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HomeMy WebLinkAboutMiscellaneous - 22 AUTRAN AVENUE 4/30/2018I I Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. h e,:: 5, 0 &/ ? &,- 77,- 1. " .............................. . ........... ................ . e .......... has permission to perform wiring in the building of ........ ........................................... at ....... ........ 4 .... ..... 0014!�� .............. North Andover, Mass. L10 7 Z4,/E- Fee..................... Lic. No . ............. .................. ELEcrRICAL INSPECTOR Check " 7807 a.ulitiiiviiwCdirn OT massacliusetts Official Use Only Permit No. � �O Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 1 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 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notii�ff of his or her intention to perform the electrical work described below. Location (Street & Number) �% % d -II -klAl A,,, Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) Purpose of Building i / Utility Authorization No. Ezisting Service AmpsVolts Overhead Und d �' ❑ No. of Meters 2_ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: table may be waived by the Inspector of Wires o. of Total. No. of Recessed Luminaires c.om letion of the No. of CeiL-Susp. (Paddle) Fans lliill . o mergency Ig g No. of Luminaire Outlets No. of Hot Tubs o, of Zones No. of Luminaires Swimming Pool Above ❑ ln_ nd. No. of Alerting Devices No. of Receptacle Outlets No. of Oil Burners Local ❑ Municipal El Other No. of Switches No. of Gas Burners Data Wiring: No. of Ranges / No. of Air Cond. Tons No. of Devices or E ...valent No. of Waste Disposers Heat Pump Totals: Number _.._..... _ _. Tons _. No. of Dishwashers Space/Area Heating KW ' No. of Dryers No. of ater Heaters Z_ KW Heating Appliances KW No. of signs Ballasts . No. Hydromassage Bathtubs No. of Motors Total HP OTHER: table may be waived by the Inspector of Wires o. of Total. Transformers KVA Generators KVA lliill . o mergency Ig g Batte Units FIRE �etection o, of Zones o. of Initiating Devices No. of Alerting Devices No. of or -BA -untamed Detection/Alertin ly Devices Local ❑ Municipal El Other Connection Security Systems: No. of Devices or E uivalent Data Wiring: No. of Devices or Equivalent elTommunications :ring: No. of Devices or E ...valent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. � �� v(/ (When required by municipal policy.) Work to Start: 11<16rP 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:) P fY:) I certify, under the pains a d penal ' of perjury, that the information on this applicationis true and complete. FIRM NAME: r �� Licensee: e Si LIC. NO.:�� gnature LIC. NO.: (� (If applicable, nter exempt" in the licensq number line.) Address:awls(`' hk'If Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl. 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: $ 157 tg t� �/-C- V41, The Commonwealth of Massachusettr kf ! Department of Industrial Accidents tt Office of Investigations l / 600 Washington Street i' Boston, MA 02111 {SZ www nzassgov/dia . Workers' Compensation Inskrance Affidavit: Builders/Contractors/Electriciaas/Plumbers Al ylicant Information Please Print LeQtbly Nanie (Business/Organization/individual): Address: City/State/Zip-Phone #: . Are you an employer? Cheek the appropriate box: ' 1. ❑ I, am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am have hired the sub -contractors Iisted ? .a.sole proprietor or partner= on the attached sheet ship and have no employees . These sub -contractors have working for me .in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its �luir'ed] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' corp. c, 1.52, § 1(4),'and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any applicant that checks bore #1 must also fill out the section below ehmvin their wo&ert' 'coin Homeowners who submit this affidavit indicting they are doing all wog, pensetron purity inmrmanon. rk and then ham outside contractors must submit a new affidavit indicting such. 4Contractors that check this box mustatteched an additional sheer showing the name of the sub -contractors and their workers' cum p. purity information l am.an employer that is;providing:workers' compensatiort insurance for my emir eeL Below is -Me o ' information. y P attd job site Insurance Company Name: Policy # or Self -ins. Lie. #; Expiration Date: Job Site Address. City/State/Zip: 2 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as.required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the.violator. Be advised that a copy of this statement may be forwarded to the Office of ° investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenaides ofperjury that the information provided above is true' and eorrecL St Lure: Date: Phone # Of, j`whd use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver ortrustee -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 lieensing 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, MOL 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) wi*.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 *uired. 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 peimit 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! eompensation.policy, please -call the Department at the nurnber. listed below. Self-insured companies should enter their self-insurance license number on the' appropriate tine. 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 ofthe 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 Basion, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia Date. . VAORTm TOWN OF NORTH ANDOVER 0 ?L PERMIT FOR GAS IN-;iALLATION This certifies that .... . �. -5. � . � ..... A. !'� :'� , . / .............. has permission for gas installation ..... P!7�! ..': ....... in thJbuildings of ... ......................... at .... �� .� .. /4.-/- /1 ....... I North Andover, Mass. Fee.. Lic. No... . .......................... GASINSPECTOR Check# -f- I C / 6183 6 a MASSACHUSETTS UNIFORM APPLICATON FOR PERNVIPT TO DO GAS kTF1 G (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations /, Owner's Name New D Renovation D Replacement D Permit # rv/ loy3 Amount $ S v0 Plans 4mitted (Print or type) r ' Che k Name one: Certificate Installing Company Corp. AddRs, 2 Partner. Business I a ep one _ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance' policy or it's substantial equivalent. Yes 13 Noo If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy 13 Other type of indemnity 13 Bond 13 Owner's Insuran Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. I s, and that my signature on this permit application waives this requirement. Check one: Signatu a 4 Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State %as no and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signatufe oUl 0 Plumber Gas Fitter Master 13 Journeyman a w V w e p O o a Z w x w w d x cc a w w N x z w > w a F" m z a a° a> SUB -BASEMENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR M 6TH. FLOOR 7TH. FLOOR 411 8TH. FLOOR 1 1 1 1- 1 1 1 1 1 — (Print or type) r ' Che k Name one: Certificate Installing Company Corp. AddRs, 2 Partner. Business I a ep one _ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance' policy or it's substantial equivalent. Yes 13 Noo If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy 13 Other type of indemnity 13 Bond 13 Owner's Insuran Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. I s, and that my signature on this permit application waives this requirement. Check one: Signatu a 4 Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State %as no and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) sed Plumber Or Gas Fitter Icense Number Signatufe oUl 0 Plumber Gas Fitter Master 13 Journeyman sed Plumber Or Gas Fitter Icense Number Date/�X 71,V ..... TOWN�F NO ZAND 0 IV E R PERMIT OR PLUMBING This certifies that .............. has permission to perform ... plumbing in the buildings of . ....................... at ... ) ...... .............. , North Andover, Mass. Fee 7. Lic. No.. . ...... 14- V...... PLUMBING INSPECTOR Check # �- I C / 7535 .it MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS �3J/ Date _ Building Location ` Owners Name Permit # Amount Type of Occupancy New Renovation 0 Replacement 0 Plans Submitted Yes No 0 FIXTURES (Print or type)Check one: Certificate Installing Company Name c Corp. Address `T ,� // �,� t, L 'h/e � i rAd Iia Partner. Business Telephone /I [] Finn/Co. Name of Licensed Plumber ' k j Insurance Coveraee: Indicate the e bf insurance coverage by checking the appropriate box Liability insurance policy Other type of indemnity 11 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 msuran t-,, to, rll�— — rgnature Owner I hereby certify that all of the details and information I have best of my knowledge and that all plumbing work anciftikstal compliance with all pertinent provisions of the Mass By: rgn o . yp of] Agent itted (67 or ent in above application are true and accurate to the performed under Permit Issued for this application will be in PI ing Code and Chapter 142 of the General Laws. Y License Title 0, - City/Town ►cense um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY T I. I m Location C;2 JtA P No. -,-Iql Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I 1�'�S I 16288 m ( Building Inspector -r. .Q TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: n / DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 22-2, y C - LAT rzFlti 19 Uc 1.2 Assessors Map and Parcel Number: -45-C d3 Map Number Parcel Number N. A N D o u E /2 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 Zane 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 iq T K I C I A t L Ge -ler /fit A K-; h{ t4 L— N ame (Print) Address for Service ..5-D Fr- !K - '9V 77 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Cor, truction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone MU M X ic Z O O Z M 90 O mn ic r v M r r Z ^ Q SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 11 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Z SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIALUSE ONLY - 1. Building 0.2.E (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 3rD 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 1, as Owner/Authorized Agent of subject property Hereby authorizea2t&�u,. 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 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date tea: NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR ITVIBERS 1sT 2 ND 3 RD SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DU\4ENSIONS OF GIRDERS —I IEfGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CIIIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE z 0. rA W ua �2u =aV*j� PQ co wa�' � w a wZW U w w�' cn co O � too A a w : o cin v cn C z O z O U C/) o, cm ca �— �, •� 'E m m CD CD CD CD L cc o a M: c CC Clca ccC d O ca O Z CD C. c - c— ' c cc C. CO 0 U) Ir w w U) =aV*j� o A : y O ' o =:s O C O C.a Vl 'D = m p m 1 : CCO3 o c a m :gym= � = m a:S 30 N LU .y Cos Cc Co H U .O C = o .y 2E O V CD O�'•C c CO O. m. O� ='O O _ F- wo o.wm a C z O z O U C/) o, cm ca �— �, •� 'E m m CD CD CD CD L cc o a M: c CC Clca ccC d O ca O Z CD C. c - c— ' c cc C. CO 0 U) Ir w w U)