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Miscellaneous - 242 MAIN STREET 4/30/2018
N) N Date.... . N . .... ....... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... has permission to perform ......... .41� . . .......................... wiringin the building of .......... . ..................................................................................... at.�. ... H ...... a ........ 4 ......... . ......................... =dover, Mass. - 44 ---01) Fee ... 15t) ... . ........ Lic. No. T. LECTRICALINSPECT Check # z --q ,- I -, 0 � 'r -1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 LO&C) Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL .INFORMATION) Date: i 0 13 ` x l 11-i City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 2.� 2.. 4.,\ S 1` Owner or Tenant sFcv` M1, C -L Telephone No. e1 -J, - LAS- 3735' Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building �-"%Vyk- - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed /Electrical Work: g�y� u I'{' �� � Cl r � «I rr'' Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators 1 KVA No. of Luminaires Swimming Pool Above In- rnd. ❑ rnd. ❑ o. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons """'"""".............. KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:`-' No. of Devices or Equivalent of No. of Water Heaters KW No. of No. of Signs Ballasts Data No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Fjt mated Value of Electrical Work: (When required by municipal policy.) ork to Start: �'�i i Inspections to be requested in accordance with MEC Rule 10, and upon completion. INNURANCE 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 N BOND ❑ OTHER ❑ (Specify:) I certify, under the gins and penalties ofperjury, that the information on this application is true and complete. FIRMNAME: (P.^� �1e.�iw-l��a-( Sef,i�w LIC. NO.: 41551-5 Licensee: '2,,J,,L Signature LIC. NO.:t_6 i 2 j (If applicable ent "exempt" in the lice n�c nzzmber li) v Bus. Tel. No. • to ° t - S r2.- eFI Lf. Address: .kL c�� _ J ,q (u•�, /l; i.(- ©Z Alt. Tel. No.: o - !" *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S"'License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. Ar F, Ir ,r D ❑ 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 - Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Y i Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL IN ECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Co nts: (/ Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Xndustrial Accidents Office of Investigations 600 Washington. ,Street .Boston, MA 02111 -www.mass.gov/clia Workers' Compensation Insurance Affidavit: Builders/Contract Name (Business/Organizationitndividual): �,t.o Address: City/State[Zip: N 4 3o S Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. P4 I am a employer with 4• ❑ I am a general contractor and I 6• [] New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner have lifted the sub -contractors listed on the attached sheet 7• ❑Remodeling ship and'have no.employees These sub -contractors have 8. E]Demolition worldng forme in any capacity. workers' comp, insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3.E] . am a homeowner doing all work officers have exercised.their right of exemption per MGL 11. [( Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), andwehaveno 12.❑ Roofxepairs insuratncerequired.) employees. [No workers' 13.❑ Other comp. insurance required.] ,Any applicant that checks box#1 must also fill out the section below showingtheirwbrkers' compensatioupouc;y information. f-Honneowners who sabmit this affidavit indicating they 9doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name% Policy I# or Self -ins. Lic. #: V IR�'Z� C_ 14 Expiration Date: J'ob Site Address: 2-� 2-- -� U rawState/Zip: %J Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,50 0.00 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 ver'if'ication. IT do hereby cerflA under tine yains andpenalties of perjury that the information provided above is true and correct. official use oply..Do not write in iliis area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone M. 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 ofbire,• express or implied, oral or written." An employd is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of a- deceased employer, or the receiver or ttvste'a of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore 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 bean employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct 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 chapterhave beenpresentedtathe contracting authority." Applicants Please fill. out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier ihatt the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicyis required. Beadvised that thisaffidavit maybe submitted tothe Department of Industrial Accidents for confirm anon 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 andprinted 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 bo -sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in . (city or town): ' A copy of the affidavit that has been officially stamped or marked by the city or town may b e provided to the applicant as proof that a valid affidavit lion. file for future permits or licenses. A new affidavit must be, filled out each year. 'Whare 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 Caxr_monmat olassac?vsPits - JDep.at�Ment dInduddal Accidents Qf e of11RV1*1g,1-aQ . 60 Wasblugtora. Stroe4 Boston, AIA 02111 T019 617-7.27 4900 QA 406 ox 1-877WASSAFIF, Revised 5-26-05 Fax # 617-727-7m WWW—wss,govaa 'IHATION DI GENERATOR APPLICATION DATE LOCATION: OWNERS NAME: `e- pv�°' GENERATOR kw 1� NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: 1,P I +�� �iw, «,.� PHONE NUMBER: GO3- SS 2_ `AS- L(, ELECTRICAL RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL "IJ, c• September 25, 2012 Harold McPhee 242 Main St 2FR North Andover 01845-2513 Dear Harold McPhee: Golumbia Gas - of Massachusetts Account Number: A NiSource Company 55 Marston Street P.O. Box 869 Lawrence, MA 01841-2312 978.687.1105 Fax: 978.688.1875 During a recent visit, our service technician detected a safety problem with your gas water heater and house heater located at 242 Main StTLI, North Andover, MA. Accordingly, we have issued a Warning Tag because of this situation. Shut off to water heater is leaking gas and the house heater above the gas valve is leaking gas. Under the circumstances, we strongly urge you to correct the code violation. In addition, the Massachusetts code pertaining to the installation of gas appliances and gas piping, established under Chapter 737, Acts of 1960, requires that the condition be remedied. If you have any questions, please call our Service Department at 1-800-698-0940 and ask to speak with the Service Supervisor. Please disregard this notice if the condition has been corrected. Sincerely, Customer Service Department Columbia Gas of Massachusetts CRR: CRR# C:\cisupdatedletters\110 09/25/12 Date.Y ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..fl%.�...�9 .%............ has permission for gas installation , /. ... AC --.0 4 in the buildings of . 4.1!< ............................ at North Andover, Mass. Fee. ... Lic. No..... . . L—t...... GAS INSPECTOR Check # D 7 '/ ` r Ti 99 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TC (Print or Type) M G UO GA,SFITTING tai' )K-ri 1 A W DOVE 12 , Mass. Date 4-12912010 Permit # C Building Location 242-244 tiAW ST. Owner's Name HQR01.1� M�Pii�G m� / ozH ANDOVER HA Type of OccupancyRES10EW1AL, ±-Ff�F�l1�r New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ Installing Company Name BAY STATE GAS COMPANY Addr6ss 55 MARSTON STREET LAWRENCE, MA 01841-2312 Business Telephone q (b — 6 8 7 -110 5 cxr #306 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # �l Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please indicate the type coverage by checking the appropriate box. A liability insurance policy P< 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❑ Agent El 1 hereby certify that all of the details and information I have submitted (or entered) in ab o pplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issu f r this application will 1,n compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. BY T e of Ucense: Plumber Title PGasfitter Signature of Licensed Plumber or Gas Master License Number 274-5 City/Town Journeyman APPROVED OFFICE USE ONLY) ■oMMEMME EEMEME MEMO INK ■����������������©��i�tson 0 NEI .. ■������������ff��tff� 01 son Installing Company Name BAY STATE GAS COMPANY Addr6ss 55 MARSTON STREET LAWRENCE, MA 01841-2312 Business Telephone q (b — 6 8 7 -110 5 cxr #306 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # �l Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please indicate the type coverage by checking the appropriate box. A liability insurance policy P< 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❑ Agent El 1 hereby certify that all of the details and information I have submitted (or entered) in ab o pplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issu f r this application will 1,n compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. BY T e of Ucense: Plumber Title PGasfitter Signature of Licensed Plumber or Gas Master License Number 274-5 City/Town Journeyman APPROVED OFFICE USE ONLY) z O F U W CL N Z N N W Ci O CL 0 U w z a n m n z� O C O z O LL ¢ w m N O a � x J OJ n z O O 0 _' .. W O N a � W t U � LL o a o U. Z a Z a ¢ � LL LL M 0 C LL O J F W W Q 0. J f" IL .rt a W Q � � z 0 U w z a m n LL O C O z O ¢ w m O a � x OJ a Date ....... 77. 64.1... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................101........ 4 has permission to perform ......... --- ------- wiring in the building of ..................... .................................. S7 ......... 1 at ...... . ................................. . North Andover, Mass. Fee.. Lic. No. ..0............. ... Check# 8254 -55 ad/s7 _`1J.parfmonl a��`ire �orvicas BOAR D,OF FIRE PREVENTION REGULATIONS Oficial Use Only PcrmitNo. c72 Occupancy and Fee Checked (Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK. ; All wor to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 INFOR1t�L4T10N Date: %- - G� (PLEASE PRYT Y INK OR TYP ) Cay or Town of: To the Inspector of Wires: By this application the undersigned gives notice of hrs or her intention to perform the electrical work described below. Location (Street & Number) 2—f2, 144fke,'n Oa Owner or Tenant /n� •}y11/'S 4,V1 Telephone No Owner's Address I- I!s this permit in conjunction with a building permit? Yes E]No (Check Appropriate Box) Purpose of Building Utility Authori7.atien No. _ Existing Service Amps / Volts Overhead ❑ Uadgrd ❑ No. or Meters New Service Amps / Volts Overhead ❑ Undgrd J No. of Meters Number of Feeders and AmpacityeCtLr —r-- J,t pr —1rc far Location and Nature of Proposed Electrical Work:y r'1 �• S �STryr1 / /`.... ler;.... nfrl.a fnllnwinV t,f10 .nifty h.P waived by the Inseector of Wires. Estimated ValAoolec i Work: tiG� (When required by. municidal .policy.) Wurk to Start:Inspections to' be requested in accordance with MEC Rule 10, and upon completion. INSURANCEERAGE: Unless waived by the owner, no permit for the performance of electrical work may tissue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete- 2 omplet S3 3 C.FIRM NAME: �-T S�curt-r� ScrUl� LIC. NO.; Signature �_. LTC: NO.: —� Licensees �( �t .59� (Ifopplicable, enter "c a pt" in the�nensnum ,mine.) / , �H a3a�9 Bus.. Tel. N0.: _ Address: d L / �r� I�_ '' " ��l' Air: Tel. No.: 75 *Per M.G.L. c. 147, s. 57-61; security work requires Department of Public Safety "S" License: Lic. No. S� CC G G ! 9 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, [ hereby waive this requiremenL I am the (check one). ❑ owner . E] owner's agcnL Owner/AgentPERMI3'FEB: qj Signature Telephone N:. _ _ -- ]fiCT of ota No. of Recessed Luminaires No. of Ceil.-Susp. (Pa e) Fans __- Transformers KVA T I`Io. of �,uminaire Outlets No. of Hot Tubs Generators KVA lr_: _t r,aergencyLig ting A ove ,n_ ❑ No. of Luminaires Swimming Pool rnd. �rnd. _ ___, Battery Units No. of Receptacle Outlets - No. of Oil Burners FIRE :+,LARNIS No. of Zones No. of erection an INo. of Switches No. of Gas Burners i'iating Devices No. of Ranges oral No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump _um _1 tons---n—o. Totals: of Self -Contained Detection/Alerting Devices space/Area Heating KW N unrc1pal Other Local F-1Connectior. ❑ No. of Dishwashers He AppliancesKtiy ecurity Systems: No. of Devices or E uivalent No. of Dryers. No. o. o titer KW °• ° Ballasts Data Wiring: No. of Devices cr E uivsl_nt Heaters Si ns ' . No. Hydromassage Bathtubs No. of Motors Total HP _ e ecommuntcatrons irrng: No. of Devices'or Equivalent OTHER: ... ..L 4,4;,,* 1 --;-d by the InraeC(Or o%Wires. Estimated ValAoolec i Work: tiG� (When required by. municidal .policy.) Wurk to Start:Inspections to' be requested in accordance with MEC Rule 10, and upon completion. INSURANCEERAGE: Unless waived by the owner, no permit for the performance of electrical work may tissue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete- 2 omplet S3 3 C.FIRM NAME: �-T S�curt-r� ScrUl� LIC. NO.; Signature �_. LTC: NO.: —� Licensees �( �t .59� (Ifopplicable, enter "c a pt" in the�nensnum ,mine.) / , �H a3a�9 Bus.. Tel. N0.: _ Address: d L / �r� I�_ '' " ��l' Air: Tel. No.: 75 *Per M.G.L. c. 147, s. 57-61; security work requires Department of Public Safety "S" License: Lic. No. S� CC G G ! 9 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, [ hereby waive this requiremenL I am the (check one). ❑ owner . E] owner's agcnL Owner/AgentPERMI3'FEB: qj Signature Telephone N:. _ _ TT TT N b yy. 1 00 m 0 C) lA ' m l rOz r l � m % 9 � S z n-4 = Z. 0 � 3 a C, Z N v W m v z 3 00 7 8 V � m z. v U: n m• cn TT 'n �. o m z CAI n �1. z o m •••1 a —1 C) c: o 0 00� o T -n a Zi (D. o J , m 0 > 0 w m Ln d •, o zrna 0> ' N m " A m �a =` o m u7 CD N 71, o�mi0 OwO�,1Nja�l 0 C) lA ' m 0 C) l � m r S z n-4 � 3 �. rrr � � cn C i vi;. 3p 3: F C: V � V', �'L ♦1.Y.lJ �1R11�M l z. v U: n m• co U) 'n z ro v x -� —1 O m A N m Zi (D. o m 0 > 0 w m r d A• V ' N CD CD N 71, o�mi0 OwO�,1Nja�l 0 C) lA ' m 0 C) l � m r S z n-4 � 3 �. rrr � � cn C i vi;. 3p 3: F C: V � V', �'L ♦1.Y.lJ �1R11�M l z. v U: ( m• CD N 71, C N m n z r T z n-4 cr P z m � cn 17 r A c7 o 0 z z ( o co U) m 0 n ro v x -� m O m A N > y zm Zi (D. o m 0 > 0 r d D ' CD =` o m u7 �.co 3 ya A o Q�.h N W CD 0 co X, r Q N N n W 7 -z-z I Y i i cA A cr N � cn n rn C) o C7 0 co U) m 0 n ro v x -� m O m A N > y zm Zi (D. o m 0 > 0 0 0-(D to C:) �D Cc O �.co 3 ya A 00 1 M Q�.h q 0 ..' CD 0 Q I Y i Date .. ';I/t-/ Q `7 ......... ° 3? ` TOWN OF NORTH ANDOVER M _O 9 - PERMIT FOR GAS INSTALLATION This certifies that .. .c� s.... ��!�. F�...................... has permission for gas installation n ................ in the buildings of k� .4 : ................................ at ..`l.l .. ? �. ! ... <-r ..... .. , North Andover, Mass, qty Fee. ?..... Lic. No.2 2 c �..... .................. . GASINSPECTOR Check # 6b�,4 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) N 7)(! UgN Mass. Date?lr�) Permit # Building Location Owner's Name v Type of Occupancy_ G New ❑ Renovation ❑ Replacement Pr Plans Submitted: Yes❑ ' No ❑ Installing Company Name_�1,1 J) AL Check one: Certificate # Address t dt ❑ Corporation O % ❑ Partnership Business Telephone ( 3 Q' Firm/Co. Name of Licensed Plumber or Gas Fitter 04 �d U Cc, INSURANCE COVERAGE: r . 1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes O No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. I A liability Insurance policy L✓y 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❑ Agent [I 1 hereby certify that all of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit ued for this application will be In compliance with ell Pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Ilerital laws. T e of Ucense: Title F lumber Sigrolute of -License um e -G itter Mouineyman astittor Cily/Town aster License Number Ar'f'11()Yi GTOTTtC _ 0 7; ___MEMENMMEMM •.9 95 C:u�CQ ...�� ��S7CC. 9C ..T:�s� � C:C::.EpCCC:::�.:8 x:07::::: 8CBp C .G D ..RC... Installing Company Name_�1,1 J) AL Check one: Certificate # Address t dt ❑ Corporation O % ❑ Partnership Business Telephone ( 3 Q' Firm/Co. Name of Licensed Plumber or Gas Fitter 04 �d U Cc, INSURANCE COVERAGE: r . 1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes O No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. I A liability Insurance policy L✓y 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❑ Agent [I 1 hereby certify that all of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit ued for this application will be In compliance with ell Pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Ilerital laws. T e of Ucense: Title F lumber Sigrolute of -License um e -G itter Mouineyman astittor Cily/Town aster License Number Ar'f'11()Yi GTOTTtC _ 0 7; 2 D M I» v m a a a M D x m 0 M M 0 X M x M N v a 0 0 a m N N 2 N v in n O 2 �a. P Date ........... ...... . TOWN OF NORTH ANDOVER , a PERMIT FOR GAS INSTALLATION This certifies that ...... ............. • .. . Jias permission for gas installation 0..... ............. . .I*in the buildings of ...r.-ri-................................ " at ........... North Andover, Mass. Fee-. ' . Lic. No.. ...... .. �-............. / GAS aci R L' Check # !. Q ; 0 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING or print) Date U d -1.9-- d 3 19VKIn AIYDOVEI2, MASSACHUSETTS ,rte I Building Locations 2 -LI Z- % r 1� t S �-1}— Permit #/NQg Amount $ ��j 11 1 ld P -%S f ^ Owner's Name New11Renovation 11Renovation Q Plans Submitted ❑ 2,0 (Print or type) Check one: Certificate Installing Company NameS;�$T�7 L.� -� !-� 1 ❑ Corp. Ad+Aress L ❑ Partner. ,ausihess Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond 1:3 Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 'o hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this aQplication will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. n % _ By: Title City/Tuwn APPROVED mFfici: USE ONLY) Signature of I Plumber Gas Fitter rM Master Journeyman sed Humber Or Gas Fitter License 1 uDe C .i (Print or type) Check one: Certificate Installing Company NameS;�$T�7 L.� -� !-� 1 ❑ Corp. Ad+Aress L ❑ Partner. ,ausihess Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond 1:3 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 ❑ Agent ❑ 'o hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this aQplication will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. n % _ By: Title City/Tuwn APPROVED mFfici: USE ONLY) Signature of I Plumber Gas Fitter rM Master Journeyman sed Humber Or Gas Fitter License 1 uDe C Date. -tel ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ 'ro .. ..... . has permission to perform ............................ wiring in the building of ' ' at ..... ......S ............................... . North Andover, Mass. Fee ..................... Lic. No..I.ZY? ?.................. ELECTRICAL'INSPECMR d Check # 48L9 i THE COMMONWEALTHOFMASSACIYUSETTS Office Use o DEPARTN1EVT0FPUWJ'CS4FL7Y G BOARD OFFNEPREVEMONREGUL4HONS527CA RI2.GYI Permit No. Occupancy & Fees Checked APPUCATIONFOR PFRMIT TO PERFORM ELECTRICAL WO.RK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:001? ) (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat vG Town of North Andover Toth Inspector( The undersigned applies for a permit to perform the electrical work described below. Location (Street &Number) /72q: /Nj '3-r Owner or Tenant Owner's Address G Is this permit in conjunction with a building permit: Yes E.7ail No (Check Appropriate Box) Purpose of Building Utility Authorization No Existing Service Amps �Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead Q Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 3011-11> {?oast- KI,;S44-Q, tad p o t --k i>r No. of Lighting Outlets No. of Hot TubsNo. of Transformers TC K` No. of Lighting FixturesSwimming Pool AboveLEw Generators KI groundd No. of Receptacle Outlets / No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. TotalTNo. ALARMS No. of Zones, Tons No. of Disposals No. of Heat Total TotaDetection and Pum s Tons KWing Devices ' No. of Dishwashers Space Area Heating KWSounding Devices Self Containedtion/Sounding Devices No. of Dryers Heating Devices; SL KW Local Municipal Other No. of Water Heaters KW No. of ' No. Connections Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP 11�4 YNIJ OTHER - Inst Mr=Cove1aW_ Rustpanttothetacgm newofMassadxmftGffiffWLaws IhawaauraltLiab&yksta- =Fbkyarhxkgt ornplet COveWorgs e4r,abt YES rn i,10 Ihaws knii mdvandptoofofswriotheOBv-- YES � Ifyoubaved�dIES OEiw ixfi�thetypeofcovwW-by dxtgthe box INSURANCE' BOND OMIR ftaseSpecx(y) EVirationDaie wcdaoS4tt _/qS{'QEftra"ValuedEacmcalWodc$ SignedunderTr Finall� FIRMNAME 047f 72,t(-A� SAO LA' -, IxenseNo. �j signature Iicer>seNo GA :S4©'_x3 BitsuressTelm �dc hnsc / AIL Tet No. )WNE[Z'SIlJSURANCEWANIRIamaware that theLicencedoesnothavethe instnaMcoverageoritssubontblequivalentasiMuredbyMassachusettsGenerelwsIa rd that mysignahueon thisperrnitapplicah'on waives thistegtruenorit Please check one) Owner {� Agent Telephone No. PERMIT FEE $_r,rQ signature o caner or gen The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affl-davit Name Please Print Name: Location: City 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. Comr)anv name: Address City Phone #: Insurance. Co. ___ _ _ Policy# Company name: Address Cft Phone # Insurance Co. ___ Policy# 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 $1,50( and/or one years' imprisonment_as_well_as_civil.penattiesln2he%rm4a_STOP:WORK_OR)FR�nd_a.fine_of.($1DD-00)-aAay.against.me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify under the pains and penalties of peilury that the information provided above is true and correct Signature Date Print name Pbone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/UcensincI Building Dept E)Check if immediate response is required .p Licensing Boa p Selectman's C Contact person: Phone #: F-1 Health Departs F -i Other R n Location o� �� h f i4 'A) No. a S Date J-111- 123 MaRTM TOWN OF NORTH ANDOVER 3: • 0 10- p # Certificate of Occupancy $ Mus Building/Frame Permit Fee $ s�c Foundation Permit Fee $ Other Permit Fee $ TOTAL $ U Check # Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Tbb flit` i#iicial Use 9jo BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: rcx.,— BuildingCommissioner/In for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: La- av I K) 1.2 Assessors Map and Parcel Number: a Map Number Parcel mber 16 N,d O V C A- SS AJ 6 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 Required Provide Reqwred Provided Re red Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record c2 l�0 doe Elf me(Print Address for Service 17f - Signa re a ep one 2.2 Owner of Record: Name Print Address for Service: i i nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licens Construction Superyi r: 1 oxo lcD �'A co aj 0/0 Licensed Construction Supervisor: - � C �� fi/t; /' l�/ Addie l ' ` "W / I / ' Signature od Telephone Not Applicable ❑ C.50 7:5 F y License Number ,Z 0 Q Lr Expiration Date 3.2 Register ome Improvement Cgrqactor Not Applicable ❑ Z -57:5-0 5-- G Tany Name — 76- �O� �j �r ��,/%C /� ��1 Addr !! l� � l� ,` ii��iX�.I�N� Signature V Telephone Registration Number Expiration Date Ma M X ic Z O v M O Z M 90 P, 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 Descri tion of Proposed Work check au a Heable New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify _ Brief Description of Proposed Work: &1t4_,9 3a c � w — /5!h I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I GGc ivc &,a& j Item Estimated Cost (Dollar) to be Com leted by permit applicant OFFICIAL USE ONLY 1. Building�+ �4 7 �� d _P (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORILAT10N TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize rev to act on Myr 1 ; in all matters r tiv ork a rU thi ilding permit application. Si nature of bwv n Date SECTIO 7b OWNER/AUTHORIZED AGENT DECLARATION ell I, 4-ldP vv 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'-' N 1 c0�9 w o� 7S Print Name Signature of Owner/Aeent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TDABERS I ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING ' X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE A 73 UD m Z 3 CD 7! CD = (n CD oou > M (D Z 0 0 2.2 C) 00 CP cn z o p p C/) co m x C -u 0 0CD m0 Q) C CD j\/7 C) C) 0 X o > 0 CA C) ^\/\ M 4D z U) c m m 0 -V C) M C: =3 QL c) C) 0 co CD CD x(c) (3) OD 41 73 3 CD 7! CD = (n 0 U) 0 Z CP 00 Cl) co m x C -u 0 v CD< m0 Q) - (1) CD C) C) 0 X o > 0 CA C) M 0 :3 cr 4D z U) m 0 =3 QL c) C) 0 co CD CD x(c) (3) CD CD CD C) Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit 6 4V C', Location: J V .�. i% em of Please Print Cit, N-6 614 drat iL � Phone # l 3 2 -2- I 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. Company name: Address City: Phone #- Company name: / \ f l y� f Address S %_t~y�4'�4t.�Lr (21 W .WTU 3 4Zb:7( 4.s� r. Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of cxirninai �p. penalties ofafine to$1,50p.t)Q and/or one years' imprisorunentas_welLas_cba penalties--thelam-dab7QP]AOWDRDERarxLafte-dA$U M)—ajl y--x-%Wnstmm t understand that a copy of this statement may be forwarded to the office of investigations of the DIA.for c mwage verification. / aiv hereby ce►tily the pains and p,Rna/ries of perjury that Me inrormatr provided above is true ane correct. -7/0/@3 Print name � Phone, Official use only do not write in this area to be completed by city or town official' City or Town P ❑ Building Dept []Check if immed ate response is required � Lkensincg Board E] Selectman's Office Contact person: Phone # ❑ Health Department ❑ Other � Nilravelers WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE POLICY NUMBER: (7PJUB-928X453-1 -03 ) INSURER: THE TRAVELERS INDEMNITY COMPANY OF ILLINOIS INSURED'S NAME: GAGNON, RONALD DBA TRISTATE PROPERTY MAINTENANCE ANNIVERSARY RATING DATE: 06-20-04 RATE BUREAU ID• 000153689 CLASSIFICATION LOCATION 001 01 FEIN 015400395 ENTITY CD 001 GAGNON, RONALD DBA TRISTATE PROPERTY MAINTENANCE 75 COCHRANE CIRCLE ME THUE N , MA 01844 CARPENTRY -DWELLINGS -THREE STORIES OR LESS 13579 -MA PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CODE REMUNERATION REMUNERATION PREMIUM 5651 I F ANY 10.62 MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $ LOSS CONSTANT (0032) ADD FOR POLICY MINIMUM TOTAL ESTIMATED ANNUAL STANDARD PREMIUM EXPENSE CONSTANT(0900) 4.50% MA WC SPECIAL FUND AND TRUST FUND TOTAL ESTIMATED PREMIUM DEPOSIT AMOUNT DUE NONE 50 328 378 122 17 517 517 DATE OF ISSUE: 07-03-03 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is -that. the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A.. The debris will be disposed of in: (Location of Facility) ()& I �,o Signature o it Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02 411 Workers' Compensation Insurance Affidavit Name Please Print 60)A -I6 V G) ,�C-woA) Location: -2- L Z- `';LL4 L�M +f /Uj (Et City yo t, 9W b0/t r tt% Phone # 6,,Pf-9 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. Company name: Address City. Phone#: �t f�C vgoprll-y *Ala Address 5 C6 GkA* u) U (14 rLc 67 Phone#. RAU-5i f SQ/Z(- Po icy # `7 p TVB `lk -)('i S-� / Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a Me up to $1,500.00 and/or one years' imprison m uA-as_wefLas_civilpenaitiesJo3he%�d-aBTOP]MDRKDRDFRmd afioe-dA$MW)-aAwagainstme, 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 un a pains and Ices of perjury that the inlarmabon provided above is &w and correct. Signature Date Print name Official use only do not write in this area to be completed by city or town officiar S Ci YY O City or TownPermd/Licensira ❑ Building: Dept ❑Check if immediate response is required ❑ Licensirig Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other U) m m m V) m CO) 10 CDZ a. r d � n =. a� .p .p o MW o p CL C� CD o Q o Co CD CO) .p CD a 0 7 CO) d ca O C O C CO2 d n CD 0 CD CD CO) CD CO) O O co 0 CD < c? -O m o -•yoa H d OCD C/2 �CCIL, COD Cl) O y . n a m Z =r-Cgo N 0, ._► .di CD H T ira..o• c CD --qcCD y C y m O -.= : O � = CD m a CD ;;:� o E, C �� O t..f O n 0 OZa'n CC CD j1••''•,1n "F "F V ' Oco w nn�:�t�: y •� Cy y co H ddV C cn y m O CVI co_ po. -. b C CD O ®o cnz _ �_ N O O O Is O = CD Q m • cnP CD �.�+. cn I ni H ' Im r: W n1 b 0 CA o O = Co 7d . C* 5' . Mu O C , n, o �r, c rD o Ix 7d n ►,y cn -n (CCD 0 ro rDi W dG �--. ^' 04 p. Phi,_... C �- W G °�°- C w 10 rt n O � z d 0, O. O ,� ► rr n ° M y � y H 0 0 c v Location y� q �� M A ti No. 17/ Date -IS y 3 4 a TOWN OF NORTH ANDOVER + Certificate of Occupancy $ Building/Frame Permit Fee $ a s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ OZ 9 y AP Check # t�Q r' 167,,7 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REM RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: _ SIGNATURE: �v r Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: aLp-a-w A41ry 1.2 Assessors Map and Parcel Number: q a Map Number Parcel Number l�) dM d duex elA w;f 1.3 Zoning Information: Zoning DisUict Proposed Use 1.4 Property Dimensions: 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 Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT Historic Distric 2.1 Owner ofRd ecorAC 1WP$/ G� fa��°�n� � inn Y Name (Print) Address for Service : Signature elephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 LiwnV struc�n�ry�sor: WA(l or: H)D Licensed Construction Supervisor: �% 5 COCA IM 9)& C -I & (4 VM' ��`/ Address , 4 � Signature Telephone Not Applicable ❑ Cso S � License Number C) `y Expiration Date 3.2 Rqed Home Improveme t Contractor 4A)Pr Id &6w')A% Not Applicable ❑ Company Name, L•- �0Ck/I kA)C— el rfC (` PI ' I 04- ` i" ..7 Registration Number 200 y AddresI 61 �� q -n (?6 LI(14 Expiration Date Si nature Tele hone L• 00 rn X z O SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 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 allspplicable New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition' Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work:wG `3 s' aW 9 x J ©" 1 011L USC 3 d - w SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be CoUipleted by permit a licant OFFICLAL FTSE O NLY 41 ' 1. Building 1 G l� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of n G1-11"Construction �Sv 3 Plumbing Building Permit fee (a) x (b) a 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. -Signature of Owner Date SECTIO 7b OWNER/AUTHORIZED AGENT DECLARATION I, ��%4 ! t/ 6OA) 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 belie Print Name 62,,, q/3 Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 sT2 ND3 RD SPAN DIMENSIONS OF SH LS DRAENSIONS OF POSTS DRAENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOT WG X MATERIAL OF CH VINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Ron Gagnon (978)689-4448 Page of Property Maintenance NAME OF OWNER rplb ADDRESS OF JOB// //r 412 -" aZVV /�ll1L 4 TEL. ` b A(Qye DATE:L�DL We hereby submit estimates for: l o x to G� who - .� w� 1paa lwuAl�- 4�ltj NTS Pt'OPM hereby to furnish material Ipbor - clompie In accordance with above specifications, for the sum of:C 3 0 V • �!. , j � ' dollars Payment to be made as follows: uo All material Is guaranteed to be as specified. All work to be completed In a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary Insurance. Our workers are fully covered by Workmen's compensation Insurance. �QQ of P"1 — The above prices, specifics lona and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Authorized Signature - NOTE: This proposal may be /`� withdrawn by us if not accepted within v days. Signature IL Date of Acceptance: Signature I I } The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02991 Workers' Compensation Insurance Affidavit Name Please Print Name: N( W ff l V (I 6� A a w o x) Location: �Z — 9L/ - A, City 10 Z 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'r-crpensation[for my employees wonting on this job. Comoanv name: �' - s��� (/ /F (�✓�L /1 !1/ Address %S 00(-�AtfVC Ct/1Gl�-- City:Phone*. Insurance: Co. &�j4WNib i Policy # /3L 2 S S' L 1 Y- 3 Company name: , Address_ Phone #- Faihue to secure coverage as required: under Section 25A or MGL 152 can lead to the imposition of criminal penalties of;a fine up to $1.5 and/or one years' imprison of -as -w t-as_chaix nattiesjoshelmn—dA c7OP _ate-aolQo- p)-aain ma understand that a copy of this statement may be forwarded to the Office of Investigations of the blA for coverage verification. I do hereby cefify the pains and p6heftfs ofperjury that the YY07 ation provided above Is trine and correct Si nature 9A/A _. Date Print. e_ Official use only do not write in this area to be completed by city or town officiar Y/ 3M3 (Ceyv W City or Town PermittGicertsLm. [jck Cheif immediate response is required Bflitdiet9 Dept ❑ Licensing Boars El Selectman's tuft, Contact person: Phone # E] Health Departm, ❑ Other NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-954 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Pe t,.A15plicant C7/ Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Subject ---- -- - - -S4 r - - _ t7--- --- lit #70443 Notes Subject l !' ,pt } ✓lie - oonvnao,,auea/� � /�,aaaae�zcraeC� 51�BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS, 075384 Birthdate: 10/02/1949 Expires: 10/02/2004 Tr. no: 12523 Restricted: 00 RONALD P GAGNON 75 COCHRANE CIRCLE METHUEN, MA 01844 Administrator 1loard of � Building Regulati HOMons an "r E d Standards IMPROVEMENT C ONTRgCTOR, ReWstrationc 125502 Expiration: 1/8/04 Type: DBA RONALD P. GAGNON RL^+QLD GAGNON' ... 75 CJCH:RANE CIRCLE AIET�jCw , iv1A 01844 ---;,� K-. a,-- CA 10 CD Cl) Z CD O ar o iii.. 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E O 4 i oc � C W W W C6 W a > a .� V a. F' H y V� � •ice U. z z o Z W c W V o �M W d Q CL Q Z Z u ? c. Q o Z m a W m m L C L L U L Y Of E a W '1 N ` lb O ` O oOC U ii ii ¢ co U. Q ii m co E � J W J MR .tt H L •w iiA i. E 4 i � C > ^ .� V a. E y V� � •ice CL c o w c m V o �M W CL Z W It Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE-- Cf� JOB LOCATION HOMEOWNER" Street ome PRESENT MAILING ADDRESS S,� P ity/Town �/ �-. s ress Section of tow one Work Phone State Zip code The current exemption for "homeowners" was extended to include owner occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the ;building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of ,North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and ,requirements. -HOMEOWNER'S SIGNATURE ,,;;�4:;;�—, APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control.