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Miscellaneous - 22 MAIN STREET 4/30/2018
w oo- f-. Date .... e .... 1;;�P ... 1.�.* ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ['I (A&IL Thiscertifies that .................................................... ................................................................. 0-- 1 e -.e— �Vk� 4 U A has permission to perform..�� ........................... . ............................... ...... ........... 4 .......... plumbing in the buildings o -f... .......... ..................... ................................................... (A at ...... a ...... ) ...... ........ a ........................... ..... . .... ... North Andover, Mass. Fee..!7� ......... Lic. No. A!.9S6 .. ...... H () ..................................................................... PLUMBING INSPECTOR Check # V 1 TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY[QO _ q ()-,Jt,,/r MA DATE ( 25L] PERMIT # JOBSITE ADDRESS 7 NlG1.L�� S OWNER'S NAME ,/ C OWNER ADDRESS TEL IFAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL NEW: [3 RENOVATION: F-1 REPLACEMENT: (] PLANS SUBMITTED: YES [] NO I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch U ER 142. YES NO RANCE COVERAGE: 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EV]4'-" OTHER TYPE OF INDEMNITYF-1 BOND [� OWNER'S INSURANCE WAIVER: I am a*are that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER M AGENT 0 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be incompliance with all Perti ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,Gj%�i1 PLUMBER'S NAME f�'�G.fr-(� („�G{,L� (5 LICENSE# ( SI NATURE MP EI` JP❑ CORPORATION❑# PARTNERSHIPQ# LLCC#[::= COMPANY NAMECt-5_n�;� ADDRESS CITY I 00 ]STATE ZIP G j �j (o—� TEL L!y -;q- FAX Z (,�(�-U (p j CELL I EMAIL ' Si_ r'1C Sh<�. �•�c�- ` ��►` lt`� pec bi i Date .... S ... �? ... A�..t .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Lee- �jv s� o Thiscertifies that .......................................... ............................................................ has permission for gas in tallation ... bi . ..... ....... .. .... .. ... .. ........ .... in the buildings of . . . ...................................................... at ... ....... North Andover, Mass. ........................................ Fee.5� . ...... Lic. No. .. 1011.15 ....... ... " ..... 4 . . ................................................. GASINSPECTOR Check # Z -Z U rl]W 0 MASSACHUSE i TS UNIFORM APPI_ICA-11ON FOR A PERMrJ TO PERFORM GAS FrffING WORK CITY �O , � ,ov - MA DATE g f o2 / PERMIT# �1 1l� JOBSITE ADDRESS pja . �1 S /' OWNER`S NAME - " OWNER ADDRESS . TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ;- RESIDENTIAL' f CLEARLY NEW:. RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO." APPLIANCES Z FLOORS— BSM 1 2 3 4 5 fi % 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR I I FURNACE _ GENERATOR GRILLE - INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT � OVEN I POOL HEATER ROOM I SPACE HEATER _. ROOF TOP UNIT TEST i UNIT HEATER UNVENTED ROOM HEATER WATER HEATER - 1 OTHER � - - -- - - - INSURANCE COVERAGE I have a current liabilityInsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 14-2 YES t/ Nfl 111= Y�U CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ✓ OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of tyre Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT _ SSG5+4ATtlRE OF OWNER OR —AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my imowiedge and that all plumbing work and installations performed under the permit issued for this application wll be in compliance Pertinent with all provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LICENSE# PLUMBER-GASFiTTER NAME SR SIGNq iE1RE MP ✓' MGF ✓ JP JGF LPGI - CORPORATION # PARTNERSHIP #,t LLC COMPANY NAMEADDRESS— — f�iG O G� Air/ _1 r-r CITY t `'1e STATE /yj Z1P (> t -&o TEL '17,V FAX y 0{0l 1 CELL EMAIL FJ ca-ss t cry �, I'1cU.S �t�6 a-✓, C clwt rl]W 0 M N3 UIA 00 :6 Lu Im V) LW 0- LO) LAJ cc C..4 C14 Iz ne Comdonwealth ofHassachaseffs , O, f,�lee o, ffmaw9afiow 660 Wayhzngton. Mfeet .Boston, .tom 02111 wrw waass govldla Wo rckejo' Comp ensa zoo. buswance.Affidavit: )3uRaers/GontractorgMectriciamil ltbers ApFlxeant Wo x anflon. PleasePrliatLe�bXv Warne (Bvsix odorganizatlau ndMdual): 0�L ,� ► _ L h c Address: Cz jfStaieMp;J-t `�'I ry(k o i ((c b Phow 91,7011"- 9"Jo& - d G d U 6Xe you an employer? Cheek the appropriate box: ., Type of project (reegdred): I am.a employer with o� � � �. ❑ I am a general contractor and? 6. []Now cbnstruc'dou .1.[� employees(Maud/orpart-time-)-* have Rhadihesub-contractors listed on the attached sheet: T 7• �( �-em.odeling 2. El am. a solepropxietor Orpariner OMP and`havena.employees These sub-coniractorshave 8. EJ Demolition working fox m -e in any' capacity. workers' comp. insurance. 5. ❑ we axe a corporation and its 9. ❑ Building addition tNo workers' comp. insnmauce officers have exercised -their 10.E[ Electrical repairs ox additions 1e9*e11 3. [l I am. a homeowner doing all work right ofexemption per MUL II [ I'Iumhingxepairs t adcXiizons myself PoworkM2 comp. c.152, §1(4), andwehmno 12.pR.00frepahs insurancererluired.� i employees. [No workers' 13.n Other Com0.1umuncereCt tal 'Aay apPlicanff(� checks box�Z musfalso �itlontithesection belbvtshowingr�ieirwbrkers' eompensationpoli�rinfomiafion. Someownes who sabnit#bk afddaVR inciicaimgffiey 9e doing a wo6T andtfienf*ei outside contractors muni mbmR anew afCdavit Meafnig shah. TContracfom mt the this boM mast attached an, additional sheet showingthe name of the sub-eoufcactom andtheirworkers' comp. policy idiom I n art er loy thatisB�ovidiag woplre��' competzsaiion ir�MTirtce• fot<riray ffAffloyeeg BetM ist/iepalicy r tciJ site in�o���tat�ar�. ^^- Trisuxance Companyhlame; ./ r l C�7 Policy 9 or Self -ins. 110. ExpiratioaDate: M SI- lob Site Address: fl?..� `� . �`'"r jCiiy/State/:1•�. Pm dove -y', r''tGi. 01 Atfach, a Copp 014eworkexs' compensation.poitcy6[eclaxatioupage (sitowmg-Me policy ll ber and eWa€ wx date). y. dare to secure coverage as requixed.under Seetion25A of MGL o.152 can leadto the imposition of crhninalpenaMes ofa fine -ap to $1,500.00 andlox one. -year #prisosnn enf, as wellas obgpenalties in th e foam ofa STOP W'OR1, ORDM Emd a fme ofup to $250.04 a day against the violator. Be advised chat a copy ofthis siatementmay be forwarded to the Of&a -of bveWgaiions ofthe DIA. for insurance coverage veriftcadon. XdolIffebyeeTouvdwfize�taimanclpedtiesofve*_ytliattltei�tfvr io:�proviriecla�oye%�tpprreaneteor ee Si mare: Date- �'lione #: oJimal use alay. Do not vae zn fills tweo, to be eomwkfed tl City or torn offixial City or Town: BermPULicense g Dsu; gAuthoAfy(ekeledne): 1. Board ofHealth 2. BuRdingDepaxbn.ent S. CitylTown Clerk 4. Electricalfrnspector 5.1'XuMbhi9ELTector• 6. Other - - NOTICE To EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT. OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: AmGUARD Insurance Company NAME OF II SITRANCE COMPANY P.O. Box A -H 16 South River Street Wilkes-Barre, PA 18703-0020 ADDRESS OF INSURANCE COMPANY NAW C426001 11/01/2013 11/01/2014 POLICY N MBER EFFECTIVE DATES GRANITE INSURANCE BROKERS 6600 Koff Center Pkwy 100 925-462-8400 Pleasanton; CA 94566 NAME OF LNSURA.YCE AGENT ADDRESS PHONE Nashoba Air, Inc. 109 Tyngsboro Road North Chelmsford, MA 01863 4 EMPLOYER ADDRESS EMPLOYER'S WORKERS`EOMPENSATION OFFICER (IF ANY) MEDICAL TREATMENT 10/29/2013 DATE The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services. in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. ' The employee may select his or her our► physician, The reasonable cost of the ser- vices provided by the treatins physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED ED BY EM-PLON ENR From:D ck Thom, CPCU FaxID: Page 2 of 2 Date:81192014 09:02 AM Page:2 of 2 NASH021 OP ID: DT CERTIFICATE OF LIABILITY INSURANCE F ATE ° 09 08111191120142014"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 'REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Dennis F. Murphy -Harvard PO Box 190 276 Ayer Road Harvard, MA 01451 Michael Murphy X5121 CONTANAME: Michael Murphy X5121 PHo C No E :978-772-0070 W;;: : 978-772-2920 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC s INSURERA:Selective Insurance Company of 39926 11/01/2014 INSURED Nashoba Air Inc. INSURER B: Travelers Insurance Co. Kerry Kelley 527 Great Rd INSURER C: GENERAL AGGREGATE $ 3,000,00 Littleton, MA 01460 INSURER 0: $ AI INSURER E: INSURER F : rnvGaACGc CFRTIFICATF NIIMRFR• REVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I LTR TYPE OF INSURANCE ADDL SU13H POLICY NUMBER POLICY EFF MMIDD POLICY EXP M1DDNYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR S 1827490 11/01/2013 11/01/2014 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POUCY PRO- LOC PRODUCTS- COMP/0P AGG $ 3,000,000 $ AI AUTOMOBILE LIABILITY AUTO ALL OWNED SCHEDULED X AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS 9091116 11/01/2013 1110112014 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PER ACCIDENT) B X UMBRELLA LIAB EXCESS LIAB X I OCCUR CLAIMS -MADE S 1827490 11114/2013 11/0112014 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/ExECUTIVE Yr OFFICERIMEMBER EXCLUDED? (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below NIA WCSTATU- OTH- ER E.L. EACH ACCIDENT $ ---'� E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ r DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Heating/AC Contractor /`COTICIf'ATC UAI nGQ CANCELLATION NOAN D01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25 (2010105) 0 19UU-2010 AGORU GORPOKATION. All rights reserve0l. The ACORD name and logo are registered marks of ACORD a I ru 5 7 i Datey........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �i f This certifies that ....�1 ow ..�!+!.�6? �........................... has permission to perform ...'.7...........?........il�-. ............... plumbingin the buildings of.........................................-..................................................... at ... c;.QA ��'1....S�...............................................s North Andover, Mass. Fee.40!:.x.... Lic. No., ........ :....:.,..................................................... PLUMBING INSPECTOR Check # �U� t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1W CITY ..• i �4.y ✓t MA DATE -✓rte Z c( PERMIT# M11 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TELI 11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: Eff" REPLACEMENT: ®" PLANS SUBMITTED: YES N0�]_I FIXTURES -1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB -( _____{ = __ f = ( I _ __ I====== CROSS CONNECTION DEVICE I J 1==== DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER i DRINKING FOUNTAIN _ _I ..____.1L—A FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) I -__J ___{ ____ T _.__j I _.__I KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET I _ _I I URINAL 1 I _ _._._ _— I S ..-- _-�J I _......-1 _j J= WASHING MACHINE CONNECTION.__f . ___ J ._J WATER HEATER ALL TYPES l I -_ I I _I (. IF. _ __! WWER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2 --NO _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IBJ OTHER TYPE OF INDEMNITY D, BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp'ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. w /� PLUMBER'S NAME LICENSE # SIGNATURE IVIP a --,JP Q CORPORATION Q#PARTNERSHIP Q# s LLC COMPANY NAME l ,/ L ;ADDRESS CITY STATE ZIP ��jg TELNJ FAX-�._ 6 CELL :4? -EMAIL C._— L._._ 1 - - -.. R.. H z 0 H U W t W m N ❑ W iii LU The Commonwealth of Massachusetts - Department o, f Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: J City/State/Zip:Phone #: Are yo n employer? Check the appropriate box: Type of project (required): 1. B1 am a employer with 4• ❑ I am a general contractor and I 6. ❑ New construction employees (fall and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• [1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.QRoofrepairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors 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 woYkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or S elf -ins. Lic. Job Site Address: Expiration Date: 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 requiredunder 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 maybe forwarded to the Office of Investigations of the DTA. for insurance coverage verification. X do hereby certify under the pains andpenadties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: PerniffMcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. EIectrical Inspector 5. Plumbing inspector 6. Other - - - Contact Person: Phone #: Information and Inst °atoms 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 ofhire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states -that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phonenumber(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 LT C or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill. in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications "Many given year, need only submit one affidavit indicating current Policy information (ifnecessary) 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: `rho Cox onwealth of Massadhwott, Departmeut ofZadustrial .Accidents Office ofIavestigatzow" 6.04 Waslubigtoa Stroet Boston} MA 0 111. TO, # 617-727-4900 ext 406 ox 1.-577 MASSAF Revised 5-26-05 Fay,# 617"727"7749 v�txr_mac.e anjrlA;a a Date.(,.(2.1o... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that(2-u--� ............................................................................................................................ T�Q> - --A- ,if, U has permission to pe orm ......................... wiring in the building of ....................................................... e- .. ................ ............................ n r tIt ......... .. . ...... .. ...... !�� ............................................................ . North Andover, Mass. "Vee ..... 5. .... G ....... ............. Lic. No;�t.w.e IN� ................................................................. 4 ELECTRICAL INSPECTOR Check # e rj -, r- " f � 0 -* B-11 - 4 o, S1 19 j 14 _ f Commonwealth of Massachusetts f Department of Fire Services a BOARD OF FIRE PREVENTION REGULATIONS 1 t� Official Use Only Permit No. I Z* 0 Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (Iv1E ), 527 CMR 12.00 (PLEASE PRINT IN MK OR TYPE ALL INFORMATION) Date: f City or Town of: NORTH ANDOVER To the Inspe for of Wires: By this application the undersigned gives notice of leis or her intention to perform the electrical work described below. Location (Street & Number)_ uvt (h i S`F Owner or Tenant Owner's Address Telephone No. Is this permit in conjunctioXi with a building permit? Yes 0 No ❑ (Check Appropriate ]Box) Purpose of Building 26S i CI e i(' ei Utility Authorization No. - Existing Service) Amps / / i " olts New Service Amps / Volts Number of Feeders and Ampacity and Nature of Proposed Electrical Work: �, e v\ Overhead n/ Undgrd ❑ No. of Meters y� Overhead ❑ Undgrd ❑ No. of Meters Completion Vthe following table may be waived by the Insvector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires, Swimming Pool Above ❑ In- El rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW.......... No. of Self -Contained y snag y� Detection/Alerting Devi es bc, No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. K Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VERAGE: 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 P --BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjuIXI that the information this application is true and complete. _ FIRM NAME:. L= Z C` C LIC. NO.: a ,7Y t 3 Licensee: cq 1 Signature LTC. NO.: J l6 6G Address applicable, e tea- 7npt'� (� C' in the license ember line.) P-� ` Bus. Tel. No. • 5;T--�2%o}" P -?O f Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, 40ecurity work requires Dejn4&6ntfbfPublic 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 �� a Signature Telephone No. PERMIT FEE: $ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be file on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Actfurthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: ***Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Ins ection Pass [M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: SERVICE INSPECTION: Pass M Inspectors Comments: Failed EN Inspectors Signature: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Inspectors Comments: Inspectors Signature: ROUGH INSPECTION: Pass D�iY ents: Inspectors Signature: 'MAL INSPECTION: Pass 0 < Inspectors Signature: :B WEINHOLD ... TOWN OF MERRIMAC, MA. Failed 0 Failed . dwein hold @town ofine rrim ac.com Date: Re - Date: Re - Date: uired ($.) ❑ ired ($.) ❑ Re- Inspection Required ($.) ❑ Date: Re- In ection Required ($.) ❑ Date: 4 , ry The Commonwealth of Massachusetts ` Department of lnclustirialAccu%nts Office oflnvestigations 600 Washington Street Boston, MA 02111 www.nmss.gov1d1a Workers' Compensation bssurance Affidavit: Builders/Cont°actorsfEIeclricians/Pliunbers Applicant Information Please Print LegUy Name (Business/0rganizaiion&dividual):C`:i f2n - ELec o ( d_C Address:_`(-,��� City/State/Zip p2o:�2faY V'4 Phone #• q 2f�� 2��'. � 9- T Are you an employer? Check the appropriate box: Type of project (required): I. K14 -6m a employer with 4. ❑ x am a general contractor and I 6. F1 Now construction ' employees (full and/or p -lime) 2. ❑ I am a sole proprietor or partner- have Hired the sub -contractors listed on the attached sheet. x 7. modeling ship and'laveno. employees. These sub -contractors have 8. [(Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work of officers have exere sed.their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. Iroworker Ia' comp. c.152, §1(4), and wehaveno 12.QRoofrepairs insurancerequired.] i employees. [No workers' 13.❑ Other comp. insurance required.] IAny applicant that checks box#1 mustalso fill out the section below showingtheir workers' compensation policy information. 1 -Homeowners who submit this affidavit indicating they gi doing all worlt and then hire outside contractors must submit anew 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 isp�oviding workers' compensation insurance formy employees Below zs thepolley andjob site information. Insurance CompanyName:_ /uor r(", Policy # or Self -ins. Lic. #: 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 covexago.as required.under Section 25A ofMGL o.152 can lead to the imposition. of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as welt 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 statementmay be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby cert& under the pains and penalties ofperjury that tree information provided above is true and correct. Signature: Date: Phone #: Official use o cly..Do not write in this area, to be completed by city or town official. City or Town: PermMicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone A Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Fursuant to this statute, an eraployee is defined as "...every person in the service of another under any contract ofhiro,- express or implied, oral or written." An employes is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the f6regoing engaged in a j 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 tha 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 orrepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be. deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage requr real." 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 b een 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(os) andphonenumber(s) along withtheir certi6icate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If au LL C or LLP does have employees, a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for confrmation 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 thatthe 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- inthe permit/license number whichwill 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 "lob Site Address" the applicant should write "alllocations 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 -V on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The GQ onwoalth of Ma uac hwetts - De,partmeAt QfTudu al.Acoldeuts QfAce ofInvestigationa 6b G Wash pgt= meet Bostw,MA02111 Tel, # 617-727-4.900 ext 406 ox x-877":MM,9FF, Revised 5-26-05 Fax 0 617-727-7749 v�w.�,ass.g¢vl�dia TH OF f.MEW ICIANS ISSUES THE. -FOLLOWING .11EN'SE AS:: A RfG I!STERED MASTER ELECTR'I C I AN : }� �a 4 GATH ELECTRIC INC I' D0UGLA$ G GAT#. 16 I NDEPf NDENCE RD �J :PEPPE#2ELL MA 01463-1633 2166617**.A 07/3.1./t3 : 36453 4�- C��b 2 � i e— Deval L. Patrick Andreavernor J. Cabral Secretary —n i�f i✓ i s i TO: Local Building Inspector Local Disability Commission Independent Living Center FROM: ARCHITECTURAL ACCESS BOARD RE: Mixed Use Building 22-24 Main Street North Andover Date: 12/5/2013 Docket Number V 13 Enclosed please find the following material regarding the above location: Application for Variance Notice of Hearing Letter of Meeting _ZDecision of the Board Correspondence The purpose of this memo is to advise you of action taken or to be taken by this Board. If you have any information which may assist the Board in reaching a decision in this case, you may call this office or you may submit comments in writing. Thomas G. Gatzunis, P.E. Commissioner Thomas P. Hopkins Director. 309 J /. .�✓ 1. -✓�!✓ s'�1 /�/JJ-�/�J •Patrick Governor Cabrallee Andrea J. Secretary 6 f NOTICE OF ACTION Thomas G. Gatzunis, P.E. Commissioner Thomas P. Hopkins Director. Docket Number V 13 309 RE: Mixed Use Building, 22-24 Main Street North Andover 1. A request for a variance was filed with the Board by Amalia McCaffrey (Applicant) on November 13, 2013 The applicant has requested variances from the following sections of the 06 Rules and Regulations of.the Board: Section: Description: 20.1 Petitioner seeks relief from having to provide a ramped entry. The Board has been notified by the Northeast Independent Living Program that a ramp previously served the building and has been removed. 2. The application was heard by the Board as an incoming case on Monday, December 2, 2013 3. After reviewing all materials submitted to the Board, the Board voted as follows: DENY: the variance to Section 20.1 as proposed in the application submitted, for the reason that'impracticability (see definitions of impracticability in Section 5 of 521 CMR) has not been proven in this case. The Board further voted that additional information about the building be provided. Spending values on permits and descriptions of work, business use histories for the various tenant spaces in the building. Please provide this material no later than December 13, 2013, so that the Board can review at its December 16, 2013 meeting. PLEASE NOTE: All documentation (written and visual) verifvinq that the conditions of the variance have been met must be submitted to the AAB Office as soon as the required work is completed. Any person aggrieved by the above decision may request an adjudicatory hearing before the Board within 30 days of receipt of this decision by filing the attached request for an adjudicatory hearing. If after 30 days, a request for an adjudicatory hearing is not received, the above decision becomes a final decision and the appeal process is through Superior Court. Date: December 5, 2013 cc: Local Disability Commission Local Building Inspector Independent Living Center Chairperson ARCHITECTURAL ACCESS BOARD I �e Comraonw' e'a�� o Massachusetts �.. Dei of Pubfic Safe Docket Number Architectural Access Boar. One Ashburton -Place, Room 1310 (Office Use Only) ='- Boston. Massachusetts 02108-1618. Phone: 617-727-0660 Fax: 617-727-0665 w .mass.gov/dps REQUEST FOR ADJUDICATORY SEA JNcG I Name and address of building as appearing on: application for variance I, 7 do hereby request that the Architectural Access Board conduct an informal Adjudicatory Hearing in accordance with the provisions of 801 CMR Rule 1.02 et. seq. as I am aggrieved by the decision of the Board with respect to Section(s) _ of the Rules and Regulations of the Architectural Access Board, 521 CMR. I understand that I nday -request such a hearing within thirty (30) days of receipt of the Notice of Act ior Date: PLEASE PRINT Signature Name Address City/Town E-mail State Zip Cute Telephone PLEASE NOTE: This form must be received by the IDmar d within thit-t� (30) day§ after receipt of the Nofice of Action. Rev, 01/10 This certifies that ...... has permission to perform ../.��. S-t- ......... _ . . plumbing in the buildings off . .? --/..?�.: , 1.4e........... at .. •..... . ,North Andoer, Mass. Fee , // -�O.. Lic. No./. /.(c, PLUMBING INSPECTOR) Check # q P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _I MA DATE ��Gvi3 ( PERMIT # JOBSITE ADDRESS S"-' OWNER'S NAME ¢. OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 NEW: J�f RENOVATION: B- REPLACEMENT: 0 FIXTURES -1 FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES _ WATER APING OTHER RESIDENTIAL 0 PLANS SUBMITTED: YES Eq NO E] 10 1 11 1 12 1 13 1 14 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES FT'NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Di BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER D, AGENT I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j- rJ Zl PLUMBER'S NAME iw �L�1s9ty LICENSE # i SIGNATURE MP ZI*" JP EII CORPORATION 01 #PARTNERSHIP [-jl# j LLC COMPANY NAME 6V_ I ADDRESS CITY -..._...__i STATE ZIP D/�%� �il TEL FAX CELL - �j}/� EMAIL �m�gyAl ._..._ _..._.� .__. _ lass H °z z 0 F U W a � r w o� z o w � W o W a a* z a 5 o a wco o W co a �t p z a a J a N w EE w I-- w Un H O z 0 F U W a z z a a a ' M h P The Commonwealth of Massachusetts Department ofIndusfrlglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/ilia Workers' Compensation. Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationgndividual): Address: CRY/State/Zip: Phone #: l('��'� ��r� -956 Are you an employer? Check the appropriate box: Type of project (required): 1. i-� 1 am a employer with Z 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2111 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ? 7. E] Remodeling ship and'have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. g• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c.152, § 1 (4), and we have no 12.❑Roofrepairs insurance required.] i employees. [No workers'. 13.❑Other comp. insurance required] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie 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 thepolicy and job site information. Insurance Company Name: - Policy # or S elf -ins. Lic. #: Expiration Date: lob Site Address: City/State/Zip: Attach a, copy of the workers' compensation policy ileclaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido Hereby certlo under the pains andpenaldes ofperjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Phone #: JO 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 ofhire,• express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and Phone number(s) along with their certificates) 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 LL C 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 ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to Co 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 -P-lease be sure that -the affidavit is-completo-andprintecl Iegibly- TheDepartmeiit has ptovided 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/licensa applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) 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 maybe 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 Com onwEalthofmasswahv.:setis De.partmextt ofJudustdal .A,ccldo-ats oNce Q Ing esii a iQ.�ns 690 Wasbi gtou Strut Boston, MA 0211I Tel, # 617-727-4900 at4Qlz ox 1;-877 MASSAFM Revised 5-26-05 Fax# 617-727-7749 IN COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: KEVIN M CASHMAN I 299 WESTFORD RD TYNGSBORO MA 01879-2410 12455 05/01/14 183753 Location 3 A N - yss r) 00 Date b `/ No. �. M MORTM TOWN OF NORTH ANDOVER Certificate of Occupancy $ swcNust<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee C �r $ / �� TOTAL $ Check # 1, '1745 NI 4 ((JAA�_ Fuilding nspector •% COMMONWEALTH OFMASSACHUSETTS Date a" 6U TOWN OF NORTHANDOVER 27 CHARLES ST APPLICA TION FORCERTIFICATE OF INSPECTION ( Fee Required (Amount)' () No Fee Required Accordance with the provisions of the Massachusetts State Building code, Section 108,15, I hereby apply fo; Certificate of InTectien for -the below -named premises -located -at -the faowing-address: Street and l ll Number `SL Name of Premises_ Sy k-lwyJ &o- c&— V e- t D IM eN Purpose for which Premises is Used ix-� S c (-� c►� Licenses (s) or Permit -(s) Required for -t -he Premisesby-Other-Governmental Agencies: License or Permit Ay_enc Certificate to be issued to Address Sia W Qe U e�W12c. ► LZ. L Telephone (9 7 F'116- S`�Ydo Owner of Record of Building Address -4 �, - o �� i� r<odA Name of Present Holder of Certificate S L Name of Agency, if any L L C, dLicwz l i i rSIGNATURE OF PERSONS TO WHOM CERTIFICATE TITLE lqa -11-1; e-1 IS ISSUED OR HIS A-UTHOIRIZED AGENT �7 DATE INSTRUCTIONS: 1) Make check payable to: Town of North Andover 2) Return this application with your check to RuildinkDept 27 Charles Street, North Andover MA 01845 PLEASE NOTE: Application form with accompanying FEE must be submitted for each building or structure or part thereof to be cert 3) Application and jee must be received befor-e -the certlf4cate will -be issued. 4) The building officials shall be notified within ten (10) days of any change in the above information. CERTIFICATE # r f�� C _ C� EXPIRATION DATE: FOPM SBCC-3-74 REVfSEB 2f99Lpne 0 TOWN OF NORTH ANDOVER INSPECTOR'S NAME y` OFFICE OF THE INSPECTOR OF BUILDINGS MICHAEL MCGUIRE INSPECT11ONitEPORT fORM CLASSIFICATION// // PASSES INSPECTION yes 0 no 0 DATED OWNER S U %�T U n.� "2 v- C/ -e --),e l -,o m `e v A- G., C BUILDING NAME OR -NO. o? oZ - d y /l'9/4 /V S 1 - STREET LOCATION S a �. TYPE OF OCCUPANCY ._ -Day -Gam-Center - kid. -0 -Cafe -0 Gym -0 .Apt. -0 /,V,5 -71-)e v c 71-/ o ^/ School Common Victualer's 0 Liquor 0 Place of Assembly U Other OCCUPANCY NUMBER-Onclude-stories -# -and-occupancy-ywAoor - use -reverse -side EXIST SIGN LIGHTED EXIT SIGNS EMERGENCY LIGHTING SYSTE M SPRINKLER SYSTEM SMOKE DETECTOR FIRE ALARM SYSTEM ANSUL SYSTEM FIRE ALARM SYSTEM -operable operable operable 0 operable expiration -date dry cell 0 wet cell 0 gage pressure operable 0 municipal 0 ELECTRIC EQUIPMENT PROPERLY PROTECTED EGRESSES LAWFULLY -DESIGNATE unobstructed `0 MAIM to XoZ.S= 70d � � STAIRS PROPERLY RAILED o 2 L - Re�r HALLS AND STAIRWAYS LIGHTED SO -4 - 1 4 y C 'L7- RADIATOR .'RADIATOR GUARDS Fey+ 1 14 Y t Z= / � � 8 COMPLIES HANDICAPPED PERSONS LAWS FIRE RESISTANT CURTAINS OR DRAPERIES HOW HEATED BOILER ROOM CONDITION VENTILATION S2. azo=y'7- (. EXISTINGS yes .0 no 0 yes 0 no -0' yes -B— no -yes yes 0 no --B' yes 0 no 0 yes 11-- no 0 -yes eo 0 yes 4r no 0 yes 'Ir no 0 yes 0 no 0 f fires -D -no -0 FIREPLACES yes 0 no UTILITY ROOM - CLOSETS JJ NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS ��� Ar— NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STORY SHOPS FOR INSPECTOR USE ONLY Revised 2199 JMC 5 'o A cD V Cn O o C7CLm :. 4P6 rn r) 0 3 O O O l< 30 rn z z lb o 0-0 'n 0-0 � 0 CL n Orn EnoO _ rn V, �° O ct 3 0 2- N D rn (n 0 V) D 0 CL - n Dm cH O rt O -h a O 3 V , 3 n 3 D rt CT a n = C 00 p Vf � < C cin [D [D `G m ca r I C O =rN C 3CL m a fD m CA C e cn O O 4fD 3 rt =r V) (D (DD o rt cn Q Fn < Cj) 0 (D U) o °�' oCD o v o 0..i CD 0 MM. z �fD O O a 0 a"' co coo)o as A)ir rDz r. m DC( o O O n X y N cD y :3 O a cc a _ �c 3 cr coCD -n s cnO 0+ m C G O tD 0 rn rt "0 CD Ln r 0 o m x n °o °O � 3 0 a• � v v 0 ai n n O C7CLm rn r) 70 O O n �' z z (np =r rn EnoO _ rn V, �° O (13 2- z D rn (n 0 V) D 0 CL o n Dm cH O rt O z O V , Lq rt N To: North Andover Building Inspector From: Atty. Scott L. Masse Date: July 14, 2004 Re: Sutton Redevelopment, LLC 22 Main Street 2„ d Floor Approx. 1,350 Sf+/- Request for an occupancy certificate is hereby made for the 2nd floor of 22- 24 Main Street formerly occupied by Curves for Women and under agreement to Lease to Ms. Charlene Tommasino, Ms. Martha Marsh, and Mr. Michael Laroque d/b/a as an Auto School. The registry has already approved the location. Per the registry requirement please include the number of occupants allowed on the certificate. The property went through site -plan review in July of 2001. No alterations are required. Thank you 06/30/2004 10:58 603-474-2432 MAILBOXES ETC PAGE 02 C. Classroom Facility All licensed driving schools will maintain or have access to ai least one classroom facility which can be adjacent to the business office or in a separate location and will; L Be housed in a permanent building at a fixed location with a legal business address and be completely (visually and physically) separated fi:om any outer buskiess, office or residence and be readily accessible by a separate public entrance so that a classroom session is not disturbed. If the classroom and office are adjacent, they must have floor to ceiling partitions with operational doors to separate thein. 2. Comply with all state and local zoning, building and occupancy requirements including the legal ,requirements regarding accessability by persons with disabilities ( if applicable ) and conspicuously display a current, local occupancy permit, 3.Be clean and suitable for conducting classes, be readily accessible to the general public and have convenient access to public zestroorn facilities. 4. Provide accommodations for not less than ten nor more than forty students at a time. The maxim= students accorzmodated will be based on the amount of floor space -(The Dept. of Education norm is 10 square feet/student and 20 square feet per instructor) !Mote, however, that one or more students can cozistitute a class! 5. Display a sign, door lettering or other permanent printed identification, plainly visible from the street, sidewalk or a public building lobby. unless it is located in a public school classroom.- 6. lassroom; 6. Classrooms shall have the following equipment as a mi�7.imum; ondividual desks and chairs for at least 10 students_ b. A desk, chair and podium (if practical) for the instructor(s). V c. An overhead projector and screen or blackboardwb_iteboard of an adequatesize to supplement or emphasize various lesson subjects. d. A color TV of adequate size to be easily viewed by all students in the r m e. A VCR attached to the above TV for viewing supplemental instructional videos. Date /1�- : 1. !. -. `.'. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...f ./'. (. j".'. �. has permission to perform .... I : �. �......................... plumbing in the buildings of ' `................. at ..� . L...:t:.... !......`'f ............... . North Andover, Mass. 1 r F.ee ..�` .... Lic. No.. S.. �. ' .. ...... - ..1.: - _.. t ._........ . PLUMBING INSPECTOR Check # t r s 5771 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING n\ (Print or Type) , ^ / .Mass. Dated 0�8 03 Permit�On Building Location a /'/1 �Sf / Owner's Name,4�)Z uP� ryt �'�� l Type of Occupancy Residential 4 New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name Heritage Htg . &Plg . Co. Inc. Address_ 35 Pleasant Street Stoneham, Ma 02180 Business Telephone • 781 —43 8-77 76 Name of Licensed Plumber Gordon Switzer Check one: Certificate EX Corporation 714 O Partnership n Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checkedrtes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy M Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. BySig ���ature o�censeclum Plumber Title Type of License: Master [X Journeyman ❑ City/Town 8322 APP O ) License Number. �i Z x 't7 to N O Z F W O (rj W W N J J N Y a V Q H Z Z _+ 7 O C7 Z d O— 0 Q Z Z W W Q ¢ F W N Cr F- 2 rt U N X - a to 0. W — �. Z a— 4,9 rt} rti 3-I w Z ¢ z O to F" ¢ to W w O Y O F- to a y Z X O a LL h U> 3 O= d ; _ Y N F Z a O p F' O y Z z w w w ~ O t> rrll a F �' w a o J a¢¢ a a o a a Y J a W z N O O a J a x ti to J LL O a Q L. w gig 3 3 to SUB-BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOG 8TH FLOOR Installing Company Name Heritage Htg . &Plg . Co. Inc. Address_ 35 Pleasant Street Stoneham, Ma 02180 Business Telephone • 781 —43 8-77 76 Name of Licensed Plumber Gordon Switzer Check one: Certificate EX Corporation 714 O Partnership n Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checkedrtes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy M Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. BySig ���ature o�censeclum Plumber Title Type of License: Master [X Journeyman ❑ City/Town 8322 APP O ) License Number. N Z O H U W 6 N Z N N W C7 O Z O W N W v LL LL O ° z O LL 3 O J W m W W LL N W V W Y F N N Z O F - v W a N z J Q Z LL �1 xI W m 2 \ NpRT► TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....'4 ........,.... r✓ ?.4: 7-- . ........................................ has permission to perform .......� wiring in the building of ...:........t(. n ........................... c� 1 at ..: ....:..i ...... 0141.` ....0 ................ 4North Andover, Mass'. Fee IS.:. �...... Lic. No�...�Sh� ....�!.........� �." .. .................... f �fELECTRICALINSPECTOR L1 Check # / 6)8 7 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer - 7HE00MIlONWF4LTHOFMASS4C IUSE77S Office Use onnlLly� % le— DEPARTAMAITOMBLICSAFM Permit No. BOARD 0FFIREPREVEMI0NRWM4TI0I N527CMR120 40AAPPUCATION Occupancy &Fees Checked FOR PERMIT TO PIMORM ELECRICAL 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) Dat4thel cTown of North Andover Tcto of W fires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Z Z - 2 y Owner or Tenant d- 4�SG Owner's Address PU /50-x- S� F o 0 • 14 Is this permit in conjunction with a building permit: Yes E] No r7 (Check Appropriate Box) Purpose of Building Existing Service _ New ServiceG/: Amps/,�o / �cyo Volts Overhead r_1 Underground Number of Feeders and Ampacity ility Authorization No: O 1 / %6 7 -No. of Meters No. of Meters Location and Nature of Proposed Electrical Work` �_So a . f /std/c.� QlK r i ��� - Ft Z caL, No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 1:1ound 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 No. of Self Contained Detection/Sounding Devices LocalMunicipal Other 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 oTI IER . CJ i% } !�✓ 7-�.�.uJ, hua=Core� Lam Ihmeawmrt di*hsLm=Pd yaldmgCm#kt ('" xWcritsskshmalegivalat YES NO IhmmhnftdNdidp1UdCfMne1o1heOffi= YES M NO ff}puha%eduiWYES,pleaseadicatethetypeefwmaWbydr"igthe M ----BOND p OTHER p (Pl =Spedfy) Fstm&d Vahted BecWW Weds $ WaktoStut InspadunDaleRaWesled Ro# Fetal Signed uxlaTr %uhn ofpajuy: /J / FIRM NAME _ ' 1 b e- - 4 1 4�2 ti e r LioaWNO. Limme 1414 -� P, me, " Z i'� Sigtone — Li=wls o % S- -� 3 TlZ BukxssTdNa l ;7,r - l • / -r-y- ;t A&km /ilG k Y R. 1U6 /? v, cQ d n dr/I /4 Al<TVl OWNER'SIIg6URANCEWAIVER;IamawatetbatlheLiomdmnot teitsuaioeoot eerAssubt>tas#ialeglivala>tasracltmadbyMassadxse�GataalLaws acrd that my sigtrahneon the permit tsar wars this tacp'"rlat (Please check one) Owner M Agent Telephone No. PERMIT FEE Ot ,,OPT" q1, O 9 �,SSACHUSE� Date. 0.. . c �- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . has permission to perform ...�.>. ........................ . plumbing in the buildings of............... . at ...� :. 1. `.� . �.r.� �!.i.° ...�?'........... , North Andover, Mass. Fee.r? .... .. Lic. No .......... ... ` t ................... . PLUMBING INSPECTOR Check # �� > 5212 a- ?" MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) E. I � 01da ,'Mass. Date Q�_ PPe�r /mitt #� /` '2— Building Building Location rn n tb,-q"t- Owner's Namel J / / /G}n 7— Type of Occupancy Residential I New [J Renovation L] Replacement Plans Submitted: Yes ❑ No ❑ - t FIXTURES' Installing Company Name Heritage Htg . &P1g . Co. Inc. Check one: Address Pleasant Street Stoneham, Ma 02180 Business Telephone _781-4 3 8- 7 7 7 6___ Name of Licensed Plumber Gordon Switzer IX Corporation Partnership n Firm/Co. Certificate 714 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, Yes V--] No l_J 11 you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy LX Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature oil this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information i have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter " of the General Laws. By Si nature olod Plumb r Title Type of License: Master lY Journeyman [] City/Town $ 3 2 2 APPROVED (OrFICE USE ONLY) License tJumber_____.___._ z In N z V x �t W I- !n J T Z p7 Q 2 Uj U. Z -{-7 -� V Z W 2 V) M (n 1: y 2 w ~ T U .t W h (n w X ': p Rf a Q fn z CC �• S '�, cr '� v (lj rti LAI 0 cc LU w zLL i 3 3 o z = X a p h Z Z d w LL Y_ i4 7-I f -r I U F- O = 2 � N F- z O O N –– W O U 41 (ll ri Q X �n N Q Q O Q J J QfL cc X Q C Q 4J 4J tr (n gig I — V U1 SUB– BSh1T. — -- -- BASEMENT IST FLOOR 2ND FLOOR aRDFLOon 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 4 8TH FLOOR Installing Company Name Heritage Htg . &P1g . Co. Inc. Check one: Address Pleasant Street Stoneham, Ma 02180 Business Telephone _781-4 3 8- 7 7 7 6___ Name of Licensed Plumber Gordon Switzer IX Corporation Partnership n Firm/Co. Certificate 714 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, Yes V--] No l_J 11 you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy LX Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature oil this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information i have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter " of the General Laws. By Si nature olod Plumb r Title Type of License: Master lY Journeyman [] City/Town $ 3 2 2 APPROVED (OrFICE USE ONLY) License tJumber_____.___._ T J z O w N LU U k LL O m O LL 3 O J w m N W U F - w Y N N z O r- 0 U W 0. N z J Q z_ LL w LU LL O z m J a O O O F f- 0 z OC O C7 w -� Z a � o m J O LL LL O fa z w LL O a O P ~ a ac U y F• w 00 W Z of a i ol I/ Location No. 1 76> Date 14001TN TOWN OF NORTH ANDOVER 0� Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I L --33S 5J /-7 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT aim - APPLICATION TO CONSTRUCT REPAIR, RENOVATE, ORCEMOLIS ONE77;O�RyTwo F ILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: / Buil in Commissioner/I for of Buildin s Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 8" loe, 13, Map Number Parcel Number / i "1 y: C3 1.3 Zoning Information: r Zoning District Proposed Use 1.4 Property Dimensions: Lot Ar sea Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RecIttired Provided R red Provided 1.7 Water S G.L.C.40. 14) 1.5. Flood Zone Information: 1.8 Sewerape,Hisposal System: Public ate ❑ Zone Outside Flood Zone Municipal f�/ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record } .�. GJL�ey e is art ce..t �, C C �� aZ'< 5FX Ak AI &O� N (Print) dress for Service ,2� '2'7 /- / s s 3 G 5 74- a e AP co gnature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3./1 Licensed Construction Supervisor: ;n L.Gc.1 i !rr �iit c.,c c 1 �Y` Licensed Construction Supervisor: '1 `( o• 4z4.&Q `(44 G/,fyf— Address co Signature Telephone Not Applicable ❑ License Number Expirati n Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (At 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 buildin rmit. —Signed affidavit Attached Yes ....... No ....... ❑ <:A_� SECTION 5 Description of Proposed Work check all a ticable New Construction ❑ Existing Building ❑ Repair(s) ❑ FAlterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS tem tem Estimated Cost (Dollar) to be Completed by permit applicant 0, _ •. 1. Buildingv t7 ..Sf J� a (a) Building P=i Fee Multiplier 2 Electrical ff 00 / © (b) Estimated Total Cost of Construction /O do 3 Plumbing S"ou S% • `"" Building Pernut fe (e X (b� 01 • �' �-W --' �o 4 Mechanical HVAC 5 Fire Protection 4. p p o • CIS+ 6 Total 1+2+3+4+5 O G Od • cC Check Number J07 SECTION 7a OWNER AUTHi3RIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,/_!! as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. —Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ��JJ 1, /-►� l'+ P �VA `s` �< C ,as/Authorized Agent of subject property wn' Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Na s d Signaturi er/A ent0 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD 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 FORM U -. LQT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT St�siz� �J ��O EU�rL�3P/����' 1-L LOCATION: Assessor's Map Number SUBDIVISION STREET OLK �t/f r.�J S; . PHONE q -7p 7 -7 // SS- 3 PARCEL 1'� / %�--- LOT (S) ST. NUMBER R - O�q *****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COMME TOWN PLANNER COM DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTION DRIVEWAY PERMIT_ Gam_ i FIRE DEPARTMENT � RECEIVED BY BUILDING INSPECTO Revised 9\97 jm /y/ TE Y J m m m m VJ 0 l - v y C � � � d CD Z ai CD o �_ d �• Cm CZ = y aC= -� o C-) o v CD cil o Q Cm CD CCD O CCD ww C O H• —• CD CZ O y = C=D I I o co CD Z O/1 a 0 CD C CD r� CrrJ cn VJ l J O cn 0 O Q VJ O O Cl) m c I m 0 c T C a?d O y m � O m y p N gym: S > > O y m "O� p O y n . m � o,m CO CL 59 dc :F O O Cl) y 'W C d ' V y O. C CL to � m � m -- m y R VJ y y OCD CD CD ..r: m n O 0 '� OCA1 m o . C.) I. :I ED V J O O W d d •� Iry d� C-) Cf o: � O � co m C/n � Cn° � 07 � ''rf p � � 0 tzEL 0 r w 1 a ON y 09 0 c CD M I I m I; z 0 X m D N E r r -i a co z D r O r � CP m cn 0 -+ m 3 O n 70 O O I i m z = I EXIST. D m I I r z 70 i I O n I i m m m I I I 12'-11/2" II I I 0 II I I I I I I I I 0 i I i I z I c EXIST. i 70 II I z I I � -i m I t Ox I 28x0 t zm I I �D I z m I I -i I -i F= C) I I O= I 70 1 ---�- T n 0 I I I }--J 70 COmZ m O I m r 0 � 70 I -0 2B x V 9'-9 1/4" mnm Ozn r----1 -J-- JI D n -i I I 70 m0n� moo= D O D i I 7K_ �I U) 0:1 Fco - r� I mm \ Orn ncn-� I 7U C) \jf ---- m�0 DOD_ I 3a0 O� / ( \\ 70D mcn I <D� —� _ n =_ 0< ImO� I �u�m D m Daim IFni5 I m70 �mX IZ�Z I 7C Emz 001m IC -i =T zZK z I I = -TT cn 70 M m 700 0 mm az O 0 D D I L- Q 70 n I z 7(J z3 m71) NO I C� n cn� >O 1�) mei T n Ln M O , z I j 7Oo r- > L� O iV O z z m 2'-0'I I I mD nE m I � 1-3 rr �I nn = Z m (D x I mDX nI � I I I I � I m ti 20 O I O I O I I I � I I - I I I m TI I I X i II I I 7-1 I mrP n -0 1O 70 00 If 1 I x �c0 N m I Mm M I -I 70 70 70 D Wim= d I I np� _s 70 <- J�, any/ Dm0 � < S zOm Co 70 �• m o m >CRAMN6 TITLE: AI-GkITEGT: D < PROP05ED THIRD cn STAIR RENOVATION GSD ASSOCIATES o 2530 MAIN ST. FLOOR RENOVATION 148 MAIN STREET, BLDG. "A" a NORTH ANDOVER, MA N. ANDOVER, MA 01845 N D • TEL: (976) 688-5422 m FAX: (978) 688-5717 y A +� No 3 Date.�.......' - /C:,- - — -- - / ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............................................................. .............................. has permission to perform ................................... wiring in the building of .... ................................................................... at ............... Ad , - .................................................................. . North Andover, Mass. Fee ..................... Lic. NOIP,21:.':% ............................................................... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer S- Uttice Use only DLPARTAfEW0FPVBL1C&4FM Permit No. c3� BOARDOFMEPREYEMONREGUlATIOASS27CMR1Z-W77Occupancy &Fees Checked APPLICATIONFOR PERMIT TO PERFORMELEC"lRICAL 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) Dat Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)C, fl -t -- Owner or Tenant S &,,.t ,Qo!? Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building d T4 I1� .f- A -C s 1.ckc �� ^� Utility Authorization No. Existing Service r() Amps / Ly olts Overhead r7 Underground Q No. of Meters New Service Amps Volts Overhead [--I Underground Q No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. ofTransfonners Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground eround 1,10of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets J 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 No. of Self Contained Detection/Sounding Devices Local Municipal Other 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 C CA— f /cX !al t; t1 £.t +e& , S r, r. /T, Ittstr�ioeCove� Pt>isUal�bthetegl>aarta�s�M�d>�c�alealL;�ws Iha%eaam=tLmbiTdyhmm=PoLyarhtdmgCa><>p*ktteCo► earitsstdfliV lart YES E] NO E] IhavestbnadvAidptcdofsmwlo eO(fm YES NO [--J Wymha%edwdWYES,plmeitdc&theWcfw&aWIrydcdmgthe aMLV bit. wsuRAN E o x 0 (Plt spears) ovt �, l� WaktoStatt >/ /J /a .� k D,* Sided ulxiaTie l?�lalhes FIRMNAME EVita6mDde Estc� VahledE7 &%nl wak $ Rough Fatal LiartseNa / S. 3 T �� BusamTel.Na .i--sDT, Ca A3 /„5ct!, qGC6. rit/v . AltTVl OWNER'S PgRJRANCEWAIVER;I.amawatethatlheLioe doesmtt theittsiraneoowm8pa-GsslbWKtale:haldtasm*medbyMamdxsMCanal Laws andthatmysag�taeonthis pacnii�wai�slhls tacgmsna�. (Please check one) Owner Agent Telephone No. PERMIT FEE $ ��. 'a N2 3 4 ' Date .... �" ./ v TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... 4. /......... Cc� r�. !. .r........ . `�............................ has permission to perform . rer/!4 r��,i..../- / ��� �' �I L ........... .... ............................. wiring in the building of o at .... ........9.4. .... 04P,..4 .... ,7..... -..... ,North Andov �M`�a/�s�� Fee.... !�� I� �T X40 � ...'.A �. Lic. No�t.Pl...3<......... .�..,e ....... .................. ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer o%in���ir[cl� U!'NUIfLI(..�li'L'!Y Permit No. BOARD OFMEPREMMONREGM7YOAN527CMR IZO OVAPPUCATIONFOR Occupancy & Fees t ! ecl. PERMIT TO PEUORMELECTRMCAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL. INFORMATION) Dat >�Jjr Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Z Z — Z y Owner or Tenant —S --4.1u&-/ AQ Z�� v-eQo r, LLr- Owner's Address An At,& s l-(. A- b . 0"OGrr4l Is this permit in conjunction with a building permit: Yes[:] No M' (Check Appropriate Box) Purpose rp g�/t�"Utility Authorization No. Existing Service �/ O Amps 24 / a4volts Overhead nderground New Service Amps/olts Overhead M Underground Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Fixtures No. of Receptacle Outlets No. of Switch Outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters KW No. Hydro Massage Tubs OTHER. J4jet? %r•r e G ifw'�S e Swimming Pool Above ❑ ground No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons No. of Heat Pumps Total Tons Space Area Heating - Heating Devices No. of Signs No. of Bailasis No. of Motors Total HP Generators No. of Meters No. of Meters �— Battery FIRE ALARMS Total No. of Detection and KW Initiating Devices KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW Local r --J Municipal Connections KV s ci-a /) �;) of Zones ID Othe' fi rar=Co R>,s 3tbttleleWWTXlt$dMwaftsWsGanWLaws Ita%eaamettLmbkyhstrmmPchyarh&gC Co►aaWori1s9ksbraleWhdait YES NO Ita%es hnftdm&poofofsame1oftOlTi= YES MNOj�f If}mhmedvdWYES pimead c* tteiypealwmaWbycfladrgir bcpL MURANCE r7 BOND M O HR M ftweSpeafy) B*AmD* �0wD&Req0ded EWn�dVaitleot?axft ralWdkWaktoStatt hspedRho-- Finalfpe� !l �., FtRMNAME ii U J >. � � Lio3seNo Blsk=TdNa A d&m Ad IkK ��Or-ep AlTdNa OWNER'SII,SURANCEWAIVFR;Iamawart:ihatlteT dMniIj tllealslxano W mol S*AytalqmiataslalltmWbyM ""Ca>eralLaws afld�ttllyrnthis pet�ttialwai�s�lequagnel>t (Please check one) Owner M Agent a Telephone No. PERMIT FEE