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HomeMy WebLinkAboutMiscellaneous - 220 PLEASANT STREET 4/30/2018 220 PLEASANT STREET 210/085.0-0002-0000.0 I Date W. • • -.{ILriA y yw...........fro';..... TOWN OF NORTH ANDOVER } PERMIT FOR WIRING J rl This certifies that . . N-\/\✓�5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . 3 .< ,- � . . . . . . . . . . . . . . . . wiring in the building of . . . . .. i` "I. . . . . . . . . . . . . . . . . . . . ... at . . . 2 °�?' '. . : . , N h Andover, Mass. ;141-�'-' 3Fee NoM�. . . . .Li �� � . . . . . . . . . . . . . . . ELECTRICAL INSPECTOR Check# 1 `i 3 0 2 �- �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 filed 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 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 acttrrity,and may be.deemed.by-theJnspector_of_Wires abandoned.and.imv.alidifhe.—__. ._ or she has determined that the authorized work has not commenced or hent 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 entitystated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 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-tern economic recovery and the Permit Extension Act furthers 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. ule 8—Permit/Date Closed: Z J000 Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: I V. ` Commonwealth of Massachusetts Official Use Only Permit No. �2"' Department of Fire Services � � � p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 12-1' City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her inttee-n�'on to perform the electrical work described below. Location(Street&Number) Owner or Tenant ���(/ ' G96 Telephone No. 5�;7,5�-dv/l7/77 Owner's Address 4 Is this permit in conjunction with a building permit? Yes ❑ No/,o (Check Appropriate Box) Purpose of Building jZ s- Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 4, Completion of the following table may be waived by the Inspector of Wires. j ranNo.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Ts Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. 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. TotalTons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons K No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Connle t oln ❑ Other NO No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or E uivalent No.of Water KW No.of No.of Data Beaters Signs - Ballasts No.of Devices or Equivalent o' Telecommunications WirngNo.Hydromassage Bathtubs No.of Motors Total HP . No.of Devices or E uivalent � OTHER: __,1 �X3 Attach additional detail if desired or as required by the Inspector of Jnres. ►V Estimated Value of Electrical Work: `Sl' (When required by municipal policy.) Work to Start: rZ 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 N the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,un der the pains nd penalties ofperjury,that the information on this application is true and complete. FIRM NAME: , l� S �7Z7 LIC.NO.: , �3 Licensee: / �'�.,C�� Signature LIC.NO.:�C��3el= (If applicable,enter "exempt":n a license number line.) Bus.Tel.No.:���9k3/?3 Address: a <— , ..,, <e" - Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee,does not have the liability insurance coverage normally required by law. By my signature below-1 re by waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agents �/ �� Signature — TelephoneNo.,2 >� 3 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 filed 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 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 Chapter 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 Act furthers 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($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: n r Date: FINAL INSPECTION: 1' Tf `" I Pass 0 avic� ed �Uc� C �s spection Required($.)❑ Inspectors Comments: Lt, fJxx�: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC.MA. .......dweinhold(a.townofinerrimac.com Y ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I * have hired the sub-contractors P 6. ❑New construction P1 employees(full and/or part-time). 2. am a sole proprietor or partner- listed on the attached sheet.$ 7• ❑Remodeling ship and have no employees These sub-contractors have 8. E]Demolition workingfor me in an capacity. workers'comp.insurance. 9 y p ty F1 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l 1.❑Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' comp.insurance required.] 13.FAOther =�-zr �� Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Iformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: V :)b Site Address: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do hereby certify under the pains nd penalties of perjury that the information provided above is true and correct. ignature• l�—/� � - Date: ,lone#: 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute an employee is defined as' ...eve ry person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants • Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if E necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. r Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax#617-727-7749 4 ,, Date . . 11-z. . . . . . . . . . . . KrLrn J2. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that �!' .'.!: . . . . . . . . has permission for gas-iiistallatio � . . . . . . . . . . . . . . in the buildings of. �.Il 'r. . at . �. . . . . . . North A1,40ver, Mass. � � ^ Fee . . . . . . . . . Lic. No. . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTO Check# 1%q 1 10 8434 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYT MA DATE . _..__.._J�PERMIT# JOBSITE ADDRESS 'O"�f �cC._..CO's.___._- OWNER'S NAME (_ '�' _......... . .... OWNER ADDRESS TEq� 717 7. FAX , TPRINT OCCUPANCY TYPE COMMERCIAL. EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION:V] REPLACEMENT:0 PLANS SUBMITTED: ?ESO NO[ APPLIANCES 7 FLOORS- BSM 1 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BOILER =1= _ _.._1 1E _. 1 _�_I _ J —_ J I . l Er BOOSTER 7.-=._I ... f C -1 .CONVERSION BURNER 1 .._ 1 1 I 1 J � 41 1 COOK STOVE I ( --j l DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE s--J GENERATORJ . GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER 1 -- J 1[_ _[ _ J .__ ( ,.__ .....,. ► J . . __I J ROOF TOP UNIT TEST ::.I( ._ >I -.I _._ -.1 I _...-1 UNIT HEATER UNVENTED ROOM HEATER ! i _ I[� 1�T I __.( 4( �, f I,� f(.,� i ��► ~i(^��{ 1 I WATER WATER___. � OTHER --~-- — a—I -- J FI INSURANCE COVERAGE I have a current lia_ bility Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO E 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY UA BOND [j] 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 -0AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tot best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be In compliance all Pertl nt provislon of the Massachusetts State Plumbing Code and Chapter s1-422 of the General Laws, PLUMBER-GASFITTER NAMEAt5pvl Twrv � j LICENSE# r�� -.. SIGNATURE MP . MGF E-JI JP 0 JGF _v. LPGI --� - L [�] CORPORATION # PARTN RSHIP G�# _ LLC COMPANY NAME:. P` `T� P `" S l[_C JADDRESS L3. .- }�� � .-°....: _ �'�'� CITY (/1�.. ..._ ..... .� _I� STATE ZIP -��TEL ....... ......' `� —1 =...__..I w FAX — CELL EMAIL7S*04—�,� lc�.S�.of�'`GT� __ r r "�O r . ���h��8 u�� �� G��rrt� �� �/�'�� G��� V ! The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �"t ��' v1. t" 10 t eJ 1 L Address: ISrbc A City/State/Zip:_ �/l��� �. AU W7 Phone 4: &tg 1ooa- Are you an employer?Check the appropriate box: Type of project(required): 1 1 am a employer with O 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ? modeling 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.) officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 1311 Other kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. rsurance Company Name: :)licy#or Self-ins.Lic.#: Expiration Date: ib Site Address: City/State/Zip: ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certify t r t ie sins Jndnnaltiesof�perjury�thatthermation provided above is true and correct. nature: Date: Lone, 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: t. 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 or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of:Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727.4900 ext 406 or 1-877-MASSAFE Fax#617-727--7749 evised 5-26-05 `xnxrov mace vnv/ilia 1 'COMMONWEALTH OF MASSACHUSETTS. LICENSED AS A MASTER PLUMBER: ;. ISSUES THE ABOVE LICENSE TO: J l' SON W THOMAS s 13 JACKMAN RIDGE RD WINDH.AM NH 03087-1670 \ . 10315 05/01/14 162624 GENERATOR APPLICATION DATE: LOCATION: V OWNERS NAME: kvy-,.p Tkjwvv GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: 'f-f A- -2 ✓� / s�spS l�� ✓ PHONE NUMBER: ELECTRIC L GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL--ll U - L,-,) V�,, c o D, RECEIVED Claim # 2160002 �4V C5 2(112 Advantage Claim Services Adjuster Assigned: Glenn O N©RTH HEALT ANDOVER 522 Chickering Road #B H DEPARTMENT North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health d Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA 01845 Re: Insured: Michael J. Flynn Property address: 220 Pleasant St. North Andover, MA 01845 Policy #: 2160002 Loss of: 2012/10/29 File or Claim No. AD 9769 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000.00 or cause Mass. Gen. Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. �& 11 10-31-12 Signature and date Claim # 2160002 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner M Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA 01845 Re: Insured: Michael J. Flynn Property address: 220 Pleasant St. North Andover, MA 01845 Policy #: 2160002 Loss of: 2012/10/29 File or Claim No. AD 9769 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000.00 or cause Mass._Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. �4� 10-31-12 Signature and date s { Sao asAN� S - S_ Location ` No. .� Date - oZ d U 0 3 MORTM TOWN OF NORTH ANDOVER F 9 • ; ; Certificate of Occupancy $ cMusE Building/Frame Permit Fee $ Foundation Permit Fee $ 1 Other Permit Fee $ TOTAL $ Check # 6 31, /17iLf� -�-- Building Inspector _ s TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T#li% 1 Farr�1, 1 USC BUILDING PERMIT NUMBER: �j DATE ISSUED: a 3 v� SIGNATURE: Building Commissioner/I for of B-uildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided v 1.7 Water Supply M.GL.C.40.11 54) 1.5. Flood Zone Inforuntion: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2 1 Owner of Record X ��o (���s�, J S+ Name Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable icented Construction Supervisor: O 1 License Number Addr4ss Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name m Registration Number r Address r Z Expiration Date ^ Signature Telephone YI e SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all a licable New Construction ❑ Existing Building ❑ Repair(s) 11Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ,AI /f X Z 1�eck ,� n l4J : c SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee ®® Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) � 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO 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. I 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 Si ature of Owner/A ent Date I NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHMINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. **************ff*************I**APPLIICANT FILLS OUT THIS SECTION*********************** APPLICANT I� IG�GQ� 1 I �U r1 PHONE�11a`j�"���( LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET 'Y�-(D ST. NUMBER ************************************OFFICIAL USE ONLY******************** ************* ECO ENDATIONS OFT WN AGENTS: CONSERVATION ADMINISTRA R DATE APPROVED �- DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWEfl/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm .SSE v�o ,co,e E-9S��nEv r,T 1 LOT /9R&-19 iz,yoo sF � V Gia. h 0 w FSG 4- 8,5,A91--1 7- 8,5,A9NT ST.65&-7- I HNRBBY CXRTIFY 710 rM TITLE INSUROR AND PL 0 T PLAN rO FWW BANK THAT TM DSSLUNG IS LOCAM ON JN ME LOT AS SHOIN AND 7tIAr Ir DOES coNFORM IIIrH MR row/ 011` .l9NDovN2 BONING REGULATIONS /'10127-H 191-14)OVEt2� RRammmG STBA FROM SrRERTS A; Lor LIN1�S." " I PURTH1sR R I . MAF MIS DIELUM0 IS Nor LOCAM INT RAL FLOOD IIAYrIRD AMU AS DRA R'N FOR SHOIIN ON Fa` ITY/.PANEL ZSG6gg 93� M/C N19CL , -z srsPHg sr r sxl, -kL.S. DArE /11= 30, JAN ZfX�3 THIS PLAN FOR MOhWACB PURPOSES - NOV FOR , Boummr DErRRMINArION. BOUNDARY INFORMArION yEMMACK RNGINRRRIA r. SRRVICRS TAKEN FROM EXISTING noftS, . BB PARK STREET ANDOVER, MASSACHUSETTS 01810 QL ---------- . f a f t _ .._�:,...,,..•.,.:.a~u'.v+u .. .... .,..,.,. ,_,..,. uwo.w, „w r»a s oKuww,.x., 1,S � y ,. e°r "•'^�u +sr�p.ww.:nsa�rm..,a .mMa�.-•�..,:ra>.ys:n�.m tg R .gra_...w..�...........,._.-.�.._-w,..e,vc�� f i 71 ------------------ � � � w"•»raw.aww _vu�c,,.s.w•mc:.ee1>`��_�u`� y..•�"W'+_..u..vwn �. � �}i � j. `..�v }W ' t i f tkORT{i q o s Town of North Andover Building Department '` ' • °'� 27 Charles Street �SSAc►+USE��� North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE lu ' 0 JOB LOCATION 7,71() q ��a,-G aux <�_� i Number Street Address C) Section of Town` "HOMEOWNER V�I��Q Cllr) —G \ l I t�{� Number Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official, a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner"certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and r uirements. HOMEOWNER'S SIGNATURE 1 APPROVAL OF BUILDING OFFICIAL Note:Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A., The debris will be disposed of in: S� ,, G.M cX J - t\,V1 (Location of F cilit ) Sign Jure /) to f Permit Applicant t o10 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector IN ' " E 0 Town of over No. LA dower, 0 C CHIC A Mass., S-70-A 0 ATED C5 H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT..... .V.I CIA 19 0 F V A.0 BUILDING INSPECTOR !Jf)g--'4**---'*'..... ....** ..... ................................................................................... Foundation has permission to erect.. ......*0........ buildings on ....... ;#.0 ......V..................... Rough to be occupied as... MCK -0.111% 1%*&V% 0C D&W,0111 Chimney ....................... provided that the person accepting chis permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. so.-a A 60000 PLUMBING INSPECTOR Alto VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough Service -400-- 111[,I)IING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Roug Display in a Conspicuous Place on the Premises — Do Not Remove Finalh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.