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HomeMy WebLinkAboutMiscellaneous - 254 BARKER STREET 4/30/2018 (2)N n� Date. . Z� ------ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that 7/ fi— ** * . 2-- has permission for gas installation :t.- in the buildings of ............ at x.............:.:`.. ................ I North Andover, Mass. '?. .'5 zo -- Fee�. a-... Lic. No........... ........... GAS INSAE60R Check# Jl 4237 7 5 4 J Date../V// ......... . n TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION N This certifies that has permission for gas installation .............. in the buildings of . �., !? ! ............ . . . ... . .... . . at ....�...� ... �? �.r`... �f ....... , North -Andover, Mass. Fee.,R ..... Lic. No.�?.. �..`..... �` .... GAS INSPECTOR Check 4 /i cj t/ 10050 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING s certifies that .!'� ' "!'^ �..q 7�..... . ha4ermission to perform.... v plumbing in the buildings of. . .' ..................... . at ... '? 5Y. .4�!q <P!2 .. /A� : ..... North Andover, Mass. Fee . Lic. No. !,/v ... ."4V . o-� C .................. . �.�.'w PLUMBING INSPECTOR Check # I fW i i o uivirumm At&IJLIGAI► IUN FOR A PETIT 10 PERFORM PLUMBING WORK r CITY _ I MA DATE PERMIT#-. / II _ _( JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL ^ FAX ° TYPE OR OCCUPANCY TYPE COMMERCIAL Ell EDUCATIONAL RESIDENTIAL s PRINT CLEARLY NEW: Ell RENOVATION' i REPLACEMENT: ® PLANS SUBMITTED: YES NO FIXTURES 7- FLOOR- BSM 1 2 —3-4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE_..__ I _.._,-f DEDICATED SPECIAL WASTE SYSTEM J J i J 1 - DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _-----I _....-.__i ! i .._____� DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I i J 1f i __.._-_____J I— DISHWASHER - i DISHWASHER DRINKING FOUNTAIN _�f -.__ _i -- _} J FOOD DISPOSER _J __..._.I ._ ___J _._—� _-_____j __( _-__j-__..__..I .-.___I ._..____� ___._..._I -[1 _ _(____J FLOOR/AREA DRAIN I ! _____-( __J (___----..._J 1 i __.__.__i __... ..-...._.._.J - -- -J INTERCEPTOR INTERIOR ° - I .__J --_----i -_—f i i __.___.._i __._._ KITCHEN SINK ._..._..._..1._____J LAVATORY , I ROOF DRAIN SHOWER STALL Ri ----i SERVICE /MOP SINK TOILET_I URINAL _____-, --; WASHING MACHINE CONNECTION j ° ` ° - _) WATER HEATER ALL TYPES - - _. — _ # __ __; __J i .__._._J ? ..__1 I ...._J i WATER PIPING f i 1 . __.._ _i J _. -- 1 .. OTHER � I _I ._ _.....J i ._____I ..__.__i 71 i --___J INSURANCE COVERAGE: I hub a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES j i NO �1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY iX( OTHER TYPE OF INDEMNITY i BOND Mf 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 application this permit waives requirement. HECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT E hereby certify that all of the details and information I have submitted or entered regarding his ap is io are trueaccurate to the st of my knowledge and that all plumbing work and installations performed under the permit issued for this ap icatio will e c c i all Pertine t rovision of the T Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME(`J,",- N�l3t' IILICENSE # I AN ATURE fV1P [ JP CORP ORATION]f # ;PARTNERSHIP _. # s LLCJ COMPANY NAME _ '- , RESS IC CITY/I ; STATE ZIP TEL it FAX ELL �1 .� -; EMAIL or -1 z (nn W m 69 di w LL .Iq /i. W f' The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Informationn i Please Print LeLyibh Name (Business/Organization/Individual): Address: T1 17-1 City/State/Zip: �� ,d ��C�L1 Od IN— Phone #:VF Are ou an employer? Check the appropriate box: 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. 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. - Remodeling 8. Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11. El 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 aie 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. Lie. #: ILA) C 32 J 41 Expiration Date: 6 " �0l 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 rstigations 250.0 �d�y against the vio ator. Be advised that a copy of this statement may be forwarded to the Office of Inoft D`I for a coverage verification. % Iqo hereby Official use only. Do *ot write in City or Town: that the information provided a#ve iskrue and correct to be completed by city or town official. Permit/License # 66 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 #: i-� 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 bum 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 ciuestions, 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 Investigatitons 600 Washington Street Boston., MA 02111 Tel. # 617-727_4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia S, COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: ANTHONY T MAGGIO 91 TURNPIKE .RD ih IPSWICH MA 01938-1077 9437 05/01/14 1769 COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND -GASFITTERS REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: ANTHONY T MAGGIO 14ORTH-STAR PLUMB & MECHANIC! 91 TURNPIKE RD IPSWICH MA 01938-1077d � 1556 05/01/14 1769 i v FIYTI IRFC W LLI z MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING a City/Town: /v` �i`hd� MA. Date: %- / Permit# Building Location: &4wL-11 � Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential;gp New: ❑ Alteration: ❑ Renovation: ❑ Replacement: �b Plans Submitted: Yes ❑ Nob FIYTI IRFC W LLI z U) < w m 2 N W = O W W U 0 V N (n H = W 2= N (n O W W QQ () J W } W W 0 m W iY y W w W N () g m W to C7 0 Q Q to (n a O H o w X W H G = LL � U W LLI Z z W>-� O J w H N J Q Q o m Z J (� W 0 z LL U 0 W WW x W F W W 1 H 0 o a LL 0 tm9 =_� O a. � W H>>>� O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 1HFLOOR 511-1 FLOOR 6 TH FLOOR 7 FLOOR I 8 FLOOR Ed 1 .-4— Installing Company Name: � Check One Only Certificate # � � ,% 2 j ❑ Corporation Address:/ q /r vr<�� City/Town: is `'W tel State: ❑ Partnership Business Tel: �,�/��� Fax: 16FPirm/Company Name of Licensed Plumber/Gas Fitter: llela az 11 INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Ye�.J] No El If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. �� A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAI ER: 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 Siqnature of Owner or Owner's Aaent Owner El Agent [I By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the nest or my rtnowieage ana tnat all piumomg work ano installations performed u the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code an"ajA6r,14ZqjMe General Laws. By Type of License: ❑ Plumber TitleGas Fitter Signa re of Licensed Plumber/Gas Fitter Master ��))6 // Cityrrown ?19- Master License Number: f S7 APPROVED (OFFICE USE ONLY) 1771 LP Installer , r r, Date . 4'./ .�.'.... . 8824 TOWN OF NORTH ANDOVER Of,"•O '•,�O F PERMIT FOR PLUMBIN40 This certifies that ...... ............ has permission to perform .................... plumbing in the buildings of L. { 1I? !..:................. . at . S^��.. 3/>!+. �7 ��'... �: f ............. , North Andover, Mass. Fee02 .^... Lic. No. . ...... /�.... . PLUMBING INSPECTOR Check # % `� FIXTI IRFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /V �' �I�C��� , MA. Date: -16 Permit# 7 s Building Location:W"� �,��i �/� �� Owners Name: U7 0/j DEDICATED Type Occupancy: Commercial ❑ of Educational ❑ Industrial ❑ Institutional ❑ Residential z New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ) Plans Submitted: Yes ❑ No FIXTI IRFC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes(�"o ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy NJ Other type of indemnity [I Bond E]r 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 Ownel's Aoent I hereby certify that all of the d I have submitted (or entered) regarding this application are true and accurate to the best of my r%nowieage ano tnat all plumping work and installations performed under the permit issued for this application will be in Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , By Type of License: Fir Title Plumber Signature of Licensed Plumber Master l f7,5 / City/Town APPROVED OFFICE USE ONLY Journeyman License Number: yo with all DEDICATED z SYSTEMS LU Y z O W W z C H } Q J J = N W :7 W Q d' S C Z Z LU V1 0. W z Z 3 h = H Q LU cc Y z H Ln W z i- H cQ G NQ 1 N yaj W LU Qa N a 3 W 0 Ct Q W z Na W J Z G' 1' LL OIS 0 W 3 Q Y 2 2 Oa LU Q Q o = Z >> Q LL 3 o= o Y Z v=i ~ H W v I Q y H a o a m m e c U x Y g g o HL -n Q a a a I- 3 3 3 o a o oac SUB BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3" FLOOR 4T" FLOOR 5T" FLOOR 67' FLOOR 7T" FLOOR 8T" FLOOR Check One Only Certificate # Installing Company Name: ` ,��/ %� Address: `/ Sf Corporation Cit i''rg o�✓�/ State: y/Town: ❑ Partnership / / Business Tet: �[" De Ay- %ZJ d Fax: ❑ Firm/Company Name of Licensed Plumber: / L'4 Lr�n c7 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes(�"o ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy NJ Other type of indemnity [I Bond E]r 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 Ownel's Aoent I hereby certify that all of the d I have submitted (or entered) regarding this application are true and accurate to the best of my r%nowieage ano tnat all plumping work and installations performed under the permit issued for this application will be in Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , By Type of License: Fir Title Plumber Signature of Licensed Plumber Master l f7,5 / City/Town APPROVED OFFICE USE ONLY Journeyman License Number: yo with all www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrinfLeaiblY Name (Business/Organization/Individual):_ Address: I &6L City/State/Zip: Phone #: [ f 72 30 - Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts 4. ❑ I am a general contractor and I Department of Industrial Accidents M AA�, Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrinfLeaiblY Name (Business/Organization/Individual):_ Address: I &6L City/State/Zip: Phone #: [ f 72 30 - 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 I am a sole proprietor or partner- 2.P. have no employees listed on the attached sheet. # These sub -contractors have ship and 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. E] Plumbing repairs or additions 12. F1 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 anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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. A,� Insurance Company Name: Policy # or Self -ins. Lie. #:Ai `6 6 d Ll �Zz I Expiration Date: 07—/40 r Job Site Address:J C� 1> afi�i`4f 5-f 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 underflafg,s�07d penalties off'"•'ury 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 of -cial. 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 they 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 maybe submitted to the Department of Industrial Accidents for confinnation 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 pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple,permidlicense 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 pen -nits 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. # 617-727-4904 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Commonwealth of Maisuse US Division of Re is rat Board of P/U bi MICHA S 39 ROC 0 MALDEN, Master Plu PL15786-M 05/01/2012 004244 License No. Expiration Date. Serial No. ti 0 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date 1,;2 — //. 0 Z Building Locations �i�i� P�� Permit # Amount $ Owner's Name 4� (.,// New © Renovation ❑ ❑ Replacement ❑ Plans Submitted or WT- ij exlc re Name of Licensed Plumber or Gas Fitter S Iffone: Certificate Installing Company Corp. ❑ Partner. 121 Fixm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes Z] No ❑ If you have checked M please indicate the type coverage by checking the appropriate box. Liability insurance policy lzr 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 [IAgent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations poformed der P Is for this application will be in compliance with all pertinent provisions of the Massachusetts S Gas C and f the General Laws. (OFFICE USE ONLY) Signature of Li ed Plumber Or Gas Fitter Plumber ❑ Gas Fitter License Number Master ❑ Journeyman &a �6D • or WT- ij exlc re Name of Licensed Plumber or Gas Fitter S Iffone: Certificate Installing Company Corp. ❑ Partner. 121 Fixm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes Z] No ❑ If you have checked M please indicate the type coverage by checking the appropriate box. Liability insurance policy lzr 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 [IAgent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations poformed der P Is for this application will be in compliance with all pertinent provisions of the Massachusetts S Gas C and f the General Laws. (OFFICE USE ONLY) Signature of Li ed Plumber Or Gas Fitter Plumber ❑ Gas Fitter License Number Master ❑ Journeyman &a �6D Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING - -r-a. This certifies that .....-�:•.....!l.�''.-...�-�-� .. V has permission to perform .......... ...................... . plumbing in the buildings of .... (:... " :" - ;` ate... �..".� '� " ... ,.tiNorth Andover, Mass. .`�.� ....., .. Fee ..... Lic. No. ............ PLUMBING'IPECTOR Check # �1 ��1" ell� 5455 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT`O DO PLUMBING (Type or print) NORTH ANDOVER MASSACHUSETTS � / • `� � f � C Building Location �� /�//�(�`;� Owners Name /�����LyJ(j/,P`c�erDatemit # i� Amount Type of Occupancy New 1zr Renovation Replacement 1:1 Plans Submitted Yes ❑ No ❑ FIXTURES (Print or type) �j Check one: Certificate Installing Company Name el Corp. Address % / G Partner. ssTelephone, y' 7 f Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy F1 Other type of indemnity r Bond rl Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perfqw6d under P t sued f is application will be in compliance with all pertinent provisions of the Massachusetts State P ing C nd d`pte e General Laws. By: igna ure ol Mcensea77577- Type of Plumbing License Title �•��� City/Townicense um er Master Journeyman 13APPROVED (OFFICE USE ONLY • _A Location kle 2 S4 No. Y38 Date N°RTh TOWN OF NORTH ANDOVER ?O'tt ♦•o x•,7.0 • .. 1 • 0....�— Q O + n : Certificate of Occupancy Building/Frame Permit Fee $ ^' $ s�cMusEt� Foundation Permit Fee $ �� ... Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ ? TOTALy ! � � Building Inspector niv Puhlir Wnrks 7 d� I' LocationNo. v3b Date t NORTH TOWN OF NORTH ANDOVER . n Certificate of Occupancy $ } TFMW : Building/Frame Permit Fee $ �SSACMUSEt� Foundation Permit Fee $ Other Permit Fee $ i a Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works 7 n Z Y{ Z a z z z +- Y z C z C �z C z m t m Z _ n U m V Z V h (A m m m N w o s_ W - - D - C C z C �z C z m =? m Z _ n U m V Z V h (A m m m N w o s_ W - - n D�_ T V, > Z V. > Z V > Z - _ Z F Z.". z T 7 �' Z m W •. top ( m v - ,, D F m z H V,F (� z X m lU� V S ZIre V V R Z T i m m T m X X z C — Y z 7 Y Z V D n m A m z x m > o j z mA Ix n z uo V) m C C z C �z C z m =? m Z _ n U m V Z V h (A m m m w o a v n n _ T T •. ( v m i= m N V LA R Z m m X X z C Y z x m > o j z mA z m Ix n z uo V) m Z N m F m , V V _d 1� _ ? T •. v C b �?,.P--Unt A. J. WALSH & SONS,INC. aSth,1r. ADMINISTRATOR N Andover NA 01.845 L • v. c y d CA CM) n z v=i CLO n� C. :q• y ,cc ca 0 v CD CD O CL CU CD CD O CD C CD y. av y —• o cc C F v CO) O CD z o CD 0 CD Oy�7d0 T z - 99/1'—° =Q�a o� CD so CA O 0 O y C o 3E CD m 2 O0-0 C m ~' O O Z C09 ' � p y p W a O O c ?_ : _ N d p,co= S .� . m o m O N C C m CD O CoCD CO N d d Q C — c• O W d CL � _ NCD = .rt I• ? N O V! O N CO co O 0 . tea: �s sm CDN : s CD go a,% C, p A _ O r} _ O O m C/) e'1 (n ~ z Q .Cj ►� /� .7 Y• p p r �'cp 41 Oz y n .X 9` OO x s (Ai 00 rp )Nq 0 9 0 c Location 4?b -/ No. �" Date TOWN OF NORTH ANDOVER • �L Certificate of Occupancy $ �� s•• Eta' Building/Frame Permit Fee $ AMUS Foundation Permit Fee $ Other Permit Fee TOTAL 0 Check # V15 U 16022 $ X29"'' \Building Inspector J MU rn X Z O i rn TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING s^ �' mm ��ti$ l�;f$C•�?)<iiCi>tAI �'SP. gild BUILDING PERMIT NUMBER: C9 ? DATE ISSUED: I I , q� SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION i- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Zs�f (a NmKe�pl sr. Co l 1 v MA Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: SFR yy, ova 1 GO Zoning District Pro -posed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 3 + -39+ 5 ® 1 Loo + 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Y Private ❑ Zone Outside Flood Zone Municipal ❑ On Site Disposal System SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT >6'6 FO R J U 2.1 Owner of Record LLL $S 1� 1 Cte)V SIU Pa N•MjDG Name (Print) Address for Service: �78`� 687r 635 Si re Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ T)n�b . 7',1 Licensed Construction Supervisor: v License Number S 1 I L L �� ' Address Ge Expiration DateWte pSi,e Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1 Name 1 v% 6?2 Company Registration Number lis � �cK GG � lv. Address 7 Expiration Date Si na Telephone J MU rn X Z O i rn SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... No ....... ❑ SECTION 5 Description of Pioposed Work check all a licable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ;1� I Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: C I SECTION 6 - ESTIMATED CONRTRTTCTTnN f nCTC I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building Z (a) Building Permit Fee Multiplier 2 Electrical 6euo , (b) Estimated Total Cost of Construction 3 Plumbing�j Building Permit fee (a) a (b) O 4 Mechanical HVAC ZO 5 Fire Protection /10 ev0 , 6 Total 1+2+3+4+5 3cf.ezz Check Number Jl'ullu1N "/a UWINEK AU lHUKIZA11U1N TU BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorizeS Ai to act on My behalf; in all tters relative to k authorized by this building permit applicafo JP0,/o2 Si re o ier Date ION 7b OWNER/AUTHORIZED AGENT DECLARATION Owner/Authorized Agent of subject Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge . and belief ernes Name Date NO. OF STORIES Z SIZE BASEMENT OR SLAB _& .S6,M,6VV_j' SIZE OF FLOOR TINMERS 1 00 2 _�,e 3 RD SPAN DIIv1ENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS 3-Z r b DIGHT OF FOUNDATION 17 > THICKNESS » SIZE OF FOOTING x2 X MATERIAL OF CHIMNEY VR ) c K IS BUILDING ON SOLID OR FILLED LAND L IS BUILDING CONNECTED TO NATURAL GAS LINE %IYPC FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION***********�7************ APPLICANTX Vw PHONE 0177_W/_�� LOCATION: Assessor's Map Number W-6 PARCEL UV2 6 SUBDIVISION Q14 LOT (S) STREET st ST. NUMBER *************************�******OFFICIAL USE ONLY*********************************** I RECO.M1nf 5NDATlM OF/TOWN AGENTS: CONSEF�/ATION A INISTRATOR DATE APPROVED / DATE REJECTED COMMENTS COMME FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH UA 1 t HtJtlr I tU DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS W111 16 PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY B ILDING INSPECTOR Revised 9\97 jm 67/2 BOARD OF BUILDING REGULATIONS ` License: CONSTRUCTION SUPERVISOR Number: CS 055417 Birthdate* 04/05/1.960 Eiipfres,04/0512004 Tr. no: 21586 Restricted; 00 THOMAS D ZAHORUI 0- 185 HICKORY HILLRDD N ANDOVER, MA 01845 Administrator Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 107679 Expiration: 8/5/2004 Type: Individual THOMAS DAVID'ZAHORUIKO Thomas Zahoruiko 185 Hickory Hill Road North Andover, MA 01845 Administrator M The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print 017W -687- I am a homeowner Worming all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City' Phone #: Insurance Co. Policy # Company name: Address Citi Phone #: Failure to secure coverage as required under Section 25A o GL 52 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years'imprisonment_as_well_as_cMI.penaltiesin jofa_STOPWORKORDERand.afine -of _(.$1DO.00)-a-dayagainstme. I understand that a copy of this statement may be forward to th Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains d penalties of:perlf�rylatthe information provided above is true and correct. _. � / - `` n-i+o Print Official use only do not write in this area to be completed by city or town official' #qW- 687 6?3� City or Town Permit/Licensing Building Dept []Check if immediate response is required Q Licensing Board p Selectman's Office Contact person: Phone #: ❑ Health Department Ei Other 2 s y g AOK VK s c, z,�P* A&3mvm (Rk 15 T 1 N Cj co to t -rt mos h7 /G Z r LL 4d O � � NZ 2 S 4 thkM ST WT NoP.1' N X KOO\MK C9 U) m m Cl) 0 m ..:: E O O O to CD CO) CD .O+ O :) CO) C9. O CA Cl)ma sr CD CD0 cD y CD CO) 0 CCD 3 0 CD 0 -• 0 O CS fA � dp�m 'CO N .n.� m n C7 y CD ti 0 m Z ?-C W _I O� to 2t m CR CL C T ? m ,y ? d Fn - CA O O N p O m CD n G r O m -k O n o O y O toc — rr0 CD: rr^^ ? V J 1 O CD m :» oO z�y%Val G O oo n ►Q co) o _ co � c_ m m d N m O O A O o w CD N A z O 'OCD O :� 1 ? CD 0 � ED G7i 0,.�• � ns CD • 0 � d s 0=:x O =CD:� A . o cn ccn w 7n °^ o a c bCA �? °R c� o arc CA -r? w o via r� c� ti? °� 7d o Or. Q x o � CL o G7 d ( �^ n r o o. x o 0 Tf O O O LO W s O O 0 0 in to z w II pp Zss W C OQ M SQ ? OZ O LO PNU 0. 10 N C '0EMw oaz x °° z p G F- p I WV QI 0:V) N wfn O �NQ JQ 0 L%d a cr = N W Y� w �Q OUU H �02 m0 A a N Q x o �����l LL- y� '—'�a Z o Z�rn 11 m o W W W m = J � c N zWm p Z U W_ lI) Z�0 Q L } >' �cl O O Z aa.. 3 � .OLLJw LU UN�U w HW ZQLu ..l% V) LL m �O LIJ N z0 .. WRN Q V) � _ a� wO zYa) 9 =m z� r- N w II pp Zss W C OQ M SQ ? OZ O LO PNU 0. 10 N C '0EMw oaz x °° z p G F- p I WV QI 0:V) N wfn O �NQ JQ 0 L%d a cr = N W Y� w �Q OUU H �02 m0 A a N Q x o �����l LL- y� '—'�a Z o Z�rn 11 m o W W W m A 4252 Date .../..... /% O t ,ORT/1 ° t"`° '• "� TOWN OF NORTH ANDOVER mom p PERMIT FOR WIRING This certifies that, � L = (.ec S ��j `�' ,- F ............................................................ .......... has permission to perform ..`^......j......... Ud �........................... Wiring in qq the building of ............ ........................................ ........0 .. ......................................................... .JGt ..�orth Anduv S. Fee..�!..J..... !�!�/ Lic. No .!�.J ......I........ ............ r��.ma�cc/..... -� />LECTRICAL INSPBCfOR Check # N THEC03MONWEALTHOFMAS',SgCHUSETTS Office Use o DEPARTNWOFPUBIICS MY BOARDOFFIREPRE[VEMONREl.'MUONS527C 1200 pest No. Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date l L.-�- C% � O -L, Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Ills, Owner's Address Is this permit in conjunction with a Purpose of Building 411, S rg pernut: Yes --) vl Existing Service Amps / Volts New Service Amps_Volts Number. of Feeders and Ampacity and Nature of Proposed Electrical Work No. of Lighting Outlets Z, I No. of Hot Tubs No. of Lighting Fixtures Z -- No. of Receptacle Outlets No. of Switch Outlets / No. of Ranges No. of Disposals No. of Dishwlshers No. of Dryers Swimming Pool Above No. of Oil Burners J No (Check Appropriate Box) Utility Authorization No. Overhead Underground M No. of Meters --` Overhead Underground No. of Meters No. of Gas Burners No. of Air Cond. Total Tons No. of Heat Total Pumps Tons Space Area Heating Heating Devices Vo. of Water HeatersKW No. of do. Hydro Massage Tubs No. of Motors No. of Bailasis Total HP :8 fill .u: .n is .i• '•i •:.n._ •' •:r••:.i,••. • • il�n,r. ,.:.i 4NAME rA No. of Transformers Below Generators round No. of Emergency Lighting Battery Units FIRE ALARMS Total No. of Detection and KW Initiating Devices KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW Local Municipal ED Connections Total KVA KVA No. of Zones ElOther M.4{`4rte.. , d, .t Signuue \ LiNo Z7 Asa \ Bt Tel.No. _ �v..�.s�ca ,•� 5 ► � �l'4-, S 1 O wt .�v L/ O � YC� '� At Tel No. lIIZ S CEWAWEP,lamaware lhatthel censedoesnothavetheir>.amicecov�oeorit a bstanhaletltuvai tal gtutedbyMa�In G=WL3ws at my signattueon Ibis pmi t app ` - . _ _ this lagtrjrlt a�r se check one) Owner � Agent Old No. PERMIT FEE $ �/ (/J) rgna ure o caner or Agent rf The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name 1\' a AeL F Ail v� o o Please Print Name: Location: C_itY 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. V Address g City: 11) ts4 S l�t ✓✓ l�Q Phone #. Z Cl Insurance. Co. Policv # Company name: , Address CatY Phone # Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.7 and/or one years' imprisonment-as_welLas.civil.penattiesin tbeJnrm-a-STDPwORK..ORDERarld..a fine-cf.($1.QOM)-ayigainstme. 1 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 wider the pains and penalties of pedurWat the information provided above is true and correct. Print name /� (�f1- r✓ L F , Official use only do not write in this area to be completed by city or town official' /Z I City or Town Permit/Licensing � Building Dept ❑Check if immediate response is required p Licensing Board E] Selectman's Office Contact person: Phone A- 0 Health Department o Other II Cn Y m a m m m m Cf) m cm, CD cc CL C-3 C7 rn CD 4A, C2 C3 p . r- = 5 =r -p Go CA 0 is =r IM C3 m =r CD 0) = CD CO% 0 ZE 0— =10 4D CD -col -9 co, cc, C3 5 10 = .4100 co w CA A cm, -00 rTl CL X. cl) CO3 1 0 cx � : U3 C, 40, .4b CL co) rCA r CL CD 0) u w C/) CD .1 ID C3 19 CD r -L cr =r 1Z. m m cA ,.0 Co CD 0-1 !'Do i CD tl] O CD C CD CD CD CA C3 C/3 to 84� "0 z CD 4CD 0 CL CD C) C, dc CD 02 IM6 0 CD C, n m M Ln C/) cc 0 C-10 !!!! 0 C; ql —a J0 —45 C) 0 c Zj k CA x 0 23 0 ;3-d OT627689-BLS o-,ITnjo%4eZ -a sewma dSt,:To Co La qaj