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HomeMy WebLinkAboutMiscellaneous - 23 WILLIAM STREET 4/30/20180 0 0 g 0 w N O O O O O This certifies that .. �� - /T has permission for gas installation .. . ................... in the buildings of. ...... atC—Z�•••••••• e�-N h Andover, Mass. C Fee Lic. No. . L ........ ........... G/�SINSPECTOR 4� Check This certifies that ....�?�% ...................... . has permission to perform .... ��+1�„11% .Vol.�c�r..... . plumbing in the buildings o v- cl at .�+..��t. , No Andover, Mass. Feet/ .� .. Lic. No. .fG�-fir .. . �y jS PLUMBING INSPECTOR Check # If ` r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY e�i/�iP - � MA DATE / PERMIT # JOBSITE ADDRESS OWNER'SNAME F �eZ GOWNER - - - ADDRESS TELC _ FAX j TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL D RESIDENTIAL CLEARLY NEWT -1 RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YESF- NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER LzJ 1= L:::j E:j 1=1 . _..,I _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER Imo... FIREPLACE =1 I_. _ I)�1 LI 1 r I _ FRYOLATOR FURNACE. - GENERATOR - ._.� _ I I- r I -_ _l II --1 �-_f _ _I 1( _ I ---J GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT mT.r_ I_ __.. .__ _ - I I _ IT OVEN .. __-- P06L HEATER Iz_ . (r-,-.�. .=rl. T _ . =I _ _ .. _ _- - - - _ �I I :___,I ROOM/ SPACE HEATER ,_.:. i J �_- - _.,- -r._.- ROOF TOP UNIT TEST —j UNIT HEATER ,^ I--1 UNVENTED ROOM HEATER WATER HEATER OTHER F F11 fli INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES�[,�_.I NOD IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND�]__f 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 -01 AGENT 0 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 toeof owledge n and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P inept prooismy of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. QQ - - PLUMBER-GASFITTER NAME pyoLICENSE # 'c--_----�e-.�._1�...._SIGNATURE MP 0 MGF 0 JP �GF �( LPG] CORPORATION _� # PARTNERSHIP 0#= LLC -:I#= COMPANY NAME: _- /t�0 _ . _(/.1y1. _ . _' _ . - - _ ADDRESS F-3. 5--__._G_J'�% � o7-/�/_-L-----_.--------_..____._�._,_..-.-__� CITY _r D.v _ _._-- _-.� STATE _ ._) ZIP �¢ TEL - - ¢ - - .. ��j� FAX --- i CELL SSA � EMAIL _._d�` Z;?/ - .... [� 0 H U a w a z� zo yF1 W >- � ~ w W = ~ W 5 acn CL w W � w c a z a a a a Q to� � w S W F- LL W H O z z 0 H U W d U' C7 ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations uv�, 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: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time). * 2. ❑ have hired the sub -contractors 1 am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: °olicy # or Self -ins. Lic. #: Expiration Date: lob Site Address: City/State/Zip: attach 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 ine 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 nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. mature: Date Ufficial 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _I MA DATE ;� _ 7 PERMIT # JOBSITE ADDRESS (,lJ� 7 �%YI S �' j OWNER'S NAME�� POWNER ADDRESS _ TEL _/FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El( EDUCATIONAL RESIDENTIAL PRINT CLEARLY ,,-�/ NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOQ FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM (_..DEDICATED GRAY WATERSYSTEM S ( f _i __-.___._( I _ DEDICATED WATER RECYCLE SYSTEMDISHWASHERDRINKING rPni, FOUNTAINFOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR ( _1 __-...._I _____1 ___ 1 i __-____J KITCHEN SINK LAV1TORY J I ....-._-.- [ --J]-----j ROOF DRAIN SHOWER STALL _f---.__� ( _.__( __.__I .._..____( _..._.-__1 L__! .._ __-._( SERVICE / MOP SINK(.___.__.( F --- _I ._. _._ _ ..—_1 _____L ___j ... __.i TOILET (_--___--!-___..-.( ._—_(_-. j URINAL - (.._-- ` ( -._____.I _ .-_.J __.._. -.� ._...._.� ..__.-_.._I _......... 1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _F I OTHER L INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO]1 IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ! OTHER TYPE OF INDEMNITY i BOND 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 0 AGENT 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 Vertinent provisi4 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME „-o-CO�LICENSE # _ SIGNATURE MPO JP CORPORATION M# PARTNERSHIP 0# _ _ _... _! LLC COMPANY NAME �tjU ,,v� E ADDRESS �/ 4 CITY ISTATE3 ZIPL+ TEL FAX ���CELL _ _A!1! ..__- -� EMAIL ©!y_s-.-_ r= o� z y ❑ } Cd W LL 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: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. [] I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Of 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 "...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 Revised 5 -26 -OS www_mnss_onv/din Date. 12., .3 /.-: (Z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.... .......................... has permission to perform ... IV. ...... .......... wiring in the building of ............ A. .r ............. at ... 2 ?- 51/17 y.'6� ........ ... North Andover, Mass. Fee Lic. No. ....... ELECTRICAL V INSPECT I r Check 4 1� 33 ,4 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. /i 33l Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL I7VFORMATI0119 Date: /Z — 17/ ZZ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address _Ckl t• Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building i� /C �/f� . Utility Authorization No. + Existing Service %G o mps /yy l 2V e 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: /_� fl- « i *; ..,fA., 4-77- 4- MM. mm by wnivad by thP_ lnSD8etOr 01 WIreS. No. of Recessed Luminaires •.._ _ _ No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Bove In- g rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. etecti on and No. of Switches No. of Gas Burners Initiating atin Dvies No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW - No. of Self -Contained No. of Waste Disposers Totals: _.....__..- - Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: AttaCn aaamonat aetau y aestrea, ur m reyuereu uy Frm Ar ycv •• .• w• Estimated Value of Electrical Work: 12— —3J /Z_ (When required by municipal policy.) Work to Start: 12 —3/ /z— Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjry, that the informagon on this application is true and complete. FIRM NAME:. .r l 1Z,Xi T LIC. NO.:�3� Licensee: Signature LIC. NO.: (If applicab e, a er 'exempt in the license numb line) Bus. Tel. No. - Address: Ali. Tel. No..— *Per *Per M.G.L c. 1 7, s. 57-61, sec ' work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE W R: 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 Telephone No, rPERWT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed — [ ] Failed — ( ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 2. FINAL SPECTION: Passed — ] Failed — [ ] Re -inspection required ($50.00) - [ j Inspect rs' c mments: (Inspectors' Sij6ature - o initials) Date 3. UNDER GROUND INSPECTION: Passed — [ j Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. �,3 Gr/!l�las S Location No. ��/. Date / HQRTq TOWN OF NORTH ANDOVER 3�Q' �t�,° I •,M�Q� i Certificate Occupancy $ s i � of s�cMuse S Building/Frame /Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # / /3 ti 17 ; 5 U �� (rc;ll_ �' Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T111 seeiiats_ filw BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building CommissioEj! for of Buildings Date c��.•r•\�v • ni.n>a .)L• t. 11 Vl\ a- x.711 G L\t mmivjiil l 1V1\ 1.l Property ddress: 1.2 Assessors Map and Parcel Number: © Map Number Parcel Number zAa 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Regaired. Provided ReqWred Provided 1.7 water supply M.G.L.C.40. sa) 1.5. food Zone Infomvtion: 1.8 sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I C cs 2.1 Owner of Record oh HcelY4� a3 allL6,1Lv�g Name (P ' t) Address for Service Signature lephone 2.2 Owner of Record: Npme Print Address for Service: Sig4ature Tel hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed C struction Supervisor: License Number -- Addrass Expiration Dat Signature Telephone 3.2 Regi red Home Improvement Contractor Not Applicable ❑ w Compan 7 /,/)33 5 P - Registration Number Addre s Expire on to Signature Tel hone F 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 it. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work checkan a cable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: - I CRCTION 6 - FSTIMATRn r0NSTR11CT10N rOSTS I Item Estimated Cost (Dollar) to be C eted b permit applicant OFFICIAL USE ONLY I . 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 ISECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Ourner/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 J r SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I as Owner/Authorized Agent of subject A 11 property Hereby declare that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and belief i"1'0 Print Nn,,U y GG��, / � Q� of Owner/. Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TDvIBERS is] 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X J MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE CS # 022680 HIC# 103358 = Propowd = A. J. Walsh & Sons 55 Pleasant Street North Andover, MA 01845 If of 978-688-6737 or 1-866-AJWALSH Proposal Submitted To: Job Name Job # Address Job Location A i /f _ Date Date of Plans Phone # Fax # / Architect q Wp hprphv cl Ihmit cnprifinntinnc anrt pctimatpc fnr- We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of: $ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delaysi� beyond our control. Note — this proposal may be withdrawn y us if not accepted within days. 0.cceptance of jropowd The above prices, specifications and conditions are satisfactory and areSignature '�k L hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature NC3819 MADE IN USA The Commonwealth of Massachusetts ,tn;_:. # -- Department oflndustrial Accidents Office Of117110090017s . 600 Washington Street 7ttr Floor Boston, Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors Applicant mfoxiri'ati'on Please:PRTNT 1Pd;hi at^l 1 s T- 4� state* /�� hone # 7/1f,31V dcAQ / LJ I am a hoi-neownerperfonning all work myself. ProjIect T e: ❑ I am a sole proprietor and have no one working in any capacity. Q New Construction ❑Remodel Building 1 Addition ❑ I am an employer providing workers' compensation for my employees working on this job. comaanv name /4. -,L a r� 'L-ev, �/Yp 115W p,, Ca y'7f- _I roff0737 urrcv i -77 I am a sole proprietor, general contractor, or homeownercircle one and have hired the contractors listed below who have the following workers' compensationpolices: company name• ci city: — nhone # —aue.auuiponal Sheefif neC,estary Failure tos secure coverage as required under Section of of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby ce fr under the pains and ialties ofp jury hat the information provided above is true and correct. Signature e Date Print name Phone # � f official use only do not write in this area to be completed by city or town official city or town: permit/license # ❑Building Department ❑ check if immediate response is required ❑Licensing Board []Selectmen's office contact person: ❑Health Department (revised Sep.. 2003) phone # []Other m m m m y m mm ► c oo g* g -� s s�aQ I _ r ELI 0Sa CO) a d m�•9 a c-3 CDMCL C2 z c .� m H T ?d.�d O_ C of ? • .. ? 0 ti m � O O y O N '-I Q 7 O m O m O . .� p O O Z2Cc,' COD oo olo' m � C Q Q C = y am 0 1 CL c � mmya d p (n m � C a� y b SURma:a CD y m :3 H a►,. O H d d ;� Q C.) `� Z o ,W �' Q� co Cosm IE CD: CL COV cr� �, �Gi� � - � CD : r m.� CD o CD w e y, Z m o cn CD O ccCL CD CO3 0 CD bd v cn y Qcn CD Cep Z Oqto ... �. CD u CD O a L C CD o = � m CnCn b7 7d �7 ro 7d � pv O wi O H c O F" O � Z7 7d Go y v I h H 0 c Date.X1L . . TOWN OF ORTH ANDOVER ° p PERMIT 1FOR PLUMBIIyG This certifies that ......��� '�..��.•••••••••••••••• e k �............. has permission to perform .... !.... . 4.?./.� plumbing in the buildings of . ��.K +r.fl4^ ..................... at :............... . North Andover, Mass. Fee. Lic. No. . .. ..��., -,` ...... . PLUMBING INSPECTOR Check 7 6975 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS ---�- Date Building Location j g! ST Owners Name .J a/�.v ww.�-iy" Permit # q7 " Amount $-I- Type LType of Occupancy New Renovation M Replacement Plans Submitted Yes ❑ No ❑ (Print or type) A,14 , ,/ Check one: Certificate Installing Company Name J'/ e- %iM13;,V G 3 1- ,9 7��t & ❑ Corp. Address /2 e^egue-cWti /t?0774 LIZW /VA rl Partner. . Business Telephone 8/S - 393 ® Finn/Co. Name of Licensed Plumber: S7--f--VC-PJ Insurance Coveraee: Indicate,Letype of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent I hereby certify that all of the details and information I have best of my knowledge and that all plumbing work and instal compliance with all pertinent provisions of the Massachu, i By ign re o tted (or entered) in above application are true and accurate to the performed under Permit Issued for this application will be in Plumbing Code and Chapter 142 of the General Laws. ype of Plumbing License Title -7-)d-)3 City/Town icense lNumDer Master ❑ Journeyman FM APPROVED (OFFICE USE ONLY i' I. In 1-0 r • ` 1: 11:NVA I ---W-M-------M------- --- `9 1 ------------------------- M N®MM-M-..-MM---.--------- =' -.M-.-.-.-...-M-..-.----- (Print or type) A,14 , ,/ Check one: Certificate Installing Company Name J'/ e- %iM13;,V G 3 1- ,9 7��t & ❑ Corp. Address /2 e^egue-cWti /t?0774 LIZW /VA rl Partner. . Business Telephone 8/S - 393 ® Finn/Co. Name of Licensed Plumber: S7--f--VC-PJ Insurance Coveraee: Indicate,Letype of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent I hereby certify that all of the details and information I have best of my knowledge and that all plumbing work and instal compliance with all pertinent provisions of the Massachu, i By ign re o tted (or entered) in above application are true and accurate to the performed under Permit Issued for this application will be in Plumbing Code and Chapter 142 of the General Laws. ype of Plumbing License Title -7-)d-)3 City/Town icense lNumDer Master ❑ Journeyman FM APPROVED (OFFICE USE ONLY N2 3- L,4 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING C, --�a_ This certifies that ....... ? ........ I T................ y ... /01.& ............. has permission to perform ...... ....... wiring in the building of ....... ........................................... ... qm� ...... North Andover Mass ... 0 ........... ........ ....... F Lic.Nd 454 J- * ....... . Rb&�ICA'L INSPECTOR Check # Z WHITE: Applicant CANARY: Building Dept. PINK: Treasurer VTHE CVW0NWE4L7H0FMASS4CgUSE77S Office Use only DEPART1MWOFPUBLICS4FETY Permit No. :1�11 0Y. BOARD OFFIREPREVEAWONREGMTIOAS527CMR 12* U'U'd Occupancy &Fees Checked PPUCATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date c -J A/ Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Purpose of Building Yes M No M (Check Appropriate Box) Utility Authorization No. Existing Service /00 Amps I J�-lUVolts Overhead Undergroundr No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work P,wa7 % ae,,7re,7 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total _UP KVA No. of Lighting Fixtures /j Swimming Pool Above Below Generators KVA jgroundground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units A 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 Locala Municipal Other No. of Dryers Heating Devices KW Connections _ No. of Water Heaters KW No. of No. of Signs Bailasis No. ffiydro Massage Tubs No. of Motors Total HP OTHER h>S ==Cv aage Laws lha%eaw=tLiabti yhiam=Pobcytndt&gCcrr#��'omComageorksskattialoWiva{ent YES NO Ihawa.h &dNdidproofofsanetotheOlireYES [ NO F-1 If}whawd-edWYES, *%ea&llethet)Wcfw4Wbydrddngthebcx - p >�p � p � ) a -I)3 & - - D* R n�Vahrecf3ectrid Wcdc $ � V. WorkiDSta<t /ls �01 hspeoLonD*ReWested Rough Feral /� �/01 Signed under= t,M0 M cfpeW.. FIRM NAME LiommNa Lionee Jur Sigrmn ._ � ' Limmisb S 6 I/ /z BusinessIldNa (S— Lw � �S r /1, Pihcd, /ui� U01rit, AIL Tel. Na OWNER'SPWRANCEWANER,Iatnawm dAtheLi=wdo�t +etht311ssist3ir6il wdettasr 4mWbyMmadttxxttsGenealLaws and fatmy ncn fispermitappkmonv i iesftmgtm men. (Please check one) Owner M Agent M CA) Telephone No. PERMIT FEE S ON21015 0 t Date ........ 7... . ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that :..........: ° ` /...... has permission to perform wiring in the building of ............... .,1,.................. J .-.................................... �> ............................................... . North Andover, Mass. Feer:.. Lic. No..Jl ..`.. .......o. �......:... / ELECTRICAL INSPECTOR 08/10/99 15:00 35,00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ,L u, qr uammanwPrinq at musmaiascuB Office Use �� Department. of Public safety Permit No. BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy 6 Fee Ctccieed3-�— 3/90 Ileave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of _ L1 --J The undersigned. applies for a permit to perform the electrical work described below. Location (Street 6 Number) �LL3 Owner or Tenant L� Owner's Address Date To the Inspector of Wires) is this permit in conjunction with a building permit: Yes LJ No I& (Check Appropriate Box) Purpose of Building S' ^' Glr /��`'� 6Y Utility Authorization No. 9 0,-I',7 14//� Existing Service 0 Amps �O Iy Volts New Service 2±-U—Amps !lD / -1 Volts Overhead U Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters / J "umber of Feeders and Ampaciry Location and Nature of Proposed Electrical Work CGA�`�% OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO O 1 have submitted valid proof of same to this office. YES 0 NO U If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ® BOND ❑ OTHER❑ (Please Specify) Estimated Value of Electrical Work $ � U' Work to Start a ~ i 7^ � Inspection Date Requested: Rough Signed under the penalties of perjury: FIRM NAME (Expiration Date) Final LIG NO. �los'L Licensee %��fCi �%, o / A d f : Signature .�z LIC. NO. Address /U A llf I' Oe- �� -,Eolffll' " 'e i�1/�f/ _Bus. Tel. No. AIL Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) O v Telephone No. PERMIT FEE S 2s— (Signature of Owner or Agent) TOTAL No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures No. A ve In - SwimmingPool gm ❑ rnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices of Sounding Devices. Heat Total TotalNo. No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices Municipal Local Connection [--]Other No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW 10 of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wirin No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO O 1 have submitted valid proof of same to this office. YES 0 NO U If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ® BOND ❑ OTHER❑ (Please Specify) Estimated Value of Electrical Work $ � U' Work to Start a ~ i 7^ � Inspection Date Requested: Rough Signed under the penalties of perjury: FIRM NAME (Expiration Date) Final LIG NO. �los'L Licensee %��fCi �%, o / A d f : Signature .�z LIC. NO. Address /U A llf I' Oe- �� -,Eolffll' " 'e i�1/�f/ _Bus. Tel. No. AIL Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) O v Telephone No. PERMIT FEE S 2s— (Signature of Owner or Agent) Location No. a Z Date TOWN OF NORTH ANDOVER ,r p Certificate of Occupancy $ Building/Frame Permit Fee $ �-- �si:.'�, SES Foundation Permit Fee $ cc Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ , TOTAL $ Building Inspector ti C612 Div. 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