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Home My WebLink AboutMiscellaneous - 241 FARNUM STREET 4/30/2018'' This certifies that .D�,�-� N 1► n�N bY1... . has permission to perform .�•1Q /Gt'1�?�.� ................. . wiring in the buildir1g,of.o, V,-�.��........................ . at ..... 2 ............. M .... ... , No h Andover, Mass Fee �.�.. Lic. No.�3.?�.4. .. P ELECTRICAL INSPECTOR/ V Check # 11254 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 C), 527 MR 12.00 (PLEASE PRINT IN)NK OR TYPE ALL INFORMATIOA9 Date: % / q / j -z City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of hjor her intention tgperform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address `f ! 1-011-101)m 5 `t . a/, Telephone No. Is this permit in conjunction with a building per t? Yes M No ❑ (Check Appropriate Box) Purpose of Building /�- �,o %a/. Utility Mthorization No. - Existing Service (L Amps ( 7o / )- 4 u Volts Overhead Undgrd New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed No. of Meters No. of Meters Electrical Work: �,`re icer Al,Qtj 6ew,4? 74 ,- Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- F1o. o Emergency Lighting rnd. rnd. Batteiy Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burgers No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons .......................'........._..........._. KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑Municipal E]Other Connection No. of Dryers Heating Appliances KW Security o Devils : 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 E u valent OTHER: /� Attach additional detail iif desired, or as required by the Inspector of Wires. Estimated Value of lectr'cal Wor1N / Z -U o (When required by municipal policy.) Work to Start: / 8 / 2 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:) Icertify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. ,�� e+. X/a v CCC Z-1 C 1 - // LIC. NO.: Al Licensee: /��, `S ,y vey Signature ��,,,, GGtti..... LIC. NO.: 3 Y (If applicable, nter " empt" in the Ucense numbef line) Bus. Tel. No.• `12 6'- 6S 8 -40 q Address: / ee P . G(/i ! �'1'�sn- f Alt. Tel. No.: 70/ -Z6 3f ro *Per M.G.L c. 47, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S IpiSURANCE 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 E] owner's agent. Owner/Agent '7 PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass [fl Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass [N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ]FINAL INSPECT ON: Pass M Z - f6 -[2.-, Fail M Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com 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: - z-1 6 AI,_G e 14 !` . City/State/Zip: �U Phone#: 22,6j— V/S�—�9�d Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors exployees 2.m 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 . D 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 Amy applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site :formation. isurance Company Name: olicy # or Self -ins. Lic. #: Expiration Date: ib Site Address: 2. �c�l`e�UCh City/State/Zip: &y,, ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tievp 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 tvestigations of the DIA for insurance coverage verification. do hereby cert,Kv under the pains W2 dpenalties of perjury that the information provided above istrate and correct. ///ay//;� 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 of 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. # 617-7274900 ext 406 or 1.877-MASSAFE Fax 4 617-727-7749 evlsed 5 -26 -OS WIMV mace an-a/rlia ---Sam. alow- Date...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............V.......! /7 has permission to perform ..........Q..... ........................................ wiring in the building of ................... 6;AR ..C L . .......................... at ...... v�Y.� ........ r jP kie ........ . ................. . North Andover, Mass. l . .. ............. Fee ...✓ ow- Lic. No. ... ELEC-MCAL INSfECTO Check # Cop 74) 7 a✓ i //�� n (�o�ntnonweat°h ol a69acku9etb 2epartr"nf opre �erviced 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 (MC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE. LLIF RNIATION) Date: � 67 City or Town of: To the 177spectot f Wit• s: By this application the undersigned wives notice of his or ter jDlgntion to perform the electrical work described below. Location (Street & Number) Zq 1 vn Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building Existing Service New Service Telephone No. (Check Appropriate Box) Utility Authorization No. Amps / Volts Overhead ❑ Undgrd ❑ Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Wo►IcAe6T be Completion of the followni table nzoy be ruonved by the Ins ector of )+ices. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total 'l Transformers KVA No. of Luminaire Outlets No. of Hot Tubs — Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. ot 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 o. o Nf Alerting g Devices No. of Waste Disposers Heat Pump Number Tons KW _ No. of Self -Contained Total 'Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kit _ Security Systems:* No. of Devices or Equivalent No. of Water KWNo. of No. of _ Data Wiring: Heaters Si ns Ballasts No. of Devices or Equivalent No. hydromassage Bathtubs No. of Motors Total HP _ Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Hires 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 cov age is in force and has exhibited proof of same tot permit issuino off CI1rCK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)"—li`',�� /z3i a% I certify, under the tri and penttlijes Qf erjury, that to information on this application is true and c to fete _ FIRM NAME: G PP LIC. NO.: Licensee: S odhe, U b.A Signature _ LIC. NO.: (If applicable, enter "exenRt" in ihlicense number �y�g.) �w /Bus. Tel. No.: Address: ��ickC�a ib Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security workurequires 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: $ r,,O 0,�, a r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 M 5. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly II / Name (Business/Organization/Individual): V� Address: City/State/Zip: ME Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship 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 2jC Phone #: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. $ The sub -contractors have rkers' comp. insurance. 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): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs l3. ❑ Other *Any applicant that checks box # I 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 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. #: Expiration Date: Job Site Address: �'7 � 5� � � � LYl S � 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 Phone #: of perjury that the information provided above is1rue and correct. 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 #: Date..:::..` �.7..- a.I....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING /-7pi 5� c6,v, i y Sc �v/e� � Thiscertifies that .................................................................................. .... has permission to perform n......... ?' � £ wiring in the building of ........—r....... !�'b��.'?..r................................... �// `•grlitiu �( Si ................... North Andover, Mass. Fee. .L.-'" - Lic. No. .� j��....16Z��........i.Yh Q 1 ELECTRICAL INSPECTOR d � \' Check # O 9 / 8598 �orr✓nonwaalCh o� //%a��•zc�al� Official Use Only Permit No.� ! U Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS , ev. 1/071 leave blank) APPLICATrON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusects Electrical Cede (NEC), 527 CMR 12.00 (PLEASE PRINT IN LVK OR TYPE ALL INF`0R.AL4TIOM Date: p2 /2- o% City or Town of: Z)29AI-17f- To the Inspector of Wires: Byjthis application the undersigned gives notice of his or ,re :n'ention to perform the elect. ical work described below. atiou (Street & Number)_ CAI// Z2 1, Te Owner or Tenant r Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Yes ❑ No (Cbeck Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of. Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:: SXca t (e,41 h-) r C0 m letion orf olfowin table maybe waived by the Inspector of Wires. _F o AlraCn aaahlUrlul ucwu y ..-. , Estimated Value of Electrical Work:" �"' (When required by municipal policy.) I Work to Start: Irispections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless -waived by the owner, no permit for the performance of electrical work ;nay issue unless the licensee provides proof of liability insurance including "coq#lcted operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has a ibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER El (Specify:) . j certffy, under the pains and penalties of perjury, that the information on this plication is true and completes -F'iRM NAME: �� ' ! h Licensee: Signature LIC. NO.: ^/ L Wapplicable, enter t "exem " in the license manber line.) Bus. Tei. No.: Address: 17P Zb 'e t .i l l'1 0 3 a 41 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 a en Owner/Agent pE,RMTT ,FEE: S�[% Signature Telepbone No. ,/ No. of Total Nc. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans Transfoi-vers KVA No. t f Luminaire Outlets No. of Hot Tubs Generators KVA AboveIn- Pool ❑ 0 o. o mergency Lighting No. of Luminaires Swimming rnd. rnd. -Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No- of Detection and No. of switches Nqi. of Gas Burners Initiating Devices No. of Ranges Total No. ei•P1r Cdad . Tons No. of Alerting Devices Beat Fump I.Nurnber Tons KW No. of Self -Contained o. of Waste Disposers Totals- Detection./Alerting Devices No. of Dishwashers Space/Ares Heating IOW Local ❑ Municipal E] other .Connection No. of Dryers ea Heating Appliances KRr Security stems: No. of Devices or Equivalent No. of Water . It 4V Nv. of No. of Ballasts Data Wiring: No. Devic --s Eeuivaieni Fieaiers Sins of or Telecommunications Winn -Na. Hydromassage Bathtubs No of Motors Total HP - ;^1a of Devices or.' Li valent OTHER: >oa h the Inrnector of Wires. _F o AlraCn aaahlUrlul ucwu y ..-. , Estimated Value of Electrical Work:" �"' (When required by municipal policy.) I Work to Start: Irispections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless -waived by the owner, no permit for the performance of electrical work ;nay issue unless the licensee provides proof of liability insurance including "coq#lcted operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has a ibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER El (Specify:) . j certffy, under the pains and penalties of perjury, that the information on this plication is true and completes -F'iRM NAME: �� ' ! h Licensee: Signature LIC. NO.: ^/ L Wapplicable, enter t "exem " in the license manber line.) Bus. Tei. No.: Address: 17P Zb 'e t .i l l'1 0 3 a 41 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 a en Owner/Agent pE,RMTT ,FEE: S�[% Signature Telepbone No. ,/ pql jauolsslwwoo 6ti00 HN 'SMOH ZIa NOIN110 OL 30831d M 2jnHi2IV S301AL13S ,kiwn03S lab :asuao11-S �\ 0•ZSL :ou A OLOZ/OE/80 :sandx3 LL9000 00 SS :jagwnN aouejea10;o a;eo41ya0 4-14�,A f/ ol-w .LSZOZ£ 011I£/LO Q 4Zoi 9ISZ-OL6I0 VW W31VS 1S WVHdn I 33831d M dmHIEV 01 3S[,13o;l SIH1 S3nSSI N I3INHO31 W31S kS CM131SID3H SNVIOldi33-13 30 S1 L.3snHOdSSVW d0 Hi-lV3MNOWWOO f: 0 r Date .l�-3;:;�609 .... 1. .......... TOWN Ot.NPATH ANDOVER PERMIT FOR-cGAS INSTALLATION This certifies that has permission for gas installation,.. ............. in the buildings of at North, th, A Mover Mass. Fee`-: '.! . Lic. No...... �� ....... . G I !�OR C Check # M G -� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Building Location 241 FARNUM ST Owner Tel# 781 993 3544 Date 11/06 2008 Permit # � s5 Owner's Name STEVE GARDELL Type of Occupancy RESIDENTIAL New 1:1 Renovationw] Replacement Plan Submitted: Yet No[] FIXTURES Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street } Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Fitter KEN BARON Check one: Certificate ZCorporation Partnership Firm/Co. INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ No ❑ If you have c ecked rtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy✓R Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in a ve application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi is qjl fgr thi lication will be in compliance with all ertinent provisions of the Massachusetts By Title City/Town APPROVED (OFFICE USE ONLY) State Gas Code and Chapter 142 of th Type of License: Plumber ,Gas fitter • •Master • -Journeyman License Number 993 Plumber or Gas Fitter Date. f. !.''. �....... . .� i o= ` TOWN OF NORTH ANDOVER 1 A • PERMIT FOR GAS INSTALLATION h SACMUSE4t This certifies that ..../-"0 ./ A- .1 .'..... has permission for gas installation .. A. Z�.... (./!t A .......... in the buildings of .. a..eqfi .& L at ...2 .Y..l.... -A-;A N. - .............. North Andover, Mass. Fee.. b.'f`.. Lic. No...�.�� .a. 4. .4-!.,. --...... . GAS INSPECTOR Check # O 3 3 Z 5524 N% e a _ J ,CHLScT S UNIFORM APPLICATION FOR PERPY�I T TO ASF DO GITTING '_ ('Print or Type) North Andover masz.A05—Permit_ Z r' 241 Farnum St. x Gs� :, Euiidirc Location Steve Gardel C?,vner'sName f.1ap: Lot: Zone Type of O�upancy New .J Renovation J Replacement Plans Fee: 30.50 SUB-BSMT. BASEMENT lST FLOOR 2NO FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 5TH FLOOR 7TH FLOOR 8TH FLOOR itted: Yes No j e I Installing Company Name �2 tiT r'�'PnT rRCi-. '�T'=' R � I T INC , Check one: Certificate Address 171 -W-`--T_.-:R ST D«N TTLRS Miz 01923 �. Estimate Value of Work: ?,t ,; 0 .0,4, o Corporation Partnership Business Telephone Rte:?_zCC,_r�;� ' � � Firm / Co, Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 'S( No If you have checked yes, please indicate the type coverage by r_heCkino the appropriate box. A liability insurance policy ;K Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent O I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowleace an that atIplumbing work and installations performed under the permit issued for this application will be in COmoliance with ail pertinent orovtsions of the Massachusens State Gas Code and Chapter 142 of the ner Laws. By Type of License: itie Plumber asfitter Signa re of Licensea P!umber or C=as atter Gl City / ;own Master U�Znsa Numrzr �—V IAPPRCVED r CE c I Journeyman �F`'.. J�E NL', , � s I line m � L1 i r N N L, w r L ¢ <n Cr O ¢ N.LU O J of ¢ O U ¢ ~ S N 'LF m - Z o ¢ m u1 w F- Q W ¢¢ O z= O O Z W ~ t rn ¢ c� w < x W - a ¢ W > < LU w (7 N (n U a w - y W a ¢0 O w F- Z -j -� F- w w O ww U y ¢ a w>¢ W Z a¢ y w J W ¢ 2 O C7 S 3 o a a o O a O w ,- C7 J U ¢ > ¢ a F- o itted: Yes No j e I Installing Company Name �2 tiT r'�'PnT rRCi-. '�T'=' R � I T INC , Check one: Certificate Address 171 -W-`--T_.-:R ST D«N TTLRS Miz 01923 �. Estimate Value of Work: ?,t ,; 0 .0,4, o Corporation Partnership Business Telephone Rte:?_zCC,_r�;� ' � � Firm / Co, Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 'S( No If you have checked yes, please indicate the type coverage by r_heCkino the appropriate box. A liability insurance policy ;K Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent O I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowleace an that atIplumbing work and installations performed under the permit issued for this application will be in COmoliance with ail pertinent orovtsions of the Massachusens State Gas Code and Chapter 142 of the ner Laws. By Type of License: itie Plumber asfitter Signa re of Licensea P!umber or C=as atter Gl City / ;own Master U�Znsa Numrzr �—V IAPPRCVED r CE c I Journeyman �F`'.. J�E NL', , � s I line Date .... ��/ .................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING • This certifies that ............................................... .............C................................. has permission to perform .... S� ('Ayi-e I -f-Feedepi ...... ............................................ wiring in the building of .......... ...... 1�4 YL4.- t4 ............................... at ....................2-V J ....... .+CKII ...... SC, North Andover, Mass. Fee ..................... Lic. No......... ..... ...3 ........ Ahj'.)ue�� .. ell LECTRICAL INSPECT'OR 4— Check # 3()-7? 5415 Official Use Only Permit No. J S qE CO�rWO9�EEAMM 9biWA�SYEM U 0epartmentpf2'u6 Safety Occupancy & Fee Ch BOARD OF FIRE PREVENTIO REGULATIONS 527 CMR 12:00 i r i APPLICATION FOR PE IT TO PERFORM ELECTRICAL WORK All, work to be performed in accord fic a with the Massachusetts Electrical Code 527 C R17:00 (Please Print in ink or type all information) Date lO To the lnspbct& of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number Owner or Tenant Owner's Address Is this permit in conjunction with abuilding permit Yes1 No 0 (Check Appropriate Box) Purpose of Buiklirtq 2-- 51,01( � Utility Authorization No. Existing Service Amps Wits Overtiead 0 Undgmd 0 No. of Meters New Service Amps Vats;rhr 0 Undgmd 0 No. l Meters Number of Feeders and Ampacityv Z C l �G L� /� Location and Nature of Proposed Electrical Work s INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES O NO 0 have submitted tmfid proof of same to the Office YES O NO 0 tfNcAheckoed S please indicate the co by checking the appropriate box INSURANCE BOND 0 OTHER o (Please Specify) / /( �4�/ Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested_ Signed under -the Penalties of perjury: `� },� �I T FIRM NAME — -----------_-_ V ✓ ,JA IJ C l (�Z� C w1llcaCl LIC. NO. ABus. Tel No. / rF�CJ O Address58§ 1j/G G Aft Tel. No. OWNER'S INSURANCE WAIVER: 1 affloiwarekhat the Licenses does not ha the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signaturL<on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ " U (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA 2-- Above 0 In 0 No. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA 0 No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers SpacelArea Heating KW Detection/Sounding Devices 0 Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES O NO 0 have submitted tmfid proof of same to the Office YES O NO 0 tfNcAheckoed S please indicate the co by checking the appropriate box INSURANCE BOND 0 OTHER o (Please Specify) / /( �4�/ Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested_ Signed under -the Penalties of perjury: `� },� �I T FIRM NAME — -----------_-_ V ✓ ,JA IJ C l (�Z� C w1llcaCl LIC. NO. ABus. Tel No. / rF�CJ O Address58§ 1j/G G Aft Tel. No. OWNER'S INSURANCE WAIVER: 1 affloiwarekhat the Licenses does not ha the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signaturL<on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ " U (Signature of Owner or Agent) Name: Location: Ci Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Com an name: Address Phone #: Ci: Insurance Co Policv # Company name: Address Ci!y: Phone #: Insurance Co Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.0 andtor one years' imprisonment -as _wefl as civil_penattiesin-the form -f.a STOP WORK ORDFR_and_a fine of_(.$1D.o.oD).arday against -me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Date Signature Phone # Print name official use only do not write in this area to be completed by city or town official' Permit/Licensi City or Town ❑Check if immediate response is required Contact person: Phone #. LI Building Dept Licensing Boar Selectman's Oi Health Departn Other umclal use Unty Permit No. Sy S TIDE C091," J I EALOf OT 911 SS.ACYW SE`ITS 41)epamnew ofTu6Gc Safety Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CPR 1 :00 (Please Print In Ink or type all information) Dade / /Old To the Inspfiet& of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number 2' ��/�►�LG�� S� Owner or c� Owner's Address— w, !c,this permit in conjunction with as building permit Yes>Ql No 0 (Check Appropriate Box) it Jse of Building 2— �' 2l I / 3?=4�e / Utility Authorization No. Service Amps Voits Overhead 0 Undgrnd 0 No. of Meters vice Amps Voits ,�7, 0 t Undgmd 0 No. ers of Feeders and Ampacity, Jv v 1z C `11c u N � Met� and Nature of Proposed Electrical Work _ INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES C% NO 0 have submitted t#&d proof of same to the Office YES C% NO 0 It y�Jhpi� drecked � indicate the type by checking the appropriate box INSURANCE BOND 0 OTHER 0 (Please Specify) � n�l/� �� Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested_ Signed FIRM NAME under -the Penalties of perjury: \f ✓ l _ _ /�/P OTa C LIC. ucensee C.i 1 0 J— • 3*nature -LIC. NO. Bus, Tel No. Address G Alt Tel. No. OWNER'S INS RANGE WAIVER: I a ware at Licerhses does not h the Insurance nt coverage or its substantial equtvaleas required by Massachusetts General Laws. And that my, signatu on this permit application walyes this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ " U Total Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 of Lighting Fixtures Swi'mming Pool gmd 0 grnd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners. FIRE ALARMS No. of Zone No. of Detection and Total No. of Ran es No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers SpacelArea Heating KW DetectlonlSounding Devices 0 Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW signs Bailases Wiring No. Hydro, Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES C% NO 0 have submitted t#&d proof of same to the Office YES C% NO 0 It y�Jhpi� drecked � indicate the type by checking the appropriate box INSURANCE BOND 0 OTHER 0 (Please Specify) � n�l/� �� Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested_ Signed FIRM NAME under -the Penalties of perjury: \f ✓ l _ _ /�/P OTa C LIC. ucensee C.i 1 0 J— • 3*nature -LIC. NO. Bus, Tel No. Address G Alt Tel. No. OWNER'S INS RANGE WAIVER: I a ware at Licerhses does not h the Insurance nt coverage or its substantial equtvaleas required by Massachusetts General Laws. And that my, signatu on this permit application walyes this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ " U .. ..... . .... .. ... .... Date. 04 NORTH -1+ ,'.. .' " 0 se -- TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ..... A..c. has permission to perform ...... ................................. wiring in the building of ......z-110 ............... ; ........................... at ....... 4` ... y ... ...... ............. . "orth Andover MAS .......... %��CMICZL INSern7EC;i�R /Iz . ... ........... Lic. No7..1,?-1.X.9 ............ ... Fee. 7-� Check # 5323 1 t Y TIM COMMONW 4LTHOFW&ICHUSE77S Office Use only DEPARTIVIENT0FPUX1CS4FETY ^� Permit No. BOARDOFFIREPREVEVHONREGUTAHONS527CNIR12M Occupancy & Fees Checked, APPLICATIONFOR PERMIT TO PERFORMELECFRICAL WOE ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 tom' (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electricalEwork described below. Location (Street & Number) Owner or Tenant Owner's Address �5`l� bY✓!� Is this permit in conjunction with a building peril t: Purpose of Building [/� PS f�Qpi,C Yes= No M (Check Appropriate Box) Utility Authorization No. Existing Service AmpsVolts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Elec4161 Work G(�!!/f t�! �' ►�`� r/a? m�� V No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above BelowGenerators rw KVA round ID ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW - Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW El Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP V OTHER- Irmuanw-Cowragra Rnst>�ttrotbeiegtme�r�ntsofMas n IsG ralLaws IbawaamaiLdAiykar&oePdtcymchlhtgCompleto CoNer,r-crilsabstmiUequival= YES El NO IbawmbmittedvandproofofsametodrOffim YES F)cuhavedrdodYES,plea5eir tre Wofcovaageby INSURANCE I/j BOND OtII-IM F1 (PleaseSpa*) -�• nQ E1�onDa� / `moo" IYI EsliyfpdV ofEkddcalWolk$ WolktoSlatt �7 hVecdmDa1P_RWsbd Rough ��Final SigwdunderTrPtrIalfl�_Qfpaw, �� FIRMNANIE /�C 16 X gp, 465E4'!°�tG"� FG ria/G 1Q A7 LimeNo. LioMsee �rG�m C�'t�2QC Signahue liamseNo /� BusmessTel No dkli Am A� `/ 4 fe ��t/t �lG�S�vd`S! C2/ 2 AIL Tei No. OWNER'SINSL ANCEWAIVFR;IamawaodiatdrI owmdoesnotil wdlekauancewvaWcritssub n eotri,AalastegL=dbyMas�GmialLam anddlatmysignattueondvspmnRapphcagonwaResdl mquitmu t (Please check one) Owner Agent (�(� Telephone No. PERMIT FEE signature of Owner or Agent v y • d C � �• a .7 CO) n n Z H 0 o �• 6 C CL y � O � o v CD CD CL _ c %C ED CCD o CSD C CD d v y a O CD I � v CA O 'o Z CD o CD CD0 t -t I � f� !o l7 V J n O cn /d O •. 0 0 Z •Ow m N =.1 _ m O c CO m s RL 0 N C 0 n N VJ R ? 1403 m m z dN �aCD N y Mu .O 1=0 !'7 m am a R N1 v'CID) �tc a m • K� N -4 = d .d•� m N T_ m a•� d =_ fl7 ;4 _' m = NO m -� �. C = coo) C'! ,ZO� a N m 3 o gEr: CD m 1 0 aCA CD col m In _06 ccl c W C � CD O N y m 1 CD a� S CR 0 � ED m CD N _ CD _ n C2 a'o �; �I A ca cs c cn 1 �o ��o �o��o �o x x r �- r �; x, a a! �, CL c�5 xo r , a- G7 z Z � x ropoi� z a N Q V lot y 0 c :j' Location i Date t No./ = r MORTM TOWN OF NORTH ANDOVER ' F ' D ;. Certificate of Occupancy $ } a S,•�°' E<� ACNUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ' 4-0 '77 • Check # f 17377 Building Inspector M M X z O rn z M 90 0 mn M z^ Q TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIJ RENOVATE, OR DEMyOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 17 J DATE ISSUED: �y A NC SIGNATURE: 4 Buildfn—g ommissi2Ea for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Lo 7 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distiic_t Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 2 -- Public ❑ Private ,.i3— SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes O 2.1 Owner of Record R r E r "� C Nume (Pri Address for Service Signature Telephone 7.3 Owner of Record: .'Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number So , _ YC9-� n J I Address in figntu4re // — b Expiration Date Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ � P 4"L" I �i [ L I � U �' 7 Company Name Registration Number � / -So Y-0 Add b Expiration Date Signature Telephone M M X z O rn z M 90 0 mn M z^ Q SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 2506) 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 biv'lding permit. Signed affidavit Attached Yes ....... V No ....... ❑ SECTION 5 Description of Proposed Work check au applicable) New Construction X Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ,5r, -g 44 nr,,-J z3 x q3 U SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant 0FOICIAL'USE�ONLY 1. Building 8 2 3 g Permit Fee (a) Building Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR OR BUILDING PERMIT I, vt 4- S c'�vt G, a r-rJV¢�lJ� as Owner/Authorized Agent of subject property Hereby authorize -{it N.tc (lam �, �`� to act on My beha , in all matters relatiy-e tb work authorized by this building permit application. ture of O r Date T SECTION 7b OWNER/AUTHORIZED'AGENT DECLARATION R/ a � �" I, n ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and be/lie�j� Print N e l r AA-,:; 6 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 9T2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE V FORM - U - LOT' RELEASE FORM 6. �96 -ey ` INSTRUCTIONS: This form is used -to verify that ail necessary approval/ permits from Boards and Departments. having jurisdiction have been obtained. This does not relieve the applicant and' or landowner from compliance with any applicabl6requ cements. �..wasasa..aasa.aa..a�.asa.■ass..■-u.w.a■.■a....aa.a.aaaa a0aaaa■aa.s■...l.pop APPLICANT ��•� �(,( PHONE ASSESSORS MAP NUMBER LOT NUMBER _60 �-j SUBDMSION LOT NUMBER STREEY F-4 �ik .K e STREET NUMBER _ '7 Ll �a.sa■.-aa..w..a�■■aaa.■..•aaa..aa.a-aaaaaa..a...a.■a�a....a.■■.as■a■.....la■ a... OFFICIAL USE ONLY �asseaaa�s�.a.aa.a-aa.aa■u-s.a-■aasaa.aa.aa�..aau■..■■..aaa■.a.■a■wns....asa.awas .Emu RECO ATIONS OF TOWN AGENT'S loan. .oioawww. sawaaa■assawswa■aw.awaasaa■aa.asaa.arasa...■■. ■a....a..a.. DATE APPROVED �� O CONSERVATION AD TOR DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED CONIIVIENTS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH COMMENTS •' ! '' r DATE APPROVED DATE REJECTPD DATE APPROVED DATE REJECTII) PUBLICWORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT DATE APPROVED DATE REJECTED CONRVIENTS RECEIVED BY BUILDING INSPECTOR - DATE The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: 4- nc '4 J�Piv'e lJarm l v Location: 2-1+ 0'.." Y,+ City Q,,fi , n h ovw- Phone # i i g- " F7 I am a homeowner performing all work myself. F-1 I am a sole proprietor and have no one working in any capacity 9 1 am an employer providing workers' compensation for my employees working on this job. Company name: S J7, Address `� S� gYbAL� 5r City. Ltu- '4-c - Aj, c4 Phone U67 Insurance Co. Cita A & C. Policv # W C_ -7 4 $ l 9 ° 1 Company name: Address City Phone #: Insurance Co Polito # Failure to secure coverage as required under Section 25A or 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_civiLpenalties in -the fnrmnfa STOP WORK.ORDPR..and_a fine of_(.$1.0.0.00)_ajday against_me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date ?iT fM o ®`' Print name C ( eKAA- P. L.� Phone #I I�-�o-% Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other r$114M Home phoneL - $ i —Work Cross -P,9 t t FAMILY POOLS & PATIOS, INC. sales • service • supplies 70 South Broadway, Lawrence, MA 01843 Tel. (978) 688-8307 • Fax: (9 78) 688-1949 CSI, #010330 HIC #118204 WC #4951074 LIAB #01098398230 Date E3o State_ 441JZip 2 Cell phone Add'l it Estimated start date �r vK Estimated completion date We propose to furnish and install o the stun of $•,[�f THIS PRICE INCLUDES: • Manual vacuum cleaner kit • 3 -Step Stainless ladder �2.� Rope & Floats • Initial balancing chemicals • 8 to 12 Wk supply of maintenance chemicals (supply depends on pool size) eLm Pool for • Leaf net ' • 8 Ft Steps L L • Wall brush • Handrail • Extension pole • Filter • Test Kit plumbed no more tF au 25ft from pool • Surface skimm6r(s) Z • Pump & motor i Z • Coping_4fZjy_ • Choice of liner_ THIS PRICE ALSO INCLUDES THE FOLLOWING WORK TO BE PERFORMED BY A LICENSED ELECTRICIAN: Bond and ground pool - wiring of a 220 volt filter pump - one 110 volt plug - wire and install one 220 volt indoor time clock - outside wiring to be done in PVC pipe - sixty feet of electrical run from service panel to filter ('mote: runs over A feet will be subject to an extra charge)_ Initials IN ADDITION TO THIS PRICE, ADD TIM ED __LD_ HOURS OF MACHINE TIME AT $_ / s PER HOUR = $ THIS PRICE DOES NOT INCLUDE: Initials Any machine time in excess of that estimated above. Additional machine time to be billed at the same rate as above due with the second pool payment. All hours of trucking will be charged at $___1Q_ per hour per truck due with the second pool payment. Any dumping costs incurred for disposal of ledge, large rocks, or soil - re -seeding of grass around pool - spreading of loam - trucked in water - patio or fence around pool or any accessories except as noted below - additional fill, if necessary, for proper backfill or reshaping of hole - dis- posal of large rocks - fuel connections - heater venting - fuel storage tanks - permits - damage to sprinkler systems or any buried items (ex. dry well, electrical lines. cables, etc.) in the access and pool overdig areas - plumbing to filter in excess of 25 feet - stumping and/or removal of stumps. brush or debris, Water or soil conditions (ex. clay, peat, live sand, excessive rgck, etc.) requiring a stone pack of the hole will be subject to an extra charge of $ _C[lU minimum to $ I_(h1 maxlmum. Use of the above mentioned stone pack will be at the discretion of the job supervisor. Customers must supply access for all trucks and equipment. It is the owner's_responsibility to obtain the building and electrical permits or to assume the costs of necessary• permits. Initials Notes: rUat. 11✓1Q 0•—�X�t�dtsl'ttt.�" V c91 1.,L, OPTIONS t A>LS Diving board ($�` "��"'7" 7 Basic Pool Price 1'7S 6,r Main drain Estimated Machine Time 13 3W Solar cover ( ) Options Pool light ( ) Heater ( ) Subtotal $ 23 61S- Environpool PIR , 8 he 5% Sales Tax S 575 Caretaker w/Electronic Valve, 16hd 29!27— Additional floor heads ( 2 ) _ � IJU Total�GiIWJro $ 230 0 Polaris Vac -Sweep --� Less 10% Dcrposit (N Polaris.retrofit only -x Balance of Contract $ AJ',r{It AOJ �r^a 1 rU PAYMENTS: 1/3 EXCAVATION 1/3 BACKOILL + EXTRAS 1/3 SYSTEM STARTUP The buyer hereby agrees to pay, in full, the total amount of this transaction upon start-up of the installed pool.Your salesman or job super- visor will meet with you two to three weeks prior to excavation at which time all decisions including pool size, shape, liner print, and all options must be final. Changes after this date will be subject to extra charges where applicable. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Credit card payments not accepted on contract amount. BUYER- date 1//-t I tt SELL R �C dateZl Md r CO -BUYER date From: Eileen P. Hart, AAI At. Piazza Insurance Agency, a division of HUB Infl. FaXID: 9789880038 To: For Family Pools Date: 1/21/2004 11:25 AM Page: 1 of 1 A -CARD CERTIFICATE OF LIABILITY INSURANCE OPID E FAMIL03 DATE(MM1OD/Y11'Y) 01/21/04 PRODUCER The Piazza Insurance Agency C . J. McCarthy Insurance Agency 299 Ballardvale S t . THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington K% 01887 INSRN Phone:978-474-4200 Fax:978-988-0038 INSURERS AFFORDING COVERAGE NAIC9 INSURED INSURER .A CNA Insurance Co. LIM73 INSURER B A. I . G Family Pools & Patio Inc. 70 S. Broadwayy Lawrence MA 01843 INSURER. INSURER D: IIJSUREF, '_ COV THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOT -IE INSUREC NAMED ABOVE =OR THE POLICY PERIOD INDICATED NCTWITHSTANDING ANYREQUIREMENT, TERM OR CQNDITION OF ANY CONTRACT OR OTHER DOCUMENT 'KITH RESPECT TC WHICH 'HIS CERTIFICATE NIAY BE IS='LIED OR MAY PERTAIN, THE INSURAPICE AFFORCED BY Tr'E POLIC ES DESCR15ED -EREIN IS SUBJECT -0 ALL -HE -FRMS, EXC-USID'JS AND CONDITIOVS CF SUCF POLICIES AGGREGATE LIMrrS SHCVVN MAY HAVE BEEN REDJCED E•', PAID CLAIMS, LTR INSRN TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE IMM/DDNY) LIM73 GENERAL LIABILITi EACH OCCURRENCE $1000000 A X COMMERCIAL GENE:AL-A81LITY C1098398230 12/31/03 12/31/04 PP.EMISES;Eaewurence S100000 !AI CM&MADE �GCCUF I MEL) _><P!Anycn>_parson) S10000 X per prof agg / BI PERSCNAL&ADV INJURY $1000000 GENERAL AGGREGATE S 2000Q00 I G'EN'LAOC-REGATELIMITAPF_IESRE PRODUCTS -CONIP/OPA33 S2000000 I POLICY F PET L00 AUTOMOBILE LIABILITY A I ANYAU-0 :8414071 12/31/03 12/31/04 COMBIN (E aoodel)IPJGLELItdIT S 1000000 ALL OWAED.ALITOS EODIL" INJURY S X SCHEDULED AUTOS (Par person, X HIRED Auras BODiL" IN.U= i S X NON -OWNED AUTOS (Fw accidanti PP.OPERTi CAIVAGE S I (Par zccidanb GARAGE LIABILITY AUTO ONLY- EAACCIDE'IT S H I APJI' AUO OTI-ER TH41 EA A---- C-AUTO AUTOONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAINI.SMAC E I a DEDUCTiBI.E i S RETEJT ON & I� WORKERS COMPENSATION ANDC'S11MA EMPLOYERS' LIABILITY TCRY LIMITS ER _ El EACFACCIDENT S100000 B ANY FROPRIETVR'PPRTNE:'vEXECU-!'JE WC7481901 12/31/03 12/31/04 OF=ICERIMEMBER. EXCLLCE_D') El El DISEASE -EA.E� 0(EE 5 100000 If ;res, d?scriba under E.L. DISEASE- POLICYLIMI, 5500000 SPECFLPFCVI5DJN5belyw OTHER DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES) EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Corm "FICA I C MUL.UCK CANCELLATION NOMORT * SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOL.DER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ACORD 25 (2001!08) CORD CORPORATION 1988 Jul 15 03 01:44p Famil� pools & patios Inc 070GO01•949 P.1 5GARE) or suiwm(3 kr:auLATions License. CONSTRUCTION SUPERVISOR Number! CS 010330 Sirtho4to:'0711 9/1960 EVIrds: 07119/2005 Tr. no, 61 Restricted: 00 WILLIAM C POULOS 70 S BROADWAY -?c LAWRENCE, MA 01843 rator �711 P Bord of Buildin Repulations ne Ashburton [Tace, m 1301 Boston, Ma 02108-161 a License: CONSTRUCTION SUPERVISOR LICENSE Number CS 011330 Exp . Ires: 07119,2005 Birthdate: 07/19/196() Restricted TO: 00 WILLIAM C POULOS 70 S BROADWAY LAWRENCE, MA 01843 Tr, no: 61 Keep top for MOO and chanq4 of address notification. p p ry o wu ❑ loa ca �, o0 ( CIS 1Phi � Py ^O o p axi 7 ce bA a CCS U s a ti d e C/� OV 42 O y y rA U) D 7:1 O . °It .9 . CCS CO Z U O 06i- 0 .c LO ami U) Z~ O N ��QUj C4 j;5 w a > N ou `fir>�z _ c 46 a ° O''> ' > W w LLI 3 Lu O, C.' LLF- _3 a1 = I •o �v '2 � � I � cu U w ❑' b 0) LO w Eo N a N Cl m a0 �:37 W w 0 O CO N C13.2 Q • 0-F-'.0 O .--1 ((L6 N CC3 O (/� a V1 M 00. /~f W O p p ry o wu ❑ loa ca �, o0 ( CIS 1Phi � Py ^O o p axi 7 ce bA a CCS U s a ti d e C/� OV 42 O y y rA U) D 7:1 O . °It .9 . 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CO) m m m �o m m CO) CD .O a Z CD O d� o � 0.= .o o p a� c CD C °D O U2 CD CO2 -v CD 0 LrJ CO) d d Cl) CO) n� 0 y 0 CD O CD CD a. -CO) CD CO) 0 CCD C CD G?oG m S �y<Q y d Om ,� y CL m�!•C.) � c y2..c a— = Z ?w a -I =r CLCL 1'11 a Ce CD ON =rm O CD a m o O y O •� _ 40 _ •:� to o csc_CC/) 10 mmy n c� y: er. d y zceCLcr cn /- /n CA c O Ovo0_:� z 1-0o v = Z IF m o om : 1 ' o p=CO) '= Ir �m G7 . .o Cr1 i C2 Cn C/) b7 '21 orf "�! z 7z orf n T C/n 'rl El q 7 g, p 0 ] T 3 CV )Nq 0 9 O C CD Location !%7 No. Date JY 0� j NORTN TOWN OF NORTH ANDOVER ST ~ i D Certificate of Occupancy $ ` '��S'^•° • Eta s�cHus Building/Frame Permit Fee $ r — Foundation Permit Fee $ Other Permit Fee $ TOTAL $� Check # U ,a 17312 Building Inspector f 41 TOWN OF NORTH ANDOVER X BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: /�� DATE ISSUED: SIGNATURE:4, /J ( 7117- , 6,C� Building Co ssioner/I for of Buildings Date 00 rn X Z O SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning Distr c t Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RegWred. Provide ReqWred Provided R red Provided 1.7 Water Supply M.G.L.CAO. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Ouiside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT i isioric District: Y,2S No 2.1 Owner of Record . Q+&ae,-1_aiar-Je ( f Dame (Print) Address for Service Signature _ r �'1 ✓ lephone 2.2 Owner of Reeord: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 'Licensed Construction Supervisor: 1 Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name 4 Registration Number Address Expiration Date Signature Telephone 00 rn X Z O SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result , in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check an applicable) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: I 1 -e �"-C Gi ._.rz. , a SECTION 6 - F.CTTMATFD irnNCTR1[T9 TTl1N OnVirC Item Estimated Cost (Dollar) to be h � bFFI l yy *se's Yv3 � U ip ;y*mak Completed b Permit applicant � �;,� .....53.;•x �). 1. Building (a) Building Permit Fee _�,.'✓, iA.9 i....xm..=. G) or Multiplier 2 Electrical 7 (b) Estimated Total Cost of S�G Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 f --41 Check Number ......... — is v.,..cntiulilVlll/.H11V1N 1V 1 Z %1VIViLrE 1tv W1MIN OWNERS AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT I, - as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. l Signature of Owner/0 Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ., as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1ST 2N. 3 SPAN DIMENSIONS OF SILLS DIINIENSIONS OF POSTS DEVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE x o O w CO v cn ® PL' z O w O C2 :a U C d. O � co C i WW O a: a� cn G W. U 0 q V. c� cn o cn C � •� C o ::g C v ca a, C W R s C 1 o i m •" m s CDt.fti ' O C o `C: m 3` 10=1 Q C A m O cp CLUoCD �• as c Q: C CIO0 CM � N C3 C N C co C ® C �C C O _ ® O 3COD N ~ h O t W p Cys_. .� •CNA dt C Z W .E vs V � L. CD 0 (/i ®" ®� O o m 0m s *0 CL� � O Q! C C Vi Q O H O O ■E ca CD 0 co CD O � ® c CD c.S 12. CMCC co o �Cc co ca C Z ; 0 CL C.3 CO) C CL C 0 U) LLI U) W W C4 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING '."` S ,.'. ,�� y�4r A..a:Si �� ' ✓`A uRk �'�.�' �� . � t"� "�� d'JA. y� . 1:?r^I �a.4� .e«€fik •p ._�+' ' BUILDING PERMIT NUMBER: n� DATE ISSUED: C SIGNATURE: 4 BuildingCo ssioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1arka.� . 1.2 Assessors Map and Parcel Number: /06&- � Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred. Provide Required Provided Required:::::[ Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Dame (Print) Address for Service: 9747- 6 ll - z Signature ephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone Ma M Z O z M go 0 I,1 r r z^ YI SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: C"C-J— '!5; c_;� � L I SECTION 6 - ESTIMATE,D C0NCTR1TrTTnN rnCTC Item Estimated Cost (Dollar) to bef Competed by permit applicant { 1. Building_ J1,70 0 U (a) Building Permit Fee Multi Tier 2 Electrical SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: C"C-J— '!5; c_;� � L I SECTION 6 - ESTIMATE,D C0NCTR1TrTTnN rnCTC Item Estimated Cost (Dollar) to bef Competed by permit applicant F ICUL USE ONLY ` 1. Building_ J1,70 0 U (a) Building Permit Fee Multi Tier 2 Electrical 7 �U (b) Estimated Total Cost of Construction 3 Plumbing (> Building Permit fee (8) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 17 L rc Check Number 0L\1liv1'q 14 %JVV111r1_M'%UJLnwJMLL.ALLV14 1V DE (;VMrLh1hU Wum4 OWNERS AGENT R CONTRACTOR APPLIES FOR BUILDING PERMIT I> as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Z -Signature of Owner �./U Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date !y FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT ��"� �O { PHONE 97?- 6/�/-V sy LOCATION: Assessor's Map Number /'Q I A PARCEL c)0,.5! SUBDIVISION LOT (S) STREETAV/ �'� ST. NUMBER *****************************************OFFICIAL USE ONLY************************ REC ENDATIO OF TOWN AGENTS: i /CONSERVATION ADMINP11ATOR DATE APPROVED 4116016Y DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INS C -HEALTH DATE APPROVED DATE REJECTED SPPfJd I CTOR- ALTH DATE APPROVED ` DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm North Andover Building Department DEBRIS DISPOSAL FORM Tel: 978-688-9545 In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be .' disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: w (Location of Facility) Signature of Permit Applicant G/IlL�G� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector N CT • J U m LA L4 0 F V b/./D , Yk V � 00 i �7 V .Z m U) R O Z OOD Ln N s PD 0 00 m 0 GAS TANK Q C::! --D N G* Y d �a 114.4' 2 ST 0 ,� 'So s� o Cb v_ Z CO£l t —10 2 2'6"4. 26' v n i1 50 Amp Service Box Roof Pitch:99' on 12 (matches existing constructin) Footing 2x8 Roof Rafters, 16' on center 2X4 Balloon Construction --- T ---Ap, Grade o T o rA C� �p LU J Z :co m c O CDts N O c Cc rO. :V ac • O A O c ;Z O O i m O c .. m�'� E5 o .r 49 s�� m c L. o�C�_ ~ v CD p• C c p Cc c 0 c O O O CD y �V ` m m ; cc c �l TN act a :vI. `o �. coo c aoa H O N O C �c at C F- o SOH m ca O _ S -0LJ C �. •iyA dt O C Z W�E c ��, CO2 CL 4D AC f- z 4�a=m a _k9l, 0 m a� O O co Z O yy E as C CD C.3 CL CA O V C. h C O O d H CD �D CD ® o L CL O O. C !D .O O O tsCD CO2 C LLI U) U) W W 19 w a a a A v up w° chi A a G w° p°4 U x to—Cd n: i=, a rz w m rx w" as cn 0 cn LU J Z :co m c O CDts N O c Cc rO. :V ac • O A O c ;Z O O i m O c .. m�'� E5 o .r 49 s�� m c L. o�C�_ ~ v CD p• C c p Cc c 0 c O O O CD y �V ` m m ; cc c �l TN act a :vI. `o �. coo c aoa H O N O C �c at C F- o SOH m ca O _ S -0LJ C �. •iyA dt O C Z W�E c ��, CO2 CL 4D AC f- z 4�a=m a _k9l, 0 m a� O O co Z O yy E as C CD C.3 CL CA O V C. h C O O d H CD �D CD ® o L CL O O. C !D .O O O tsCD CO2 C LLI U) U) W W 19 w Lncation No. ' ) f /'? _ Date �aRT� TOWN OF NORTH ANDOVER t•`tO '•,hOOR O?O• . „ Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ CH Other Permit Fee,�wrr 1,.t /$ Sewer Connection Fee $ Water Connection Fee $ 2 OTAL $ Building Inspector Div. Public Works r 'ocation�T No. 4 Date TOWN OF NORTH ANDOVER CertificateWQccupancy $-.a Buildingvhj�l�i $ r u 1 uv Foundation Permit %6;j"� p,� Other�� /mit Fee �A N/"Sewer C rme(Jq Fee $ Mit, Water Conneption X92 $ A(11 TOTAL $ /(,2/, Building inspector Div. Public Works d Location_> � No. Date �--� 7 TOWN OF N R A 01",,o ,•;+, O TH ANDOVER z-wagidilkp Certificate of Occupancy $ Building/Frame Permit Fee $ 'Ss,C„UsE` Foundation Permit Fee $ pA11) �� C hill" Permit Fee $ ----� �' NORTH AND0I.ER Sew�erOConnection Fee $ Water Connection Fee $ 9 � aT�9y� l � DEC r Building Inspector `� Div. 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D Hy = N m OOOZ Z Z A -m \ z x T 3 n p _= N inmDv Q Q D 3 mz�o N O p m 3 m p N A +� Z { 0 � H p r c n 3 3 �c n<>O> D ym m r x D p °v Op x C z0JOyw < { T NKn3„ yJO y _z o xm Z x0 lozIQ y y m D Q nJO m i O p v A n n H D O m w 00N 00 O O 6 R N x- A O �A, Z OZGz1�N 3 A N N Z_� D m W mwnn N D;�n v c z m D Fnpz� N A n D A y� -m \ C m m p m m w Z D H p r c n 3 3 m Z x C < { T y Z Z CR I I ISL p rp n D mZ m z<aDzl c T °oxvl OD may; Z ti F Z 9:E Nm r ° y O { a~ W A ^Z C .iti = 1. ;arzi _ 0ON N MN Mzm 0 > z m> Cox MXN D� `CO3: N"' v l m �;nz / N m c {rte M mm 00' e a, �. ' FORM U - IAT RFT EASE FORM INSTRUCTIONS: This form is used to`veri+fy that all necessary approvals/permits from Boards and Departments having jurisdiction' have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: PhonenS LOCATION: Assessor's Map Number Parcel Subdivision P Lots) / Street FAiP RJ fA VY\, St. Number �--% ************************Official Use Only************************ RECO ENDNDA IONS OF TOWN AGENTS: �'" "" "� Date Approved Conservation Administratore Date Rejected Comments Comments Health Agent Date Approved 2 Date Rejected Date Approved Z Date Rejected Comments -1F U A 7- /A/ ' 7C_1 r Public Works - sewer/water connections 007�pwo✓& (A., /1 3 - driveway permit Fire Department `cam 03 ( � Received by Building Inspector Date 115 Gi �A.I lA3 t 1 � t IQ DEC 8 SGW--2-TIj�yTHAM ATZ,E, Totr. THE, 'TNIE, aF"F'SFTS �� off" . F3 .vtL+�tw.1C� uSPtrClt� Epl1H Or v w r'r'i4 THE 7�=U IU G t O t...a C71= r—o I`l 1►`J Cs � �' y t�AkJS o F CouF-o2M Ty of�., 1,10..1 Cows �02�'( fTY {v� A�►Oo�FR N. N E. U 44 M O CO) 10. Cl)CD Z CD O CL r O O O � 0. F ncm .� .� O v CD cr CD O O O O CD L�� CO) 'v D! d Cl) CA 'v C7 c O C CA WL O n CD O CD CDa y CD CO) 0 O CCD 0 CD v m �' a G Av �7Ix O `� O .o O O n (A tz O w a Ca � C O w C O� aGc G O 0 r �' b C al O CL �- Gd O o x tTj 9 t'7 O 11 �C O 21 7N M-� O O • N O a N C h C� O.C2 T Z E -o CO) m c T C° r. 0 y ,.,, co') co o �m m -4N O CO) CD to c CD c =r C=, CL �c o W sCD c� 4 c n � � . O. Co N C N N N Q !, ! =r m N. N CO) N � N O O CD O CO) � o m = m C rM W co za = C m ZCL !nbi CA 0 00 c, =CDCD! m C/)C/)w 0 d �' a G tTl� �7Ix O `� O C O O n (A tz O w O aGc �' Z co O w nCf) eCf)x O� aGc G O 0 r �' b C al O CL �- Gd O o x tTj W M �c qO 70 �L 0 Al 01'1.1(.1,01'. r, Towli of (.1 1 1 171111.` 11t t I A1111iAI S �'• N01tVAN 'lJ �1 N110VLlt IIL111.1)1N(. •:..'= � t�Ic1�;�ci11111 ;1 .I,tllu-1 `' 111\•1: ilt IN 111-* II i 1 r 1 1 ill! i -17 7!; I Il A1.1'I I I�i.�\NNwc; l'1.��IVNIN(; F� (;Of11f111!NI'I'1' UI;VIsI.OL'l111N'1' \t ;t CHIMNEY APPL1CAIION ANO PERA111' ATE _ ,�.� ' f - PERNIT # )CATION Lc•T: =pre NQk4 s� ' LINER'S NAME: 1I LDER'S NAME:... - 1 ISON'S NAME: /9 ry'—? QL -1-zc ISON'S ADDRESS: ISON' S TELEPHONE: e/ -,Y 7C I .JERIAL OF CHIMNEY: l3}- JiERIOR CHIMNEY: ,� .__LXI ER1 OR C11104LY: 13 ---- IM BER AND SIZE OF FLUES:' / IICKNESS OF HEARTII: chb11ney oa Oiken,Cnce con()oAm to Vie acqu<il(eme114.16 u() the code (uld Have aucn alld 79u,I'ati.ow been nece-bed: -- -- ATE: IGNATURE OF MASON: -RMIT GRANTED: J )BERT NICETTA .IILDING INSPECTOR t� F -EE asp' JSPECTEV: -- NARKS: SOLID BLOCK REQUIRED THIS PERMIT" I,IIISi GE U1SPLAVEO 014 ME t'RLllli SLS Town of - frrlw�!JP C'MIAWNITY DI"OVIIAMPA11"N'1 KAHWIq I I.P. NIA.S'ON. CHIMNEY APPLICA1*1014 ANO 1'E1311 I' ATE. PERMIT # )CATION— Z t,. T LINER'S NAME: I I LVER'S NAME:- 4 SON'S NAME: 1. P kSON'S ADDRESS: �.SON'S TELEPHONE: 4?/ 7 C7 JERIAL OF CHIMNEY: CK IFERIOR CHIMNEY: EXILRIOR C11HINLY: 73 et&k IMBER AND SIZE OF FLUES: fICKNESS OF HEARTH: ' R ;u chbliney 04 ()(Aep.Cace con(joam to 41te U() -cite code and have ,tt1cc.5 (111d igu-Za.tiow been /Lece-be(i: , JE: .GNATURE OF MASON: __:RMIT GRANTED: )BERT NICETTA JLVING INSPECTOR F E E iSPECTEV: :MARKS SOLID BLOCK 11 EQU I It ED THIS PERMIT MUSr GE VISPLAYLO 014 ME PIZU11SES a m n rn c � r z — mn C 3 Q CD 0 OO V H y x 3 MON Cl) 00 [V t _ O 0 n N � M z z d n z � d � � CO) 10 CD az CD CL CD CL%C r.r CD 0 qm =r C2 mco) 0, QWE CDCO2 CD C.) U2 CL m o c a RD . 2, R. ca co) H CO) 0 CD CD C, CD a'g 02 CD S. Wo C=l 4c CD CD C,* co CL —1 q CO2 CaD co 0 w CO) r CA = '= CID C/) C. C, N%o CA =r CD Va C/) co, CD (A CD 0 O CD Fat -0 CA C OD �_ �� . CD C/) iib a CD C= cco CJ 's.. CE M: 2c CD ci DF MU m mmi 0 N" GQ OQ Cc: Cc: QQ , F�t�io a 0 M CL y0C9 0 W 4 -j 0 c z `0 W 0 c C." Location 2,y aA,-.-^ No. Date �oRTM TOWN OF NORTH ANDOVER + p : Certificate of Occupancy Building/Frame Permit Fee $ $ �'�b'•••°''<�' sJ�sE cMu Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ 5 Water Connection Fee $ TOTAL $ r 12632 06/09/98 13:19 Building Inspector Mon PA O Div. Public Works 0 Location? MNo. • � Date NORTH TOWN OF NORTH ANDOVER A Certificate of Occupancy $ a ; : Building/Frame Permit Fee $ • i cMusE CHU cam Foundation Permit Fee $ s� Other Permit Fee $ r� ?J� Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Oz16;198 13:19 38.00 PAID ` Div. Public Works I L'J � z O Q CV 0 �.r z Q F r.. f z -x — V) Z z z Z Z_ Z LU Ln I� v W Z W J W L L^ 9 © m W G � O � O U F G - W C L \ ¢ y W V z L W 5 W L6 z z W W Q 6- Z C_ z L� C N c W O N S n n m _ z Lli O 7� I¢ LLI LL ¢ U Q n W .S' Ci F- N f'n CA W — W V zcr Z a z a ti W z z z 00 T z 6 z W IIQ z ct J LUu r V) W Z 3 ., 1 C 7t U — � u C W ¢ 404 L W Q Q z L C H 1 i C y 3c w i� ::� ?C X .• fes. N N .^ _ X a C n Z Z Z C Z m _ _ ��.. Z z z Z Z_ Z LU Ln I� v W Z W J W L L^ 9 © m W G � O � O U F G - W C L \ ¢ y W V z L W 5 W L6 z z W W Q 6- Z C_ z L� C N c W O N S n n m _ z Lli O 7� I¢ LLI LL ¢ U Q n W .S' Ci F- N f'n CA W — W V zcr Z a z a ti W z z z 00 T z 6 z W IIQ z ct J LUu r V) W Z 3 ., 1 C 7t U — T 6 z z 3 � u C W ¢ 404 L W Q Q z L C H 1 i C TP .r..; 7( VO - -- -- - - f . P : w J ' ' r • f! _- •r i . r. aA 104 f Y- , 1 --- .s . _� i e Sk Ir -�s t ...��.•/�-'�.rt+"�'-T-'?:�.__�,L.,J � � W —{-__/: J'e�'-s-_~.4I.....�::�,1. -.M �,,,,.��.J-3-sem.•.-:._� .•,,.,—__. r ,�a zZ sa SSUI 3A 6b:ri 8661-To-tgnr r .i. 1. ... i «r.:.�r-r.LJ�IMi„"11:,J.':w..A.ili�':'f�N�r�f-r:wll"A!'�I:'.'/.'.:••!d•i.i:•\i.[I.R•,'M�1:'�M3J ��..•'}ii[�15•wf'.IJ,1M:iJf7%,'AMr•L.'4r!'�i1TfIM:wM�>♦tr'i`?e�'A'BAi+��tiY lVir: il�iti'[YS:i'.•. �1 "n•I"': '.Y'r; r�ifl r[n�F.v:: w1!I �� .wy.�:...,„N. ON SO MAN" r'Nx � `' y i� ! ��: KM i�Y 1� il} • 71 '�`"iR I r''ir'i�. i ''/.rT..`«'::,�1L�;'.�y'l'. :'4M'!•v:. •'. .. ' -.. r ... s+1�. ': - •�`f•. •:Iii."(. .. ,. Jh �..AL 'sS 745 •1. fir.., .c.' -yT` W4--771 -:f. -�-I. "p: �,j i,�,yl ff��M y�+'• ;7r1 \i 7`- `p•l�nA�:. �1-;M�•.. �.r:.. ,� n '. q�4-ii_�1 ,.Yi'r b %fig`, • ` r.. '' • ,, .,; �4-�'s � �,� ar I w h • 1 r�G 3 y auy �r '�,. i - . - •� ?l .ice � ..,. � .. 'rad' ,F:�a`>• fil, sJ. Ir r .s.. 'M W,Yw t �4'' pjA IOL w .. Zm t l' -r=tea. r .. _. 3:'�"'"� .r+^ --....,.• •T r �rwiw G 6 t7o/Zo 6 JZ ss SShc 31J ev:PT 8662-do-i4nf to *d ldlol ma 1 .ice -...-7--- -E '.- -E SH SHN7 310 6b:VT 866-Z©-Nnf .ice -...-7--- -E '.- -E SH SHN7 310 6b:VT 866-Z©-Nnf t 0 Ri JUN -09-1998 11:00 k15 - GTE LABS E5 2F 11.E:. ]� 417 P.02/02 w #Nr -ie, TNE. / V L"7 1 La tts i a.+ a-Mtb) �? 4i .yew..! ►.�1 CAp�PI. O U�Y P1 O + C. )c W rr}I "T"rt E. �.pl..t IiJ ��`*" eAr- t-r'l +.t Q% -v - t o w„ 1 L-4 a, %-V L-Av..1S Q F ¢.��oQ.a� a -t -y oR. IJo►..t Ce�,1 �C►>�,p.� fTy 4 .v n p� o D TOTAL F.02 86f 8-999 (LI9) xvd £££8-999 (Li9) b000-SVIZO VW `Z)llWamoS `Utgt Xog 'O'd `Aemo!H ulu-loz)w 6SZ M,7 -96Z (098) XvJ 0808-Z99(098) ZZ00-ZS9 (098) ££090 LD `tinquolsu10 `plBAalnog WOISEg Lb SHIN VaNO3 52I2tSWVH3 UH:4H :4HZ \\- w x °� uN a ° w � ,.a 5-° m C m 7 c c w W a ` w a o p, a W a° chi w 7 ao' w a d W w v c cn' z V) ' o V) M ►:T L1� Is CD O E co 0 O D w CDH .E CDL CLQ L C O Q V co O co C O V m L O V co Q H C CO CM C CD O •C m m c o m c � o C N O ' rr C O •d -cod C m M= i=+ O m m ms's CL y o -- r Of CD C E C To � mm :m; y r cm m y m � A C y C A\\JJ A y O O E� caC m 0 o.c CLC.) m V = Z O cm coQ .� ^ act 0.2 r m (j C, y Z O �..: c O a. C H Q m y m C •O = m 0 mro y m F' N m L_ •(aaG• r (.. Z !.s Z LU m 'E 5-0 o c o y 0*a g `0m H Sr $m CL ►:T L1� Is CD O E co 0 O D w CDH .E CDL CLQ L C O Q V co O co C O V m L O V co Q H C CO CM C CD O •C m m �U cn cn u z Ilk O Cr Q F O — z � z z K ¢ 3 Z Z Q L i4 z ^ �_ Z Z C 7vi 3c X x 7 is x Z Z Z ylijz Z Z w C 5 w Z Ly ? a G C $ p o Z ' O `h U r G _ wcer � w u LU V 2 � V C Z z c z O 5 w — Z F < Ci w z C v w U uj p— F v LW z Q z d 2 n Z v Y z .., ,.• — a Z z a LL � v w ZZ Z 4e G G C C y' N N V1 Mal w Z Ln C z z w Z L LU 5 � H 1 z cn w — G U LU v ZCL w 07 a V N u Z z w y Z— — z 5 _ w z N z _ g :J L A, a LL; C7 in w 3 U U — W N z z w Z L LU 5 � H 1 z cn w — G U LU v ZCL w p a V 3 u z w y Z— — z a _ w MW Z a C Lu J < i w 18 -ft" w W n i wlu■ cn cnu z p ry F- X C C z Q F ' r. G O - z OWN Uri Z 7c Z 7e t; z �{ U U Z v v v z Z Z Z Z Z W w H w Z 71 U C s z < <_ ^� _< �W _ �! J Q mix N V l ; N G C O � L Z � O F U r r r Lu Q � S L � W a`l 11 I✓ 0 V) 5 Q S Z.W 4 Z uj C_ C Ww C N � 1j N ~ z W C w Lm z cr 3c v n w �= LuU y L Iv N z Z CG 6 Z y Z Z Z — tk G r CW u Z Z Z - -, C C o C N Zq MW Z a C Lu J < i w 18 -ft" w W n i wlu■ Locations" No. `� % Date f% NORTH TOWN OF NORTH ANDOVER 0 p Certificate of Occupancy $ Building/Frame Permit Fee $ s �CMUSE Foundation Permit Fee $ RL Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL / $ / — Building Insp6ctor Div. Public works ' ON fr J X :L I V N 2 I ._ v N LU ? - x l V C 1 I I j _ v I _ LW i✓ N O I I j J L N y ✓1 z 4 Y s n i 1:J . O .. �I IZN Z 1 �.0 V = y - r v 5e- T Z a T N Z Y Y - I � � _ Y = Z •n Z < •n Z < •n z 9 L^ = I ON fr J X :L V � 2 LU ? l V C 1 _ v _ LW i✓ N J L N y ✓1 z 4 Y t_L' E., a 01 0 rA it 0 S� Q O¢c m LE >. cis O w z A R wo U w O w o 0 ro w O w a2 cn w x O GO d 7 ao' in w z w m cn cn 0. N y.+ N N C 75 a m Of CIO C cm c 'c N m L O Z O g O r 01 U O O E C L O o C.3 Zco d O CO) CD CM 0 � C C y � � C LA G� C �E m co —ca �r 3 CDO � � 0 O _R O C' CL a c< y C C C R R V J 10 'a. O CO o ca Z a V y R C �C C _R CL 0 o m c c o 0 C N O C � O V V a C R ea m c o � CD N � Ea wm+ C Z � r.. V o n N . O t o O :mom :aw N �C CD m o �' ca N m 3 Qf m C � C mc R 'O = •L C N N ED m` o LZ N m s Ca N p,Ct m C � N V Z = a`� CD 3 H N m rO� r0+ O LL m �•• C cc � E a � r.+ 0 v .o cm w�"""omEc CO) a m O � �J = R � y H t . ai CO 0. N y.+ N N C 75 a m Of CIO C cm c 'c N m L O Z O g O r 01 U O O E C L O o C.3 Zco d O CO) CD CM 0 � C C y � � C LA G� C �E m co —ca �r 3 CDO � � 0 O _R O C' CL a c< y C C C R R V J 10 'a. O CO o ca Z a V y R C �C C _R CL 0 r j 01 Z L� x .J X 9 / I I , i Ln �- s I J V N x r� I� I� O I� I Y y I Q V Li Z � � y x X X �C '•j� K Z Z �. Z v 4 LM L_ L_ G_ O � Z � J Q t lu J Y Z Z Z Vc •—^• C - C� L� x .J X 9 WOOD STOVE INSTALLA MON CHECKLIST Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove A. New 1/ Used B. Typ rads Circulating C. Manu acturer tab. No. Name/ Model No. -e C ny M. Collar size 01mensionwHeightw Length Width Chimney /r A. New Existing V S. Size (flue area) C. Other appliances attached to flue (Number and flue size) D. Prefab (Manufacturer—name and type) E. Masonry/lined F!ue liner Unlined BYO. 6 manes mrul F. Height (refer to diagrams) cap CHIMNEY HEIGHT Hearth (non-combustible) A. Materials B. Sub -floor construction C. Minimum dimensions (refer to diagram) Clearances and Wall Protecticn (see stc•je ins;allat:en c!e=_rances chart) A. Type of wall protection provided B. Clearances (refer to diagrams) FIREPLACE CORNER HEARTH WALLCENTER. 13 - REGULATIONS After obtaining the permit, there are three consider. First, the stove; second, the chimney; First: All new woodburning stoves instz approved to U.L. 1482 -and/or U.L. 737 as apprc building department or the fire department. Eve. permanent and legible factory -applied label cont 1. Manufacturers name and trademark 2. Model and/or identification number of 3. Type of fuel(s) approved 4. Testing laboratory's name or trademai 5. Date tested 6. Clearance to combustibles a. Side b. Rear 7. Test standard 8. Label serial number Second: Existing chimneys should be. c general structural condition. A smoke test may t the flue is without obstruction and if there is ar chimney is needed to check for creosote deposit is in good working order. The following two ar inspect. The area where the chimney penetrate checked to be sure that there is at least two incl - and the chimney. Third: Chimneys and chimney connectors (see installation clearance table). The connecto ney and the connections overlapped upwards tc ance shall be maintained where insulated pipe pc and approved for lesser clearances. A non-combustible hearth must be provi6 below; if the legs are not present, an air space provided. Clearances vary with circulating and shield should be installed with ventilation behind clearances, and if the wall is a concrete foundati, The following systems have been approve Permaflue, Air Krete, Smi Exterior Insulation ane IsoKaern. The code requirement for two inch a because of its high insulating and refractory qL :as in the stove installation process to :he actual installation. lassachusetts must be tested and Sed stoves may be approved by the .el -burning room heater shall bear a east the following information: ince 3tion or the presence of a flue liner and determine if the draft is adequate, if leakage. A visual inspection of the cracks or breaks, and if the damper :d to the chimney a.re important to the floor of ceiling joists should be nce between combustible materials istalled with the required clearances .e sloped upwards toward the chim- creosote leakage. A two inch clear - a combustible wall, unless it is tested toves have legs and allow air to pass ,e non-combustible hearth must be eves. In general, a non-combustible 3r clearances, no protection for large minimum distance may be allowed. onstruction Material Safety Board: stem, Supaflu, Thermo Crete, and exempted from this type of lining 5 V.- 4. m m m m 0 m _v y� 10 C � CA10 0 CD n 0zy r E; o n. � � o C3. =• y 10mmlO O CD CD o cr d CD CD O CCD 23 C CD N! C3. y Cc CD S- CO) O 1 CD 0 Cr r) CD O O C CD 0 C�7 cn \ J V J C^ \ / O w z� � . cf) 4J: C�7 C7 C O c?�o o S. Vl O Cr N = _O.O - mCL 10 Cj y CO) m d = �• = =r= co) .d.� CD N T M -� O O H O y = O N m O tom'!CD . aCose: CL C:, m O H 0 CD a,.. i t -M. m 3 H M y a�cr C O° a gyCD: c m H O m m w co) CD IO Cl oci ..: 0 0 Er o CA 33 o co 6 .� CD _C y CD m �• rF O m _ Sm _ Q� C H = c o = c c O cc G E a W ;?7 G G� w c `� F (rQ n � p In y 110x G Go Z O G w n ?' ` 7z G •n G ° z p cn U rr cn -n O x C7 O o PTI y M .• V y 0 0 c Location --24 i 'PAQNU�M- �—r No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ S�CMUS Foundation Permit Fee $ Other Permit Fe)r6C Ll $ frV Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Z� _ r ' l• Building Inspr' PAID !26/95 11:05 25.00 T1 5 4 Div. Pu" N 2 W Z Y U_ I r N C m N W J r O J 0 � N 4. 0 W O ` 0 z O Z w L O rc 4 V 0 Z P O 0 6 U. 0 W N U) W 0 0 U 0 m r z W m J z w z w < rc w 0 Z i 0 C r U. 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O.CD -CD - m M y CL m �m n m �.o a� �m ?t ?n -+a m mocoS .. y o?m o = ��o� 0 Z�= o ea y� m � SIC CL o �m � ON C-4 CL m m C. 01 N O a' CL p1 : O •C �•57 :� C-10 m CD h N Q :� O O .mom► d1 7 m m O o � H 0 0' o m �m .� N moCD: m ns o� a'a n� c o �o CD o � ^) z W K d ii °= o c S- � cn °�— CD 2 (D o c � � � CA It 'n m o c �- "7' Z ^n n °c o c A.. tz zEl M (/) b n Q . R � d H O0 N V13 0 y 0 9 0 c TOWN of NORTH ANDOVER AFFIDAVIT .•n- bVmenit QrMmtor law �• uio i r• 'sun •� ✓. ■ • �. :• r ; 1 - :rr• � ■ ■ • z;•5 ■ • 11111111111liz I 0711wro I Vz:1 ■ • IM60 .wY • • s. -r • n r e • 1 of •- • • r• w r •_ rr �•■ar■ • • r • r a :• Type of Work: bec �'� Est. Cost ZSorS Address of Work 2-(-/( Owner Name: 5+ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): For d6ce Use Qtly Work excluded by law Job under $1,000 Building not owner -occupied =Owner pulling own permit Other (specify) Notice is hereby given that: Ea3mt ND. Date OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS--' FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRA- TION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed uzler penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice I hereby apply for a permit as the owner of the above property: Date wner Name The Commonwealth of Massachusetts J -_ - Department of Industrial Accidents wee of/ Jeffs 600 Washington Street Boston, Mass 02111 Workers' Compensation Insurance Affidavit ame: S � e u'---- (Tr �PA -C ( l location: citv /�' U' :/T O V phone # 4d o 6 Z S �' I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. _.. _... _.... .... _ ......._ - .. _:.... ....._.._ ... _..... .. ......... _...... .._.... .......... ... ......._ _.. I am a sole proprietor, general contractor, kr homeowner (o* Ie one) and have hired the contractors listed below who have the following workers' compensation polices: 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 DLA for coverage verification. I do hereby certify un a ains and pe Ities of perF that the information provided above is true and correct Signature Date /Z A S Print name :Ci Phone # official use only do not write in this area to be completed by city or town official city or town: 17 check if immediate response is required contact person: (revised 3/95 PJA) permit/license # nBuilding Department oLicensing Board pSelectmen's Office 0Health Department . phone #; nOther Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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. :;rX '"t :,,r4s ",.� u' 0....-::+. #. aw:..,.,. `2.'fat ,� `,.#' Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. r � -ii .,»:."L` � � `�. y i, � ,`r'y {� .. � m: - � "�. xr, / ✓4* S"x x,s„ r `� % ,:, � s City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. ,e - FYy�,�e"`-Ze „P._ Mr.+F• sMe.Sra7""�::.r_,a A _ h„`'�p f • �' Y Y � y , Vie, , f >ra z s �c.��r ., •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 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 zo O t0 0 QY W v I J LO to OD z 129.2' L_S 0(y 00' 00" W 238.00' / �O _ 1 I C7 NNvl Sj � Q 0 J 0 Z) co N F - LL. ,'J.' s w .to N U) b' f L)Jy LOLO t0 6000 ro Ln oo z Al ,y 129.2' L_S 0(y 00' 00" W 238.00' / �O _ 1 I C7 NNvl Sj O '• J b .. t4 GO If 1 In ,'J.' s O O t ua m U) b' f L)Jy F— 6000 Ln oo t X53 O '• J b .. t4 F— 6000 t X53 O Q+%. 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