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HomeMy WebLinkAboutMiscellaneous - 245 JOHNSON STREET 4/30/2018 (2)17 O A t00 � V C- O OZ O Z 9 Z O X O m o m Date .I.- . 1... 1. � . . . rtv, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. 1 . h. r... .. C .:..... S.............. . has permission to perform .. . �. ?'�` .. �....`'. �' .'......... . �ts�wiring in the building of ..... ..... . �................... . J 1 at. �.... ,�.Q. hsan...� 4 ... .... , rth Andover, Mas Fee 70..... Lic. No. ��! d.. M Q........ EL CTRICAL INSPECT Check # 11340 c J commonwealth of Massachusetts Department of Fire Services aM BOARD OF FIRE PREVENTION REGULATIONS official Use Only Permit No. ! �g -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 C 12.0 (PLEASE PMT T ININK OR TYPE ALL INFORMATION) Date: i XT 'S City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned -gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant 0 �9 e s r-4 Telephone No. Owner's Address p. t Is this permit in conjunction with a building permit? Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Yes No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Attach aaatnonai aetuic � uesueu, v. uv icy..w �u y .••�-•�------ -� Estimated Value of Electrical Work: 2 f� - (When required by municipal policy.) Work to Start: I JO Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenal ies of perjury, that the information on this application is true and complete. FIRM NAME:. G t' 4 !w4 5�,a LIC. NO.: y761 -f : Licensee, r Signature LIC. NO.: ( applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 0 � � 3% Z If Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent I PERMIT FEE: $ 76: Cionntnre 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 F 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 ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re -Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: L Inspectors Signature: Date: ROUGH INSPECTION: Pass'. Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP CTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: aoxle 'z ;� rVp Ltd Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts 02 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,- Please Print Legibly IV4Name (Business/Organization/Individual): 1� t C f'Ztj am CiS S d Address: y / A -Z City/State/Zip:/,* C N, 03 Phone #: 663 a-73% 7 X97 Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I mloyees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have ^ working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [0Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ 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 gmployer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: r Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is�true and correct. 46 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 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 of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia C CL -'x-13 ToU� /) q M. 1-4-n doves j �lt o /S 4-0 S Gt,D� Y YYl,2� ovo v b 2 4,5 T S s t OU -`t" U -f-- ,e- -ems d `tom per i S Lt) Q- Chil l_, I- l rle This certifies that ... 1). t(e I.C—C ................. has permission to perform ... 910.on ° M...��i15 � plumbing in the buildings of . 0..l�? S �� �... . ............. . at .... ? 4 \�� asp . �--'� , North Andover, Mass. Fee. Lic. No..I��P. �.. ul .................... ... PLUMBING INSPECTOR Check # 2 { MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 44 n �! _- __I__Ij MA DATE / PERMIT # JOBSITE ADDRESS 51 Sohn ' oh 5 f JI OWNER'S NAME p ,� POWNER ADDRESS S _ TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: 5Q REPLACEMENT: © PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 6 __ _I i ._.__ I ._ _ .1 .._-_.-_,_i _ I _.____ ._.__. ,___ I ._ (. _.....- f l __j _I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I 77-7- I==== .... _ __. l .__-__.! _.__._.J __._._1 I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) K_. -_i KITI;HEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I ._{ .---._.._ _. i _1 _._ _._! ! _._71 URINAL 1..___._.._4 ( I _..__..__J 1 .....-._- ......._... i ! ` .-._-- f ...._._i ...._._I _.._. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ! I I .._..___i } I ; ..___ ! ... .-.-_ _' ..__._._1 ? I WATER PIPING OTHER ____-._I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYJ OTHER TYPE OF INDEMNITY BOND Eg OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 10 SIGNATURE OF OWNER OR AGENT i nereoy certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # _G�„ SIGNATURE AAP JP Q CORPORATION �i #[_W -M7 PARTNERSHIP E]# _ i LLC DO_ COMPANY NAME _ /�y,b ` ; ADDRESS/ d44n o,e CITY ! - - -)STATE !!/ /f j ZIP U- off' 1 TEL FAX aGa- /� ;CELL EMAIL �a .._ 1 - r or -1 z W m Fs -r u.i w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www_mass_0,0v/clic O, m m -n q2m z min > (J) Ul 'Signatq re This certifies that ............. �. Cd `�? ... . has permission for gas installation .'.� . ���!►!'�?.�.�. I DPs,c- in the buildings of .. +�................. at .... U...`".''� ....'....... , North Andover, Mass. Fee %� . �... Lic. NJ' Iq .I.... ..H-� ................... ... GAS INSPECTOR Check #�20 8546 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "CITY,_ h,J,� MA DATE—/v = /3 PERMIT # JOBSITE ADDRESS OWNER'S NAME T� b GOWNER ADDRESS TEFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL f _ \\ CLEARLY NEW: 0 RENOVATION: REPLACEMENT: © PLANS SUBMITTED: YES ❑J NO Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR__!-- GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER I . _ ROOM / SPACE HEATER I L-3 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER . 6THERF INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES IEJI NO D I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY P' OTHER TYPE INDEMNITY [I BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER(( AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME �y� q-, LICENSE # /3L - I SIGNATURE MP,\\MGF JP JGF [�� LPGI 0 CORPORATION []J # PARTNERSHIP ©#= LLC [�# COMPANY NAME: �/: Cj�m ,`h ADDRESS CITY �` h �; �) _� STATE /t ZIP ]TEL FAXI--- CELL EMAIL . -- — -- — --- �)!o i3 ►�tiw , �, exp 770 oo z W a w LU F t, 0 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): Z e d",Lk 1C)(24, 1!:I Address: /!�! C', crrc!,eil City/State/Zip: i`�LC b I LI /ji# 03 af� Phone #:_ ��/ 8) 67/,S - j o Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. 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 ib Site Address: City/State/Zip: Itach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # i,:fv --/, Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M GE 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. # 6I7-727-4900 ext 406 or 1-877-MASSAFE .evised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia 0 ' � / . ' ainjib is ' ' / ' / Lu Ul ` U co -M ' �LL w o 4L i � LL MLU LU � `� . � / ' ' ' / ' / / ' Of&* use Only Gc/ U�E Crammunlutalth Of Su5adwsPermit No. EtPMtMrW of Public *afttg Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 1 ma pos"a blttink) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat& 4 '2 T& or Town of NORTH ANDOVER To the inspector of Wlres: The udersigned applies for a permit to perform the electrical work described below_ '. Location (Street 8 Owner or Tenant Owner's Address I IS this permit in conjunction with a building permit: Yes ✓ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps _J Volts Overhead _I Undgrnd C] No. of Meters New Service Amps _1 Volts Overhead Unagma C No. of Motors Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorK _ /,y 13 130 2.'/,Ip No. of Lighting OutletsI No. of Hot %cs I No. of Transformers Total KVA No. of Lighting Fixtures i Swimming Pcoi 6b o e I _ Into. I Generators KVA No. of Emergency Lighting No. of Receotacie Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas 2urr.ers FIRE ALARMS No' of Zones No. of Ranges No. of Air Czrc. Ola' No. of Detection and chs Initiating Devices Heat Total .otai No. of Disposals I No.of Puincs :ons K%V No. of Sounding Devices No. of Self Contained No. of Dishwashers SoacerArea Heatin° KWOetection/Sounaing Devices No. of Dryers I Heating Oev,ces KW Local — Municioali Other Connection No. of o. 1)t Low vouage No. of Water Heaters KW I Signs ?a lasts Wiring No. Hyaro Massage Tubs I No. of Motors Totai HP OTHER: rurauanl io ins reuuirement5 Of '.1aSSaC'U56r5 general Laws I have a current Liability Insurance Policy including CJmc:elec Ocerations Coverage or its substantial equivalent. YES = NO = 1 have suomittea valid proof of same to the Office. YES = NO ZIf y'ou nave checxea YES. pllasse indicate the type of coverage cy checking the approo box. INSURANCE = dONONO = OTHER = (Please Scec:h?) Estimated Value of E!ectncal Work S�f,2(0 (Excitta/tionOatel Work to Stan Insoecnon Date Pacues:ec: Rougn Final ��d ^ / � ? 7 Signeo unaer the Penalties of perlury: F1RM NAME _ o � LIC. NO. r Licensee i 1 /Aiy,` x `�,q S nra....o vl.,,, J /l� /4 �_G `15 r.rGs S s -z ,-ou-), v sus. 7eo. 4x,3 z, Address Alt. Tor No. OWNER'S INSURANCE WAIVER: 1 am aware that the L:censee toes not nave the insurance coverage or its substantial equivalent as to- qufreo by Massacnusetts General Laws. and that my signature °n :his «ermit aoptication waives this reouirement. Owner Age (Please check onel� �..�� Tefeonone No. PERMIT FEE S (Signature of Owner or Agent 12 1206 pORTI{ Ott"�D �6 �ti0 FO A ,MACHUSEt Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . -J. W P..'�..... 1.Y � �S �..�. E`�..`.....1.. ................................... has permission to perform .....�I.. a.Q........�J:.! `� - ...�................................... wiring in the building of Wy 11v at ...G7� ......... K. .... f.......�......................... . North Andover, Mass. Fee...l:. ..... Lic. No./ .............................................................. ELECTRICAL INSPECTOR C � 4 C , b 10/10197 11:10 15.00 aalD WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 3 1 4b Date .G?%./?... MORTM TOWN OF NORTH ANDOVER Py.ao I e,MOOL p PERMIT FOR GAS INSTALLATION ' S y, AC14U5Et 1?�i This certifies that ..1 ,- ¢ ...... ........... • . • . --� has permission for gas installation ............ in the buildings of . ` ,: -. `!� ...........✓............. at `��e5. .. t`:' ti`- . x%-' • ... • . , North Andover, Mas': Fee?F? ... Lic. No /HG ... . v / GAS INSPECTORS ' WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ✓IASSACHUSETTS UNIFORM APPLICATOR FOR PERMIT TO DO GAS FITTING cQ or print) Date Moz 92 19 / 1v1JKI11 AIN UVV�V,LK, MASSACHUSETTS Building Locations y `Sy "J S J Permit # J /`/ O Owner's Name New 1� Renovation ❑ Replacement ❑ /� Amount / Yl 43. 1 Plans Submitted ❑ (Print or type)� / 1 C' Check one: Certificate Installing Company Name /- / G%L� �— J ❑ Corp. Address �-� ❑ Partner. Business Telephone v/-^--0 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: 1 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 ❑ 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: Sienature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 installs ions performed under Permit ssued for this application will be in compliance with all pertinent provisions of the Massachus s State Ga Chap�heraeneral Ls. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter I/ ❑ Plumber Z'L EL ❑ Gas Fitter 71cense I umber ❑ Master ❑ Journeyman Z F � z z �- Y z nL W z W C W V) W z :i n SUB-BASENI ENT A S E M ENT 1ST. FLOOR 2N D. FLOG R ORD. FLOGR 4TH. FLOOR 5T Ii. FLOG R 6T H F L O O R 7T If FLO G R 8T Ii. FLOG R (Print or type)� / 1 C' Check one: Certificate Installing Company Name /- / G%L� �— J ❑ Corp. Address �-� ❑ Partner. Business Telephone v/-^--0 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: 1 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 ❑ 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: Sienature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 installs ions performed under Permit ssued for this application will be in compliance with all pertinent provisions of the Massachus s State Ga Chap�heraeneral Ls. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter I/ ❑ Plumber Z'L EL ❑ Gas Fitter 71cense I umber ❑ Master ❑ Journeyman (Print or Type) FUR PERMIT TO DO GASFITTING NORTH ANDOVER , Mass. Date * oZ 1g / Building �— Permit # Locatlon y Sa nJ cs Owner's / Name i� New ❑ Renovation Ot Replacement ❑ Plans Submitted.. Yes No d;} i • sus—sstwT. �AalM�•)f1T 18T FLOOR :NO FLOOR >1RD FLOOR ITH FLOOR STHFLOOR GTH FLOOR 7TH FLOOR aTH FLOOR Installing Company Address nZ / dCheck one: ..Corp. v d Partnership Certntcate Business Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: Chek one have a current liability Insurance policy or Its substantial equivalent. Yesc19L If you have checked Yea, please Indicate the type coverage by checking the approprlate box. A liability Insurance "Icy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does nd Chapter 142 of the Mass. General Laws, and that my signature on this perhave the Insurance coverage required by mit application waives this requirement. Check one: nature o Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that ah of the details and Information I have submitted (a entered) In abov epplicallon are true and accurate to the best o1 m knowledge and that all plumbing work and Installations rlormed under the permtt Issu for it a tion will be c Io the all PwOnenl provisions of the Massachusetts State Gas (oda and Chapter 117:gnTattijeo T of License: TRIe Plumber ;nsZeuer or as e� Oasntter Clty/Town Master License Number _ /y ❑ Joumeyman AMMED (OFFICE USE ONLY) j h W ��[C w Z ! '= O .jh �Fi. d w 0 d fAF- { pp M ►• .��.. r� h t ao rt 0 v >' JO tl s 0 VIa. „ H Z 0 h e h 31 O 0= > ae X r•, Opp 0 ec w J ` qhyy fl r O dCheck one: ..Corp. v d Partnership Certntcate Business Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: Chek one have a current liability Insurance policy or Its substantial equivalent. Yesc19L If you have checked Yea, please Indicate the type coverage by checking the approprlate box. A liability Insurance "Icy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does nd Chapter 142 of the Mass. General Laws, and that my signature on this perhave the Insurance coverage required by mit application waives this requirement. Check one: nature o Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that ah of the details and Information I have submitted (a entered) In abov epplicallon are true and accurate to the best o1 m knowledge and that all plumbing work and Installations rlormed under the permtt Issu for it a tion will be c Io the all PwOnenl provisions of the Massachusetts State Gas (oda and Chapter 117:gnTattijeo T of License: TRIe Plumber ;nsZeuer or as e� Oasntter Clty/Town Master License Number _ /y ❑ Joumeyman AMMED (OFFICE USE ONLY) j •' 5 - Date ................... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9 • • LN This certifies that :...... .......... ... '............. as permission for gas installation—.—. .. ....................... 'h the buildings of .....' .. .: .lr . ...................... . at .. �'..`.....`.......`..... . North Andover, Mass. Fee:..,'.:. Lic. No/��rp� .... '.................... . H��' GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Location No. Date 4 TOWN OF NORTH ANDOVER y o, 4ndoVJ L $lublIector t Building Inspector Div. Public Works p Certificate of Occupancy $ { Building/Frame Permit Fee $ wsE Foundation Permit Fee $ 16a - "gee $ Sewer e� lon Fee Nov Urj nection Fee $ y o, 4ndoVJ L $lublIector t Building Inspector Div. Public Works Location No. Date 0f NO"T" A '40 TOWN OF NORTH ANDOVER •• • OA p? „ Certificate of Occupancy $ Building/Frame Permit Fee $ S wino ► E i, Foundation Permit Fee $ RECEIVED Other Permit Fee Connection Fee $ %Muer t $ Water Connection Fee $ NOV 121991 TOTAL Ab. Andover Collector $ Building Inspector Div. Public Works PEWAITT NO.� a APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. `7 LOT NO. Lj f. :lr 4p I 2 RECORD OF OWNERSHIP DATEBOOK I 'PAGE SUB DIV. LOT NO. (�iI— v [ZONE''' LOCAT 'f Y.� Cil Ll iJ g PURPOSE OF BUILDING ric p -,2s ly" VNEISNAME NO. OF STORIES SIZE / %ice% ADDRESSZ ya,i J CJF-� JSO N J \l -r BASEMENT OR SLAB I/ / i C � Sp� _ IO 7S ARCHITECT'S NAME -- SIZE OF FLOOR TIMBE IS O 2ND 3RD C BUILDER'S NAME .{�O�t 1�1 ®n SPAN -N DIMENSIONS OF SILLS --- C•. DISTANCE TO NEAREST BUILDING DISTANCE FROM STREET f POSTS DISTANCE FROM LOT LINES - SIDES (JO ( REAR q j f GIRDERS AREA OF LOT I�(t FRONTAGE l0 I HEIGHT OF FOUNDATION f THICKNESS IS BUILDING NEW SIZE OF FOOTING �d r� X I� 4 Cr77 IS BUILDING ADDITION MATERIAL OF CHIMNEY r �'ik IS BUILDING ALTERATION IS BUILDING O OLID R FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODEyrs //`"� IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY . 9b I`� IS BUILDING CONNECTED TO TOWN SEWER %7Lr7 IS BUILDING CONNECTED TO NATURAL GAS LINE pJ0 INSTRUCTIONS 13 PROPERTY INFORMATION SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS I - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE 2SrO'C7 /PERMIT GRANYVD q , 19 �--- OWNER TEL # /CsiL,i..:1f-263 CONTR. TEL. # =. Ald.7 CONTR. UC. #&3-26t 3..... LAND COST EST. BLDG. COST=77a j_ tll EST. BLDG. COST PER SQ. FFT.,T7S EST. BLDG. COST PER ROOM Q SEPTIC PERMIT NO. w 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN 4 4 NV1d 101d S30V"Id3H SIHl-'a35OdWlM3dhS '013 'S30VU 'V9 'S3HOMOd H11M 'SON1011f19 d0 SNOISN3WIa lOVX3 0NV S3NM 101 WONA 3ONV1S10 0NV 10'1dOSNOISN3Wl0 1DVX3 MOHS1Sf1W N01103S SIH1 El a1033V JNlalln9 OOV0 31 _ 21001d 31 S38n1XI3 N8300 d3MOHS 11V. _ ON19Wnld C AMS N3HJ1 QOIVA� _ 13SO1J 831V I'XI3 ZI 'W8 131K •X13 EI Hlt ONiswnld OI ON 13008 1108 13AV80 '8 8V1 31VlS S30NIHS DOOM S310NIHS 11VHdSV 03HS 1Vld 08VSNVW 1389WVO d1H 1 1 319VO doom 9 3W"3 NO 3NO1S ONINIM kSNOSVW NO 3NO1S JI19 d30NIJ 80 JNOJ _I 3WVd3 NO X0189 80013 S 'SM J111V ABNOSVW NO JIJId9 — �3WVNI NO OJJn1S BNO ASVW NO 555n1S 3111 'HdSV ON101S 'MA NOINwOJ ONIOIS 10113111VSV O.MOdVH ONIOIS 1lVHdSV H1dV3 S310NIHS DOOM 313dJNOJ ONIOIS d080 Z t 9I I SOdV09dV1J SN001d 6 II S11VM b N3HJ11X N8300W W006 OV3H S3JVld 3813 1.W 9 ON V3dV J111V 'N13 %r 2/1 %i V3dV .1.W.9 N13 lln3y38V 1N3W3SV9 £ N13Nn y 11VM Ado d31SVld Sd31d O.MOdVH 3NO1S, 60 X0Id9 3NId 'A.194313dJNOJ _ E I Z 2 3138JNOJ HSINId 80V31NI 8 N011VONnoi Z NOIlonUISNOD S1N3W18VdV s3J133o—_ Allwvd ulnw 53180!S kIIWV3 916N SS ADNVdfIODO l 0N111t3H ON PIE I1sl I .9 P -Z 1. W110, JI81J313 SWOON dO—ON L VO S2131V,3H, 11NI1 O.1.H 1NVIOVB ONINO1110NOJ NIV _ SY31dVM OOOM 1 OdVA 80 8.1.M lOH _ S10J V 'SW9 1331S ' • I •.. WV31S _ 'S10J'8 'SW9 839WI1 { 'NBnd 81V lOH 03J80d 3JVNdn3 SS313dld 1sIOf 0008 ONIIV3H it 11 ONIWVNd 9 NV1d 101d S30V"Id3H SIHl-'a35OdWlM3dhS '013 'S30VU 'V9 'S3HOMOd H11M 'SON1011f19 d0 SNOISN3WIa lOVX3 0NV S3NM 101 WONA 3ONV1S10 0NV 10'1dOSNOISN3Wl0 1DVX3 MOHS1Sf1W N01103S SIH1 El a1033V JNlalln9 OOV0 31 _ 21001d 31 S38n1XI3 N8300 d3MOHS 11V. _ ON19Wnld C AMS N3HJ1 QOIVA� _ 13SO1J 831V I'XI3 ZI 'W8 131K •X13 EI Hlt ONiswnld OI ON 13008 1108 13AV80 '8 8V1 31VlS S30NIHS DOOM S310NIHS 11VHdSV 03HS 1Vld 08VSNVW 1389WVO d1H 1 1 319VO doom 9 3W"3 NO 3NO1S ONINIM kSNOSVW NO 3NO1S JI19 d30NIJ 80 JNOJ _I 3WVd3 NO X0189 80013 S 'SM J111V ABNOSVW NO JIJId9 — �3WVNI NO OJJn1S BNO ASVW NO 555n1S 3111 'HdSV ON101S 'MA NOINwOJ ONIOIS 10113111VSV O.MOdVH ONIOIS 1lVHdSV H1dV3 S310NIHS DOOM 313dJNOJ ONIOIS d080 Z t 9I I SOdV09dV1J SN001d 6 II S11VM b N3HJ11X N8300W W006 OV3H S3JVld 3813 1.W 9 ON V3dV J111V 'N13 %r 2/1 %i V3dV .1.W.9 N13 lln3y38V 1N3W3SV9 £ N13Nn y 11VM Ado d31SVld Sd31d O.MOdVH 3NO1S, 60 X0Id9 3NId 'A.194313dJNOJ _ E I Z 2 3138JNOJ HSINId 80V31NI 8 N011VONnoi Z NOIlonUISNOD S1N3W18VdV s3J133o—_ Allwvd ulnw 53180!S kIIWV3 916N SS ADNVdfIODO l FOIA U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP A 2 7 - r- SUBDIVISION LOT(S)A- ,.0 PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET .ToffpJo" S� APPLICANT PHONE �• f7g3 DATE OF.APPLICATION TOWN USE BELOW THIS LINE PLANNING TOWN -PLANNER CONSERVATION COMMISSION CONSERVATION ADMIN. °BOARD OF HEALTH DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTIOe DATE .DATE APPROVED l� • �� .�� DATE REJECTED DATE APPROVED DATE REJECTED PATE APPROVED IC>1311211 DATE REJECTED This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuaiice of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. \AJ -lq� C5 lam z J Q W W In Q O CID °C O u Z Z Q m L j L�O c E L U N c ii p ~ W Z Z m J d L j O fL t6 c ii 09 O V W G. Z0 V W` L O Q U c0 tT- 09 O W a. ?ce Q L cc ii W p LU W O co Y CO O c .O T CL M :O 'n u O .y ' `n Lc O C E d V u O U Q L a •Z .a a C � c D c� s ° .a o � a. �y O £ Q CLo u) C �. y O r Location No. Date . TOWN OF NORTH ANDOVER amago V Certificate of Occupancy $ " • ; Building/Frame Permit Fee $ Foundation Permit Fee $ SS�CH _ � .on ' � Other Permit Fee $ J ('jfG� 9 Suver Connection Fee $ �vzoater Connection Fee $ o�e�G TOTAL $ �d Building Inspector Div. Public Works PERMIT NO. ' APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. -.I PAGE 1 MAP a-40. LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK PAGE ZONE SUB D I LOT &. r ,r�•� �g— LOCATION {p PURPOSE OFILDBU ING GJ OWNER'S NAME f1 % ( NO. OF STORIES SIZE OWNER'S ADDRESS .J. US J BASEMENT OR SLAB ARCHITECT'S NAME - SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST UILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDIN IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OU&SECTIONS I - 3 PAGE 2 FILL OUT SECTIONS I - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BEE%,,FILEDJ!ND APPROVED BY BUILDING INSPECTOR DATE FILED '[ 1V1,e SIGNATURE OF OWNER OR AUTHORIZED AGENT 00 F E E + OWNER TEL. # PERMIT GRANTED CONTR. TEL. # 19 _ CONTR. LIC. # 0 h't-N'7J e2 atm&���6v� 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN MVILHINa IN6P6CTOR 1 OCCUPANCY SINGLE FAMILY STORIES MULTI. FAMILY WOOD JOIST OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION TIMBER BMS. & COLS. 8 INTERIOR FINISH CONCRETE STEEL BMS. & COLS. B 1 2 CONCRETE BL'K. PINE BRICK OR STONE HARDW D RADIANT H'T'G PIERS UNIT HEATERS PLASTER SAS DRY WALL _ 3 BASEMENT AREA FULL 'G 1/} 'G NO BMT HEAD ROOM 4 WALLS CLAPBOARDS DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME CONC. OR CINDER BLK 5 ROOF GABLE HIP GAMBRELMANSARD FLAT A SHED FIN. B'M.T AREA _ FIN. ATTIC AREA _ FIRE PLACES _ MODERN KITCHEN 9 FLOORS 8 1 2 3 CONCRETE �_ EARTH HARDW D I _ COMIAGN A WIRING DEQUATE I I NO 10 PLUMBING ATH (3 FIX.) 1st 3rd NO HEATING I I BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. t TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G 7 NO. OF ROOMS UNIT HEATERS SAS 1st 3rd NO HEATING I I BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. t No O i y 60 �+ O y N a O~v+ v ZM Wco m D _ Q i7 0 Z n ti N D O m o ' �O Di =TZ Z < V1 W m c N m r om>x V10 m m 'V N S m xm� ♦� G1 O Z0 0 imi2.71 V yn ; ♦ o l m 0 A Z, 9 /� (Zmr 'o o C mNC 0 �G)2� �a oa m j yorn 4c rrf T C5 v� T� G� 0 00� 0c r�Cior �+ ? 0; m p= J m r Y;O ar 1F 0 D w O tin -n C r'r: N � .0 o i C •� m m a t/! .0 C m m Z o,y n �-s •� i m m J!! N p0 so Cr r yr n m Z y •i . .. .+,>•,t. ..: a m s.1 Z D c m �` �G �- x .� fp p a -y � v •a = fl m m Ln =rra �_ ti •� 1 0 n R r r �O C ` Cy O• �•� TJ � _ y' s p o m m r 6 A 0 O T C_ m kA Ln co Cc, I'DIIIVVV c A ;:N c=C 4 ,cn , vq a ri. V,1 Nf'd'�C*!� '9ri i 41 i;•.: •• .w y� r,,etl,{�1:,�i+k�,r: .`�fv, `f 65k": '`w, ':fYiyt��'.t ., 45�ySv7 'N� nF��`4 LYc�w .'r. Y�V��' : Z r `"'? '_i'� '�E4WwW';a "jv,k•4 _-- I - AI ISI' �'III�I Put Your Roof under the protection of our Umbrella P.O. Box 8051, Lowell, MA 01853 PROPOS "WE'RE ALWAYS ON TOP" --p ALL TYPES OF ROOFS �� r CHARLES WOOSTER LOWELL-(508) 459-1501 LAWRENCE -(508) 689-2174 NASHUA, NH -(603) 886-6818 Proposal No. Sheet No. Date 5/15/92 N REASONABLE DEPENDABLE Proposal Submitted To Work To Be Performed At � S�hL Name i4s. Lally T6 Street ,_6A Street 245 Johnson St. City City N. Andover State Zip gode State Zip Code 01810 Date of Plans 1 Telephone Number _U9_( 7_ co `3 Architect We hereby propose to furnish the materials and perform the labor necessary for the completion of the following job. We would strap the entire roof down to the roof deck. This would not include the tar and gravel roof. 1. Install 811 metal dripedge. 2. Install ridgevent-�approximate ly -79-L - r, 3. Paper the entire roof. a_ Tnatall new pipe boots. r` 5. Install PRC Seal King (25 year) shingles of all debris. y(Bird. z LV. c.1 — - •� ` – -- – - ---- – ` ,A 4_- �X OPTIONS To install _ _water barrier would Le $ 150.00. _ Workmanship guaranteed for 10 years. We are fully insured with workers' compensation -as well as liability insurance. Please return copy of proposal. All material isquaranteed to be as specified, and the above work to be performed in accordance with the drawings and spec- ific io s mitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ . 0 with payments to be made as follows: Job paid upon completi . Respectfully submitted Call For Our Refe ces t, N e—This proposal may be wit drawn by Fully Insured if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You ar to do the work as specified ill be made as outlined above. > Date 6 ?, * 410 ( q'2-) I OFFICES OF: APPEALS 1 1.111 )ING CONSE-11VATION HEALTH PLANNING t? Town of NORTH ANDOVER ss+cwuH�` DIVISION OF PLANNING & COMMUNITY DEVELOPMENT KAREN 1-111. NELSON, DIRECYOR 12o Main Street North Andover, Mitss.u'huSCIIS 0 184 5 (6 17) 685.4775 In accordance with the provisions of MGL c Q, S 54, a condition of Building Permit Number is that the dcbris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. -ne debris will be disposed of in: S al Cou 5o l (—J cJ Tac k- u L v.,t rc- (Location of Facility) U Sig ature Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Ins ector P i co z 0 0 i y Cd 2 nW ai cc Z W 1 Lamm, • C oc cc O 7 O `n u 0 CL C 0� _ O w O ` E 0 ciO y V ac o CL E_O E _ W 0 U o +r 0 IOC V C6 C 06 V H OUl) a Q1 3 > LTJ H = _ MX 0 MUW h H a U u _2 ., Q W Z coow Z •_ Z Z e W •� N h a W e o s 0 ... _ Z t 96 0 •v W " F" C Q 'C i u •� 0 u < h Z Z V ? -' u o m m L C J L J L U L Y co W` ` O O L C C Q U ii cc ii ¢ 0 ii ¢ ii m 1 Lamm, • C 4. 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