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HomeMy WebLinkAboutMiscellaneous - 240 DALE STREET 4/30/2018s ya Dae 4:`'.1 ................ --.,0 V ...... t TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .��1 .....`.'.�....................................................................................... has permission to perform Ar.x:.....d.A-^!ti> o .... �,Q, ,2 .......... .................... wiring in the building of ...................... p.,.11,�.. ................................................................ atiJ ( -P–................ � ................ , North Andover, Mass. ..................................................... Fee ... 12 Lic. Noa�.. ..�%� ..................... ELECTRICAL INSPECTOR Check # �� JN� '5k� A I -,A Commonwealth of Massachusetts Department of Fire Services �BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH .ANDOVER To the Inspector of Wires: By this application the undersignedgives otice of his or her intention to perform the electrical work described below. Location (Street & Number) e / ' /f Owner or Tenant Owner's Address Is this permit in conjunction with uilding permit? Yes ❑ Purpose of Building Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. - Existing Service Amps Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire OutletsNo. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency Lighting required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of GasTurners No. of Detection and Initiating Devices No. of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number ' Tons KW ' "'""" "' ' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuriNoto Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent OTHER: ?� tiach additional detail if desir , oras required by the nspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of 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: INSURA-NCE El BOND ❑ OTHER ❑ (Specify:) Y certify, under the pains p1malties of perjury, that the information on this application is true and complete. FIRM NAME: �EA'y'�� �����—� i ,A LIC. NO.•TjCT/� Licensee: SignatureL, LIC. NO.: _ (If applicable, enter "exempt" in the license number line) Y Bus. Tel. No.: Address: 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, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent 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 filed f° 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 Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signatur . Dater ROUGH INS P CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com Y V IL r 0 �-f The Commonwealth of Massachusetts Department of Industrial Accidents a I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: /Phone #: Are you an employer? Check the appropriate box: 1 ` am a employer with _employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 F� Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *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 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveraize verification. / I do hereby ceztify uun ai and penaltie of perjury that the information provided above is true and correct. / ---_.- l /1 `� Signat�lt�e� Date• r, 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 "...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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia `1221" Date.a.l.. t..�.1�"� .. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING (� N This certifies that........ C�''L..........................e--................................................ ,has permission to perform ..................................`-.!.'4�............................ plumbing in the b ' di gs of....��.� l... at ......... ��....... .......... ............. North Andover, Mass. Fee .... ...Lic. No..�. Check # PLUMBING INSPECTOR �P� 1811 - I 4< rvi b �1s Hk MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY po , odaa P MA. DATE �- `,'� PE IT # JOBSITE ADDRESS 4 d DC le OWNER'S NAME POWNERADDRESS �f�6 �a�P �� TEL F TYPE OR OCCUPANCY. TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL [� PRINT NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES [3 NO CLEARLY FIXTURES 7 FLOOR -a BSMT 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER 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 (NATER PIPING OTHER 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® 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 Massachusetts General Laws, -and that my signature on this permit application waives this requirement. ❑ ❑ Signature of Owner or Owner's A ent CHECK ONE BOX ONLY: OWNER AGENT 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. PLUMBER NAME Peter J. Crane SIGNATURE LIC # 21805 MP ❑ JP CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Crane `s Plumbing & Heating ADDRESS: 70 Douglas Street CITY Haverhill STATE 1'k ZIP 01830 EMAIL annacrane.ac@verizon.net" TEL 978.771.1155 CELL 978.771.1155 FAX The Commonwealth of Massachusetts Department of IndustrialAceidents 1 Congress Street, Suite 100 Boston, MA 021142017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 9 Please Print Legibly Name (Business/Organization/Individual):�d J Address: City/State/Zip: / P -'lune #: J Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with employees (full and/or part-time).* 7. New construction 2. IV.1 am'a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. FJI am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 � Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. E] Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ 13. E] Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] *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 state whether or not those entities have employees. If the sub -contractors have employees,' they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifyand the pai� nd pe/al'ties of perjury that the information provided above is trueand co t, Phone #: 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 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 oPhire, 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia This certifies that ................... has permission to perform Z Date .... 7 �� ...................................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING S (,v win ng in the building of ........................... ...C.7........................................................ ,ter ... ST , North Andover Mass. .................................. . Jee.� Lic. No...01. �? /. 72.....................�!?.................�!..�� ...... ....................... ECTRICALINSPECTOR Check # y Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 (NEC), 527 CMR 12.00 (PLEASE PRINTININKORTYPEALL MFORMATIOA9 Date: 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 Owner's Address Is this permit in conjunction wit/a building permit? Purpose of Building ;?,o, S.X - Existing Service Amps New Service Amps . Number of Feeders and Ampacity Location and Nature of Proposed Electrical Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Volts Overhead ❑ Undgrd ❑ Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIn- Swimming Pool rnd. ❑ grnd. ❑ o. o Emergency 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. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumpNumber Totals: . Tons .................... KW .....'.........._....._ No. of Self -Contained Detection/Alerting Devices 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 Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of 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, under the pains nd enalties of perjury, that the information on this application is true and complete. FIRM NAME:� `/ �/ LTC. NO.: Licensee: SignaturLIC. NO.: (If applicable, ente,exempt" in the license numor line. �� Bus. Tel. No. t Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 7-61, security work requires Department of PublicSafety "S" License: Lie. 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 PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-withthe 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. C 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 Inspection Pass Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: .. Inspectors Signature: Date: FINAL IN CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: 4 f If ^ q / Date: 7 —- DEB WEINHOLD ... TOWN OF MERRI AC, MA........dweinhold@townofinerrimac.com Vr The Commonwealth of Massachusetts _,i Department ofIntdustrigl Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass govt dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual): Address: City/State/Zip:) .21p,7 Phone #: Are an employer? Check the appropriate box: I am a employer with 4. El 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. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [:1 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.] t employees. [No workers' comp. insurance required.] 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. T Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N 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 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 the information provided above is true and Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Z,7— 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy workers' compensation insurance. If an LLC 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 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 Massac�husetts Department of Industdat ,A,ccxdonts Office ofInvestigations 600 Washington Street Boston} MA. 02111 TeX, # 617-727-4900 ext 406 or- 1-877:,MASSAFB Revised 5-26-05 Fay, # 617-727-7749 www,mass,govfclaa 9 S FULL'-'" S�Ut IRD toy 3 r This certifies that�70 �.5w:RA ,............................... .......................................................... has permission to perform ..,.;. � �. `'` �� R LA .//..........:............................................................................ wiringin the building of............................... k............................................................................... G at...................40 ...................................................................................... North Andover, Mass. Fee.. ........ Lic. No��� A.�.... --fin ................................, .........:............ yG ELEC RICAL INSPECTOR `Check # 1 1 K Date.. ..................................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING if V Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. '2AW 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 (MEC), 527 CMR 12.00 (PLEASE PRINT.W INK OR TYPE ALL INFORMATION) Date: 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 & Numbe , r)�d� �— . — Owner or Tenant Owner's Address Is this permit in conjun tion with�bding permit? Yes E]Purpose of Building ` Telephone No. No /1. (Check Appropriate Box) Utility Authorization No. Existing Service Amps / �Ze> 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: /,9,%0 Ir .4 Af 1- No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans uukc utu ua rvue veu u cae Llls occur u Yrlres. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In ❑ o. o Emergency Lighting rnd. Md. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. c iDevi Initiating es No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons '"' ""' KW ' """"""""" No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El other Connection No. of Dryers Heating Appliances KW Security Systems:x No. of Waters No. of No. ofHeater No. of Devices or Equivalent KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: v►v Attach additional detail f desired, or as required by the Inspector of `Wires. Estimated Value of Electrical Work: 0 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for tlie 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 coves in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains en Ities ofperjury, that the information on this application is true and complete. FIRM NAME: iGf' L'Y,J LIC. NO.:, Licensee: Signature LIC. NO.: (Ifapplicable, enter `exempt" in the lice number line.) Bus. Tel. No.: Address: /) //� �c,+c►�2L�� AA ,:P,3 Alt. Tel. No.: *Per M.G.L c. 147, . 57-6 , security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INS RA W . I am aware that the Licensee does not have the liability insurance coverage normally required by la signa r owl hVeby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Ag t �— p�0 3 l�G� 4 D PERMIT FEE: $ Signature i Tele ne No. • ELECTRICAL PERMT Ii®, T�PEC �I�I P�k�7C: ELEC7lMCALI NSPECTCR... . RO ) G7x.]NSPCTON': PA9S2 [) YaRed-- [ 7 . Pe-�inspeetion x egUI recT ($50.00) - ( ] inspectors' comments: - (Cnspecfors' Signature -no fniiiaTs) _ Pate 2. FWAL WSPOIC Passed-[) Tailed -j ] Rt inspection required ($50.00)--[ Inspectors' cotnm!e 'his: r. xispectors' Sign tore -• o initials) Date U i • J. UM.L'R iYR0:..J.1.iJJ JWt R)ffCJ.I0 : passed -• r I wed— j ] Re-insp action required ($50.00) - [ ] Inspectors' comments: (fuspectors' Signature •• no initials) Date I)O OR TA G,5 ARE TO BE TILLED OUT AND LEFT ONSITE IF THE AREA. TO 3E INSPECTED IS NOT .ACCESSIBLE AND .ARE -OSPECTION OFMSD.001S TO RE CHARGED. 1a .-_ The Commonwealth of.Massachusetts , - - Department of indifstrigl Accid nts Office of Investigations 600 Washington Sheet Boston, MA 02111 kvi www mass gov/dia Workers' Compensation Insurance Affidavit: BuRders/ContractorsfEX P aye nsf Plumb b Apphean� Xnformaiion - - Name (Business/Organizationllndividual): n Address: 7 City/State/Zip: I Phone #: 4�, C.5 --:) ! � .ML 0 employer? Check th appropriate boX: Are�Yin a emwith 4• ❑ I am a general contractor and I _______ employees (full and/or part-time)-* have, I&edthe sub -contractors listed on the attached sheet. 2. ❑ I am a sole proprietor or partner- These sub -contractors have ship and: have no employees working forme in any capacity. -workers' comp. insurance. (No workers' comp. ansuran.ce 5. ❑ We are a corporation audits officers have exercisediheir required.] 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. Ti c. 152, §1(4), and we have no employees. [go workers' insuraucexequixed.] comp. insurance required.] Type of project (required): 6. [] New construction F 7. ❑ Remodeling 8. [] Demolition -r 9. ❑ Building addition 10.Electrical repairs or additions 11.❑ Plumbing.repairs or additions 12.❑ Roofrepairs 13.[] Other 'Any applicant that checks box#t must also fill outthe section below showingtheir workers' compensation policy information. i i -Homeowners who submit this affidavit indicating they go doing all work and then hire outside contractors must submit a new affidavit indicating such. ?r'nnirar:tnr.4 that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an em ployer• that is providing workers' ca nperzsation insurar2ce for my employees. Below is the policy and job site information. Insurance Company Policy # 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). Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,50 QAO and/or one7-year imprisonment, as well as civil: penalties in the form of a STOP WORK ORDER. and a fine ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office- of I;tvestigations of the DIA for insurance coverage verification. - � do Hereby MatteMatoe information provided above is true and ---�-- Official use o' y..Do not write in this area, to he completeiiby city or town official. city or Town: Permit/License # Issuing Authority (circle one): 1. Board. of Health 2. Building Department 3. CityJTowni Clerk 4. Electrical Inspector 5. Plumbinglnspector 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 def7md as "...every person in the service of another under any contract of hire, - express or implied, oral or written." An employei 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 hpuse having notmore than. three apartments and who resides therein., or the occupant of the dwellinghouse of another Who employs persons to d6maintenance, construction orrepair work on such dwelling house or on the grounds or building appurtenant thereto shallnot because of such employment be deemed to be an employes." 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 buildfngi.in rite commonwealth for -any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notregaked to carry workers' compensation insurance. If au LLC or LLP does have employees, apolicy is required. De advised that this affidavit may be submitted to the Department of Iudusirial Accidents fol confirmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should be returmdto the city or town that the application for the permit or license is being requested, not the Department of In 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 Departmenthas provided a space at the bottom of the affidavit for you to till 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 afffdavit indicating current policy information (if nocessary) 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 id on file for future permits or licenses. Anew affidavit must be fillgd out each year. Where a homeowner or citizen is obtaining a license ox 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 Xnvestigations would like to thank you in advance for your cooperation and shQuId you have any questions, please do not hesitate to give us a call. The Department's address, telephone anal faxnumber: 1 The C6ugonwal_:t1l of Mo. rhu �epa�xtelal; o£h1d�i�tXaX �:ccxc�e�.t� `� � - ' Off tce of1RVe& igaa(?)RS 600 Wa8.bkgfiot7. S e'e-t Botonk MA. 02111 Tei, # 617-7.2,'x_4 00 0A 406 ox z-8,77-MA.SS.FF Revised 5-26-05 Fax 0 617-727-7749 wWV-M,1ngQV1(Ra 1* '0 sir i FSR L�j�� DATE 4�MIZ TIME o6( --)-- M M HONED'. OF a 2 3 6- –1� 9 2 RETURNED.. PHONE J J YOUR CALL AREA CONU BER EXTENSION MESSAGE � � � �- EASE CALL W / - e (ill �GC AGAIN LL �, CAME TO SEE YOU WANTS TO SEE YOU SIG D 4j�iv—erSOI- 48003 FA A.M. FOR —DATE—TIME—P.M. M PHONED RETURNED', PHONE "`��/ YOUR CALL L PLEASE CALL NUM AREA yy CODE ER EXTE/NSIIf MESSAGE(,vAws'. V WILL CALL AGAIN CAME TO. SEE.YOU WANTS TO SEE YOU SIG ED EtvLelSaI 48003 FA a NOTES r_ NOTES __ North Andover MIMAP May 6, 2014 ! f ' 9 • d � M * '-�-'' � -. -'• .--• ,.'-:.• - "-�=.. _ . - _`_- .0-00 .. _ x:/�!/ 244 DALE S Rrotect�on //% eater 234 ALE STi �� ,% 1 A DAL-E'ST /E 259.0 ST ;. ' y - - • - - 220'DALE,ST - - 061. -- Rail Line =Wetlands Zoning Interstates :: Exempt Lands _ I Busine i9 Busine s 1 District s 2 District Hodwrtal Datum: MA Slaleplane Coordinate System, Datum NAD83, — SR S, Busine IIIIIIIII Busine s 3 District s 4 District KORnK Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of Roads C ,Easements MGenera GPlanne =' Corrido Business District Commercial Dev�ss Development Dist sea .s r 's s� North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is ❑MVPC Boundary ©Municipal Boundary Zoning Overlay Corrido D Corrido Industd Development Dist Development Disl 1 District 3. F _ T =' yr { for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY BAdull Entertainment Industri 2 District - f i OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT O Downtown Overlay District QHistoric District C Industri 1671ndustri 3 District S District # • q► ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF E3Water Protection Reside ce t District+ns " THIS INFORMATION O Parcels Reside 0 Reside ce 2 District rz 3 District C`. Hydrographic Features de ce 4 Distnct -- Streams 1" - 92 ft de de ce 8 Dislnct ce 6 Dislnct Dislricl `^ (JL A /'l' (% iii//{��\ LA- "ge esidential 6YL- ,fin s -- t to, North Andover MIMAP May ,, 2014 34 -„ eg � .alb ; ' �. "' � h • :et.,, d�� �" �� ' ^�. 5 � , a u ro � �, 4 f,• yam, � �• p`. s F.3 h ♦ 'i / 's L .. M wN � - A a''tr'v +. A. 4 S 5 .x i Interstates —1 — SR Horizontal Datum: MA Staleplane Coordinate System, Datum NAD83, Roads Meters Data Sources: The data for this map was produced by Merrimack �ORTN Valley Planning Commission (MVPC) using data provided by the Town of L rEasemenls of au North Andover. Additional data provided by the Executive Office of r�� O Environmental Affairs/MassGIS. The information depicted on this ma Is I MVPD Boundary j � • P y I (Parcels 3 L for planning purposes only. It may not be adequate for legal boundary F 9 definition regulatory Interpretation. THE TOWN NORTH ANDOVER MAKES NOOWARRANTIES, EXPRESSED OR IMPLIED, CONCERNING # * THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY # i # OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 1" = 92 ft North Andover Board of Assessors Public Access l Click Seat To Rctoen Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 �roperty Record Card Location: 240 DALE STREET Owner Name: BUBAR, MICHAEL W C/O VIRGINIA L. BUBAR FAMILY TRUST Owner Address: 240 DALE STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6 - 6 Land Area: 0.38 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2688 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 418,000 427,100 Building Value: 242,600 242,600 Land Value: 175,400 184,500 Market Land Value: 175,400 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=2436169&amp;town=NandoverPubAcc 5/6/2014 > Date.... G�`�. .,1 .�1 • • .. �� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ... ....� C` has permission to perform �..�JR j/ .............. ................................................... r 'FIT9 in t/hee building of ........... jl!I....... i..P....... ..� a. ......................... No Ando�ve; ass. .....`......!./............................... ........5.......... Fee............. Lic. Now -'."."t ....... ............................................................ FI: CTRICAL INSPECTOR Check # Ido S/7 5U?6 ( ommonweald o f MaejacItueelia 2'Parlmanf "15i'. SirVlCQj r'I BOARD OF FIRE PREVENTION REGULATIONS lug, _� X APPLICATION FOR PERMIT T All work to be perl'ormcd in accordance with th (PI.E,1.SE PRINT IN INK OIZ TYPE ALL INFORM, IAI City or'Fown of: NU l>i k/y By this application the undersigned gives notice of his r he Location (Street & Number) 1--,-(cr) L E Owner or Tenat,it It l Owner's Address 2 Is this permit in conjunction with n building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts p Number or Feeders and Arnpacity Locatiun and Nature of Proposed Electrical Work: Official use Only Permit No. � S Occupancy and Fee Checked (Rev, 11/991 (leave blank) ,r a 0 PERFORM ELECTRICAL WORK c Mussaehuscus Mectrical Code QvIEC), 527 CNIR 12.00 ON) Date; d( NO O Y 011-Z To the Inspector of 1•Y'ires: r intention to perform the electrical work described below. S% )q Z Telephone No. Yes ❑ No ❑ (Check Approprinte Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Nleters ,rttacn aaamonai aetatt y aesirca, or as required by the Inspector of Wires. INSUIZ.-'uNCE COVEILIGE: Unless %waived by the owner, no permit for the performance of electrical work may issue unless the licensee pnyovides proof of liability insurance including "conipleted operation” coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of sarne to the permit issuing office. CHECK ONE: INSUIZU\NCE ❑ BOND ❑ 0.1•1-JER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Datc) Work to Start: _ Inspections to be requested in accordance with MIEC Rule 10, and upon completion. I certify, under the pains am( penalties of perjury, that the information Iris applicaI, i re and complete, FI101 NAnIE: M rt, .67 Ect e 42L.(c I, I"UC LIC. NO.: Licensee: A ti l t/On y +9 U.2 E Signatu c IC. NO.: /9 L5 3 7 5 (If applicable, ciao ill r/Ic license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: 0\VNER'S INSURANCE \VAIVEIZ: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby %vaive this requirement. I ant the (check otic) [] owner ❑ owner's a eat. O%sner/Aoenl Sigilmure 'Telephone No. PI-Ri)IIT FEI:: S / S -0 - - - ----- -• '.._ ,_..._.. ...� .-�•� ••.... vc nurveu UV' ole III CC(OI'O/ ll'll•C'S. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fags N No. of l'otat Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators K1'A No. of Lighting Fixtures Siviniming Pool A15ove ❑ Ili- ❑ rrrd. mid. o. of zinergencl-y Li-"itnig Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARI•IS No. of Zoites No. of Switches No. of Gas Burners r o. o electron and Initiating Devices No. of Ranges Total No. of Air Cond. Tons No• .of Alerting Devices No. of Waste Disposers fIcat Pu lip {„.ung er bons 1 o. o r S_CTrZ0_ntaincd Totals: Detectioti/Alerting Devices No. of Disim.vasliers Space/Area Heating KW Local ❑ Co clic cion ❑Other No. of Dryers Heating Appliances KW ecurity ystems: No. of Devices or Equivalent No. of Mater KW o. of r NO. of Data Wiriug: I enters Sins Ballasts No. ofllevices or Equivalent No. Hydromassage Bathtubs No. of Motors Total h113 Telecommunications 11 icing: No. of lleti ices or E uivalent OTHER: ,rttacn aaamonai aetatt y aesirca, or as required by the Inspector of Wires. INSUIZ.-'uNCE COVEILIGE: Unless %waived by the owner, no permit for the performance of electrical work may issue unless the licensee pnyovides proof of liability insurance including "conipleted operation” coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of sarne to the permit issuing office. CHECK ONE: INSUIZU\NCE ❑ BOND ❑ 0.1•1-JER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Datc) Work to Start: _ Inspections to be requested in accordance with MIEC Rule 10, and upon completion. I certify, under the pains am( penalties of perjury, that the information Iris applicaI, i re and complete, FI101 NAnIE: M rt, .67 Ect e 42L.(c I, I"UC LIC. NO.: Licensee: A ti l t/On y +9 U.2 E Signatu c IC. NO.: /9 L5 3 7 5 (If applicable, ciao ill r/Ic license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: 0\VNER'S INSURANCE \VAIVEIZ: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby %vaive this requirement. I ant the (check otic) [] owner ❑ owner's a eat. O%sner/Aoenl Sigilmure 'Telephone No. PI-Ri)IIT FEI:: S / S -0 N° 2 i v 3 Date .,�-?—�/p- aj°e�� `°.a• "o TOWN OF NORTH ANDOVER ° ' p PERMIT FOR WIRING Thiscertifies that .......................................................................................... has permission to perform ....'' j �''-. .. ................. wiring in the building of. , North Andover, Mass. Fee k _ c -U........ Lic. Nor 4. U . ........... ................:.........:........................ ' ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Service 044 CgnmmDnwralt4 DF AasBBtltusetts Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Final Office Use Only Pemut No. 2j?/ ,3 1-011, Occupancy a Fee Checked 1_42 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusem Elecu" Code. 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Data City or Town of Aj u A- fJ Do y (--Y(- To the inspector e>< Wires The undersigned applies for a permit to perform the electrical work described below. Location (Street b Number) Owner or Tenant L-( Yi'N C -- i5 V $I¢ Owner's Address d U C- ST K) U w Dove)"— M19 © I e It S Is this permit to conjunction with a building permit: Yes U No LJ (Check Appropriate Box) Purpose of Building a t`� f � E�%l1 � � � L Utility Authorization No. tj V / / .10 Existing Service Amps / Volts Overhead Undgrd El No. of Meters New Service Q Amps �J .SZ Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampactty Location and Nature of Proposed Electrical Work 4 E`l�/¢ /Z C) (' S E 7 L U r C f No. of Lighting TOTAL Outlets No. of Hot Tubs No. of Transformers KVA No. of Rec le Outlets No. of Oil Burners Battery Units No. of Switch Outlets . No. of Gas Burners FIRE ALARMS No. of Zones No. of Ran No. of Air Conditioner Total Tons No. of Detection and Initiating Devices No. of Disposals Heat i No. of Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of DishwasherSpace/Area Heating KW Detecticin5ounding Devices ❑Other 'No. of Dryer Heating Devices KW LocaltJ Connection No. of WO-9—Low Voltage No. of Water Heater KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motor 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 O NO O 1 have submitted valid prop/ of same to this office. YES CJ NO (J If you have cher YES, please indicate the type of coverage by checking the appropriate box. INSURANCE LfJ BONO ❑ OTHERD (Please Specify) Estimated Value of Electrical Work $ (Expiration Daw Work to Stam Inspection Date Requested: Rough Final Signed under the penalties of perjury. FIRM NAME C_ LIC. NO. A-1 s 3 7 S Licensee A} lyl`14o N If 11/4 G & F Si c � LIC. NO. Address &utJ N t `� � L d / Bus. Tel. No. 97k - 371t- Sf 7 7 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) OCOLAM CCC e /5-00) Location No.Date Z `t TOWN OF NORTH ANDOVER Certificate of Occupancy $ { Building/Frame Permit Fee $ s " to t Foundation Permit Fee sACHUS < Other Permit Fee ,.eMC&4 Sewer Connection Fee $ Water Connection Fee $ TOTAL $ I i ding Inspector 71c 5 91.00 PAID Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP d40. LOT NO. It I 2 RECORD OF OWNERSHIP DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. LOCATION Aq /A %� V >A j✓LA�/ PURPOSE PURPOSE OF BUILDING n14rt k -t€3 ,'"_Y ON:NER'S NAME JQ� Ly�� �,1 T V Y l� `� NO. OF STORIES SIZE OWNER'S ADDRESS ��� BASEMENT OR SLAB -�� ARCHITECT'S NAME b t / c?g SIZE OF FLOOR TIMBERS IST 2ND 3�J, SS FlU1LDER'S NAME p/ � SPAN -- DIMENSIONS OF SILLS POSTS I !STANCE TO NEAREST BUILDING / PTANCE FROM STREET /�[� DISTANCE FROM LOT LINES - SIDE`S✓ REAR�D GIRDERS AREA OF LOT f -2, lajN FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW / SIZE OF FOOTING X IS BUILDING ADDITION MD MATERIAL OF CHIMNEY IS BUILDING ALTERATION `f� IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REj6UIREMENT7 OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANYNN/z IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS n SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED // � SIGNATURE OF OWNER CR AUTHORIZED F E E q l l PERMIT GRANTED 1 Z 19 _ o ' NOV 2 11994 3 PROPERTY INFORMATION LAND COST EST. BLDG. COS U EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING OWNER TEL.# CONTR. TEL. >Y CONTR. LIC. #� H.I.C. # BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE PINE B 1 2 13 CONCRETE BL'K. BRICK OR STONE HARDW D— _ PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL V, /1 '/ FIN. B'M'T AREA FIN. ATTIC AREA _ NO BMT FIRE PLACES _ _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS CONCRETE B _ 1 2 �_ J_ 3 _ DROP SIDING WOOD SHINGLES EARTH HARD!✓'D ASPHALT SIDING ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE— STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBRELMANSARD TOILET RM. 12 FIX.) — FLAT 11 SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ,.r 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM ■ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. cC C m D m Do C7 m z m C7 O z Cn m D C) z _D CA C � .O -r =• �1 CA CD n Z y cD O CLmm r �. O � C Q. CA O C2 CD CD o CL _ Cr CD �F CD O CD Go w a. C O co CD CZ O CA co CD v U) O 1 Z CD .O -r a oCD 0 C CD 60 u C c N C O co 0 CD 0 �a 0 C m CO A c m O N C 0 Ci N y CD 11 y 0 9 cn o ro d y i �. y S CDCL w y mmC -n w m Nonc 3, W -60 y T m aid �_ m 0 CD N C o o x 0 a O ...r .0 f�m�x O � Amo: 2 O o o NES C.) 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OO OZ a) (DLA 0rt,0 rt o(A) r) OD � .�M 1 i ;} OD 0 rt t) C O a o o z T W £ -0 V/�' O ./� V J T �• < N N r Y N C asp o z ��m a- rt -i M C !Z3 w �_ ►� G C fA _O y 1-•.• A O -t D 3 cr Z t -f C7 0) 0 (a --1 T O -G C7 zrn0 f) - X0 0 x;o 0) VW O ►+ O 0 r(0 Z w ^: A> (A tD A► D C) cr `I., 0 (t• O O U) XJ :3 m0 'o c; a o ro 0 to EA _ rn O 00 OD N 3 At ;o o "" Oe H i+ =Irn off, ►-� o ;� o(AW F,� Q ON •�- o -1^^ O 0 Z . _: — — — — — — — — — — — — — — y — _ — _ _ - — _ _ — _ — — I I y I I p I y I I t Y I t m <D -t r• co m 4. 7£ cm 13 I = N > A r Pt I O O 7 O •moi O 40 v T ar_ n O +s r. o0 o I r• \ A OD p CD O 00 00 A } '�O T Z A O O� 70 7D I 7 O O 1 i 1 I 4 MR. & MRS. MICHAEL BUBAR 240 DALE STREET NO. ANDOVER; MA. 01845 LOWER LEVEL FAMILY ROOM k �/co►/ a V y" H/Ift-eS Nov 2 11994 2N- r/It G9t'tA6fr D�D� ti Li �w N k �/co►/ a V y" H/Ift-eS Nov 2 11994 PERMIT NO. f'U APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP NO. LOT NO. I 2 RECORD OF OWNERSHIP (DATE BOOK PAGE ZONE SUB DIV. LOT NO. LOCATION /L_ .. PURPOSE OF BUILDING (! OWNER'S NAMED- NO. OF STORIES SIZE/l• OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 6 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING , DIMENSIONS OF SILLS DISTANCE FROM STREET Alo POSTS JJ `I DISTANCE FROM LOT LINES - SIDES % AR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING IS BUILDING ADDITION MATER;AL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND C J WILL BUILDING CONFORM TO REQUIREMENTS OF CODE n� _ IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS i - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR FEE IOt6-0 PERMIT GRANTED 3 95' 19 4 3 G t - . 3 PROPERTY INFORMATION LAND COST G EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN _ c%cam �oC BUILDING INSPECTOR 'NVId 101d S30V1d3H SIHl 'a3SOdWl2A3df1S '013 'S3ovu -VE) 'S3H0H0d H11M 'S9Nlallfl8 d0 SNOISN3W1a 1OVX3 ONV S3NIl 101 WOMA 30NV1SIa C3NV 10Id0SNOISN3W1a 1.OVX3 MOHS1Sf1W N01103S SIHl ZL aao:)aa Owiaiins ONIIV3H ON JI81J313 l l0 cH� `JNINOI110NOJ 211 80dVA 80 21.LNI IC W1'3. Ndn3 NIV lOH C19AC 3JVNbfld SS313d ONliV3H ti r h _ I PIS puL j51 i. 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