File
n
- v
Location ` l)) R i
No. oacr
i
C14UStS
s
{ Check #
i65-3
Date 17 - /S 0-3
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
IM I
Building Inspector
a,
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCq$T° REPAI RENOVATE, OR DE}.MOLISH A ONE OR TWO FAMILY DWELLING
Y;
BUILDING PERMIT NUMBER: ® 1 DATE ISSUED:
SIGNATURE:
Building Commissioner/IEE3pwtor o Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zonm District Proposed Use
1.4 Property Dimensions:
Lot Areas Fronta ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide ReqWred Provided Re red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No
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:
5- f
Addres
6779 4075- 7`-1 Yy
Signature Telephone
Not Applicable ❑
License Number
0/�/a
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
(.
Address
Expiration Date
Sign re Telephone
y
SECTION 4 - WORKERS COMPENSATION (KG.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 ❑
Existing Building ❑
Repair(s) ❑
Alterations(s)
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
1262'-70 CZ -7 f IZRZ19, /R� G��1
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by 2Lrnut applicant
OFFICIAL FTSE flNY
1. Building Z4 We
+
(a) Building Permit Fee
Multiplier
2 Electrical(b)
31
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 Z p
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I"6' ��2��'e n e ^` �e �! as Owner/Authorized Agent of subject property
Hereby authorize r )1 a J e Ort; to act on
My b , m 11 matter elative o w authorized by this building permit application.
Si ature of Owner, -*'Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, �FJ`�i`lC= / as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
� ,
Print Name
Si ature of Owner/ ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 No3RD
SPAN
DMIENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHININEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
e
J�ie >G'om�za�Zweal�/ a���raac�uaeC� I
BOARD OF BUILDING REGULATIONS
' License. CONSTRUCTION SUPERVISOR `
Number' CS 071934
1 + Birthdate: 08/26/1966
Expires: 08126/2003 Tr. no: 12120
F "t
,Restricted:00 9 j !
ALAN D JENNEY
57 HIGH PLAIN RD
ANDOVER, MA 61810 ' Administrator
-Y-- _ _
� i ��ae �anvriaarzueilli o�✓�eaar�,cia tlt
'Board of Building Regulations and Stands s Iti
HOME IMPROVEMENT CONTRACTOR
E Y Reglstratiopi 138076 a
�i Expiration 2711/2005
c'Type DBA ! `
-ATLANTIC RESTRORATION + DEV.ELOPMENT '
iALAN JENNEY _
j 57 HIGH PLAIN RD�,_ __ -b:✓
1t 't ANDOVER, MA 01810 Administrator 1
N
t,
3
N
�"1 G
Xe' �v
NK7
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name: R/ZL2114 7- (G
Address
City / -r�� 7Z" P� alF°!® Phone #- j75 97 5 - Ng4 `-of3
t 315 -3v 316
Comnany name:
Address
city. Phone#:
Insurance Co. Policy
Failure to secure coverage as required under Section 26A or MGL 152 can lead to the hiposition of criminal penalties of,a fine up to $1.500.00
and/or one years'imprisormnentas_vicetLas_civdjmakiesjnihelom -cfa-STOPYAORK FaMPand-afi -d-(,4;i�)-ajagaiastme 1
understand that a copy of this statem forwarded to the Office of Investigations of the DIA for coverage verification.
I do herebycertTy under ��I a4d pegd/ e of peoury that the information prov,*d above x true and correct.
7//,v43
Print name � � ��"7�1 r= Phone# q7L �f - �f�
Official use only do not write in this area to be completed by city or town official'
City or Town PermilA icensing.
Building. Dept
[3Check d immediate response is required .0 Licensing Board
p Selectman's Office
Contact person: Phone #.- Health Department
Ei Other
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