HomeMy WebLinkAboutMiscellaneous - 27 LISA LANE 4/30/2018 (2)Date .....
k TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ Xa. 6.�wb . ...................................
has permission to perform ........ /—�
7--
. ...........................................................
wiring in the building of .......... .................................
at ..... .7.-2 ...... ................................... North Ando er, Mass.
Fee..9-�.— Lic. No. ,40$27M .......... ... ....... . .....
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Commonwealth of Massachuseffs
Department of Fire Service,�
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. /,0 -7 �- /
Occupancy and Fee Checked
,[Rev. l/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PRNT)7V RVK OR YTPE ALL BVFORAM TION) Date: Ll / Y / /?—
City or Town of- NORTH ANDOVER To the Insplektor 0^ires:
By this application the undersigned gives notice ofhis or her intention to p6rform the electrical work described below.
Location (Street& Number) -2 7 4qn e -
Owner or Tenant - Kos c-, n*)nw Telephone N 0.
Owner's Address 5axne-
Is this perml i t In conjunction with a building permit? Yes NOE] (Check Appropriate Box)
Purpose of1luilding S�r-,RkZ_ Vl� k RXAX-k�ty\ Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd
Aew Service Amps Volts OverheadEl u-ndgrdE]
Number of Feeders and Ampaciti
Location and Nature of Proposed Electrical Work: on
[No. of Recessed Luminaires
No. Of Luminaire Outlets
es
Luminair
No. of es
N o
or. of Recept9de Outlets
No. of Switches
No. of Ranges
LNo. of Waste D isposers
NO-of Dishwashers
0. oj�Hl
U
No. of Dryers
INO. 01 Water KW
Heaters
No. Hydromassage Bathtubs
OTHER:
No. of CeII.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Po Above
rnd. DIgni-ad.
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. TotaF—
M---
table
No. of Meters
No. of Meters
Generators KVA
ALARMS INo. of Zones
of Alerting Devices
Space!Ar�a Heating Kw Local D Mu
Cox
Heating Appliances KW Securlty —Syst
No. ofDei
No. of No. of Data Wiring:
'" I
Signs Ballasts No. of Dei
Telecommuni
No. of Motors Total HP
0 Other
AttaCh additional detail 1fdesired
or as required by the Inspector of0res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with TVIEC Rule 10, and upon completion.
INSURANCE COVER—AGE: Unless waived by the owner, no permit for the performance ofelectrical work may issue unless
the licensee provides proof of liability insurance including "completed operatioe' coverage or its substantial equivalent. The
undersigned certifies that such VVerage is in force, and has exhibited proofofsame to the permit issuing office.
CHECK ONE: INSURANCE n- BOND D OTHER El (Specify:)
I cerqy, ufider thepains andpenalfles ofperillry, that the informatior on this application is true and cm,,�Ieie.
FIRMNAME: 'P' cr3,
I Cc, LIC. NO.- -ZC�-r
Licensee:kue- i); C -r -CO: Signature Z�,o A
(IJ r applicable, enter "exempt" in the license number IMW LIC. NO.: 19 C)4-91 e
Address: 1 �—N Gft, . I S-\nv-,e Bus. T I N
'Per M.G.L c. 147, s. 57 Alt. I OA
019%2 'el:No X(9' -(+9W
-61, security work requires epartment ofPublic Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) n owner D owner's agent.
Owner/Agent
Signature Telephone No._ FEE.
zo 0
tors C
4 A -L dl
Pate
tMAR GRODND _WSPOCTION.
m spar
s _tors' c
pectors, cominents.
Pate
4 )NSPXCWON—BRPVfCW,:
DATE, CAMT *,rf —0 W-MYONAL GIR D"
Passed—[ )
(Jkspectorsl islga�tura - io �ul
WBI?ECTkON - OTfdER:'
HAMM'.
passed — F I ^Ize-inspectioureqi&ed($50.00)-[
asj?ectoxsl colfiments:
Date
Winatue - no juiluals) Date
1) 0 OR TAGS APX TO BE MMED 91-MiT AND YFFx oN RITE iF THE AMA To BE WSPECTED 19 NOT
ACCESSIBU, AND A RMURPECTION OR $50,0 0 IS TO BE CBMGFD.
P I 'It.
The Commonwealth ofMassachusetts
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
Name (Business/Organization/Individual): C_c4c-o ecizx c_
Address: 0�- Gvcj
City/State/Zip: 0\cjo�o Phone#: A � `) )
Are you an employer? Check the appropriate box:
1. VLI am a employer with �-\
4. El I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2.0 1 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. n We are a corporation and its
required.]
officers have exercised their
3111 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. F1 New con.struction
7. F1 Remodeling
8. n Demolition
9. rl Building addition
lgi,EQ.ectrical repairs or additions
11. El Plumbing repairs or additions
12.F1 Roof repairs
13.rj Other
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inforination.
T Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:. C6VV-,(V\e4-Ce._
Policy # or Self -ins. Lic. #:.
Expiration Date:
Job Site Address: -�� -\_C,-4__ , City/State/Zip:_Cx>,�� A�,cbUe!�_>
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one�year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do h ereby cerAQ under #wvalns an dpen alties ofperjury th at th e information pro vided abo ve is true and correct
Phone #: ?�? 1 - dL__� V_ / 3 _? —2
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
PermitUcense 9
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 ofhire,.
express or implied, oral or written."
An employerls defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 apa�tments 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."
I
MGL chapter 152, §25C(6) also states that "every state or lo'cal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or , o 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) aiid phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited, Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' coinpensation 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 permittlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site AdNess"' the applicant should write "all locations in -(City or
town)." A copy of the affidavit that has been officially starriped 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 fillqd out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercialventure
(i.e. a dog license or p*ermit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to tharik 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 Westigatio u*s
600 Washington Street
Boston., MA 021 It
Tel, # 617-727-4900 at 406 or 1-877�,MASSAFR
Fax # 6117-727-7749
Revised 5-26-05
wwwmass.gov/(Ea
U
4
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Date.Z!?..—.: .... I ............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. ......
......................................................
has permission to perform I I I _::67-7—
... ........................... �: ...........................................
wiring in the building of ....... ..............................................
___el
at . ....................... North Andover, Mass.
Fee.ze Lic. No ............
PELE�E,'-,L �S �M
Check #
64,A
U,
Commonwealth of Massachusetts Official Use Only
NEW Department of Fire Services Permit No. �L/S (,--3
S Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATION .[Rev. 9/05] (leae blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLF,4SE PRINT ININK OR TYPE ALL INFORMATION) Date: 1C)12;169
City or Town oh lvoj� �-h CV u2_ 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) 9—� Lis,-,_ tq_nJ_ ,
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes EJ No El (Check Appropriate Box)
Purpose of Building ! Utility Authorization No.
Existing Service Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity I
Location and Nature of Proposed Electrical Work:
/I I �t k"g " 12t_ 0 ffvz. t / 0 t -u o k, lt,�
OverheadEl Undgrd r_1
Overhead [:] UndgrdE]
J-1 _e 1P I lr--
No. of Meters
No. of Meters
V Con6letion ofthe followincy tahle mav hp wnivpd hv tho himortnr nf Wi—
No. of Recessed Luminaires
No. of Cefl.-Susp. (Paddle) Fans
No. 5T, IFO_�'
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above E] In- Ej
grnd. grn j
No.'of Emergency Lighting
BatteEy Units
No. of Receptacle Outlets (0
No. of Oil Burners 0.
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No . . of Alerting Devices
No. of Waste Disposers
Heat Pump I.Number
Total!
I Tons
1 7-7-
N -o-. -o-f-S—e-I TZ o n t a i n e d
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocaIE] Municipal El other
Connection
No. of Dryers
Heating Appliances KW
S—ecurity Svstems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HIP
Telecommunications Wirin
No. of Devices or Equiva cut
N
OTHER:
Att6ch additional detail ifdesired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. Ile
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE R BOND F] OTBER F1 (Specify:)
I certify, under thApains andpenaldes ofperjuryi- that the information on this application is true and complete -
FIRM NAME: �—Ir C h�� L LIC. NO.:
Licensee: R((,Pz 11((a_ZZv Signature LIC. NO.:
(If applicabFe enter "exempt" in t4e license nu ber 61
,�ine) Bus.lel.No.u��,_' tl-.70
Address: 7E�, Alt.Tel.No.:' /0' 7
*Security System Contractor License required for this work; ifapplicable, enter the license nu. - mber here: J3
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 (che one)E] owner E] owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE.$ //,�3,
.0
As
Date .... _,e76
...................
TOWN OF NORTH ANDOVER
Mow PERMIT FOR WIRING
This certifies that ............ /���xp/ .......... A& r ............................
has permission to perform..A,2./�, ........
wiring in the building of ....... 5 C-41
.............. ( ....................................
at ....... ........................ North. Andover, Mass.
Fee.R�E.'.. Lic. No,-�q��?
.......... LCMICAL INSPECTO
Check #5w6o
( 1
8 4 L U
Im
commonwealth ofMassachusetts Official Use Only
0 Permit -No.
Department of F
ire Services
Occupancy and Fee Checked
U BOARD OF FIRE PREVENTION'REGULATIONS [Rev. 9105]
eaveblank)
APPLICATION'FORPERMIT TO PERFORM ELECTRICAL WORK
All work t6'b� perforined in accordancewiih the Massachusetts Electzical Code (MEQ, �537 CMR 12.00
(PLEASE PRINT INNX OR TYPE ALL 17VFORAL4 YTOA9 D06: C)
City*or Town of:
To the nspec'tor of Whres:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street &_N_umber) 9--7, L i '7_�Zk_ L_CX_o.L
Owner or Tenant
Owner's Address
Telephone No.
is this uilding permit?
pernu in conjunction with a b Yes No (Check Appropriate Box)
Purpose of Building I rN I Dwe
Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd No. of Meters
New Service Amps Volts Overhead Undgrd n No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: (Y\
gn-ayn
Camniptinn r)ftk,, fAllAud"a MAlo m'- An 1,*-* 4 A-
No. of Recessed Luminaims
No. of Cell.-Susp. (Paddle) Fa ns
�y w_ _p�wvf Oj rr&rw.
No. of 'Total
Transformers KVA
No. of Luminaire Outlets
-INo.
No. of Hot Tubs
Generators KVA
of Luminaires
Swimming'Pool Xbove r] In- F
grad. grnd. ]
N o. ot Emergency Lighting
BattM Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners,
of Detection and
Wtiating Devices
No. of Range's
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pu
Totalq!
umber.
I -
Tons
I
KW
I
No. of S-eT-Contained
Detection/Alerting* Devices
No. of Dishwashers
Space/Area Heating KW
LocalE] Alun"'Pal [].Other
Connection
No. of Dryers
No. or water.
Heaters KW
lNo.
Heating Appliances KW
No. of No. of
Signs . Ballasts
Securltys_ystems:7� -
No. of Devices or Equivalent
DatoWiring:
No. of Devices or Equivalent 'S
No. Hydromassage Bathtubs
of Motors Total HP
Telecommunicati Wirld-9
ons 'Tent
No. of Devices or Equiva
IOTHER:
Attach additional detail iftlesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: GOO:) (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion,
INSURANCE COVERAGE: Unless waived by the owner, no permit for the peribrmance of electrical work may issue Weds
the, licensee provides proof of liability insurance including "completed operation!' coverage or its substantial equivalent. The
undersigned mfifies.that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCEE] BONDE] OTHER 0 (Specify:)
I certify, under f&e pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAM
E� P- LIC. NO.& 910�0 A
Licensee: C_Q f, Signature\lUbA LIC, NO.: 2MOD-9 . E'
(If applicable, ente "e�;mpt It in the license nwnl!$n� ,,.) J —Q I -
C�r � (�() C Bus."Tel, No -=Ir-1 10 - ('37/
Address: 7 M1 _`�I_to "_ S C�3 . - * 5 01
*Secu . itYSY r Alt. Tel. No:: - I'M
A . stem Contracto License required for this work; if 4Dfficable, enter the license number here:
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 tb . is requirement. I am the (check one) 11 owne r . Eh�mer's agent.
Owner/Agent
_TF
Signature Telephone No. PERMI EE: $
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
,W-tf 0-1, www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LegibPv
Name (Business/Organization/Individual)-?V ccco C—
Address: I �-� b M '/ StC) C*-P—
NO
City/State/Zip: M Y:)- C) 9 QG Phone
Lre.you an employer? Check the appropriate obx:
a employer with 4. El I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. 1 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. 11 We are a corporation and its
required.]
3.E1 I am a homeowner doing all work
myself [No workers' comp.
insurance required.] f
officers have,exercised their
right of exemption perMGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. [] New construction
7. D Remodeling
8. 7 Demolition
9. El Building addition
10 -El Electrical repairs or additions
I I - F-1 Plumbing repairs or additions
12 -El Roof repairs
13 -El Other
,�Ily appIlUdIlL UIUL L;nt;(;Ks DOx ff I must also n1l 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.
lContractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:_Q2)vr,1_,es,+e(- rr)o+uc�\
Policy # or Self -ins. Lic. 4:_0 J �? i � (o Expiration Date:_IJ -4R� I o
Job Site Address: a -7 U'S A LC Y\.O-- City/State/Zip:.)\ J)YcJ0U-e_ r
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 irfsurance coverage verification.
I do hereby rtrfy ry
< -ce i under the pq�ns andpenalties ofperju that the information provided above is true and correct.
SiLrnature.�,� Date: J01 � S-1 0<?
Phone#: _�91_ a-_�\
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#:
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN9 MA 01833
978-352-8318 fax 978 —352-2858
cell: 978-502-5921
October 23, 2008
Mr. Kevin Murphy
169 Boxford Street
North Andover MA. 01845
RE: Rosenthal Residence, 27 Lisa Lane, North Andover, MA. 0 1845
Dear Mr. Murphy
As you requested I visited the project 10/16/08 and 10/22/08 to review the LVL
members used in the framing of the addition to the above residence. These are shown on
drawings prepared by Steve Foster dated 7/8/08 and certified by me 7/18/08.
Based on these site visits I can certify that to the best of my knowledge the LVL
members utilized in the above structure are acceptable and meet the loading conditions
required by the 7th Edition of the Massachusetts State Building Code.
Should you have any questions please do not hesitate to call.
Yours truly,
Lawrence H. Ogden, P.E. Structural 27765
" OF
LAWRENCE 43/
HAROLD
N
27 6
D a t e 7. 7.
TOWN OF NORTH ANDOVER
jr
"d 0
PERMIT FOR PLUMBING
This certifies that g -i— C Mo ..........
...............
has permission to perform ..... . .............
plumbing in the buildings of .... Ko
....... �YTIIAI ............
at. . i.514 .... 4.4/ ............. I North Andover, Mass.
Fee. ���Lic. No .......... ............
PLUMBING INSPECTOR
Check #
7871.
17
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Lo�ation �J 1 Y/4 Owners Name 1q, Date /o—?—o ?",
Permit 4F—
Type of Occupancv Amount
New 10 Renovation ID Replacement ' El
FYYTT Tllz� ve
Plans Submitted Yes No
. 1:1 11
(Print or type)
Installing Con
Name Check one: Certificate
Corp,
fill"/ ri
Address /I-' 0'i � 111 —1
p_-- �Ld 7a 0 Partner.
Business I elephone 1-1
Firm/Co.
Name of Licensed Plumber: IR42hAld-
Insurance Coverage: Indicate the tr -insurance. coverage by checking the appropriate box:
Liability insurance policy Other type of indemi-ii
ty E] Bond
Insurance Waiv I, the undersigned, have been made aware that the licensee of this applicatiori does not have any one of the above
three insurance
Signature I Owner 1:1 Agent El
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 )erfo d
compliance with all pertinent provisions of the Mas V I rme untler Permit Issued for this application will be in
s setts tate I b d Chapter 142 of the General Laws.
1By:
Title Type of Plumbing License
City/Town 2 2,t 64
APPROVED wFicE usE oNLy Master Journeyman
U El
MMM
mmmmmm
W-40 tj
mumm
M
MWM
M
mmmm
WN
MW
MMMM
OMMMM
MWON
(Print or type)
Installing Con
Name Check one: Certificate
Corp,
fill"/ ri
Address /I-' 0'i � 111 —1
p_-- �Ld 7a 0 Partner.
Business I elephone 1-1
Firm/Co.
Name of Licensed Plumber: IR42hAld-
Insurance Coverage: Indicate the tr -insurance. coverage by checking the appropriate box:
Liability insurance policy Other type of indemi-ii
ty E] Bond
Insurance Waiv I, the undersigned, have been made aware that the licensee of this applicatiori does not have any one of the above
three insurance
Signature I Owner 1:1 Agent El
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 )erfo d
compliance with all pertinent provisions of the Mas V I rme untler Permit Issued for this application will be in
s setts tate I b d Chapter 142 of the General Laws.
1By:
Title Type of Plumbing License
City/Town 2 2,t 64
APPROVED wFicE usE oNLy Master Journeyman
U El
Location C 9, 7 1 ,�-
No. �� Z-- Date 6-17-0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee
TOTAL
1. 1 --� a
Check # 67 /A)
17384
Building In6r-Itor
ft
It TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR. RENOVATE. OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERMIT NUMBER: rl / DATE ISSUED -
SIGNATURE:
Building 6jrfi0ssi"o'n'"er/Ir9&AW6f Buildings Date
I qF.CTION I- SITF, INFORMATION
1.1 Property Address:
g77 usck LAqf\-P—
I t;o -,—pq U
1.2 Assessors Map and Parcel
�PP /-)-
Map Number
Number:
00,1,3
Parcel Number
Signature Telephone
1.3 Zoning Information:
Zoning District Proposed Use
s6l�
Address for Service:
978 - (o o" 0
1.4 Property Dimensions:
Lot Area (sf)
Frontage (ft)
1.6 BURDING SETBACKS 00
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Front Yard
Side Yard
License Number
Rear Yard
Required Provide
Required Provided
Required
Provided
Registration Number
Address
1.7 Water Supply M.G.L.C.40. 54)
Public 0 private 0
1.5. Flood Zone Information:
Zone Outside Flood Zone 0
1.8
munict.1-11--,
Sewerage Disposal System:
— -. .- - OnSiteDisposal System 0
SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT
I t;o -,—pq U
2.1 Ownerof Record
fL0WV%)(k(
Naw.e (Print)
(?-71
Address for Service
4a-39-73
Signature Telephone
2.2 Owner If MR cord:
eoz v*6j
Name P t
s6l�
Address for Service:
978 - (o o" 0
§i:g—naturd Telephone
SECTION 3 - COMTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable /4/
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
00
M
X
ic
--i
z
0
SECTION 4 - WORIORS COMPENSATION (MG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check appficable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) -13"-
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0, Specify
Brief Description of Proposed Work:
VtVh-'J� 9�01RCCAIX-� VQ) JCQ'-/E
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
'U
-
I . Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Pennit fee (a) x (b)
-e)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5) _3
Check Number
SECTION 7a OWNER AUTHOkIZATIbN TO BE CONIPLETED WBEEN
OWNERS AGENT OR CONTRACTOR APPLIEES FOR BMING PERNHT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
I matters r e or� by this building permit application.
utho
Sig�atur6f 6xner 4 Date
SECTION'7h --T-Tk�IbIAYT THORIZED AGENT DECLARATION T-
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoin� application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of 0,,vner/A ent Date
0 1 I'll, ---- M—j--
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TWMERS iST 2 N15 3 RD
SPAN
DIMENSIONS OF SILLS
DINENSIONS OF POSTS
DINENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUUDING ON SOLID OR FILLED LAND
CONNECTED TO NATURAL GAS LINE
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is *that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
J V, 9 's
ree,qclp-d, bq (Location of Facility)
CJP'q+1-C,(GW e-�4 /
n3�7-q
'Signature of Pbrmit Applicant
J-7/0
Date'
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Town of North Andover
Building Department
27 Charles Street
North Andover, MA. 01845
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542. Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DAfE
00-01
JOB LOCATION a -� Lucc� Canc
Number Street Address Map / lot
"HOMEOWNER
Name
Home
PRESENT MAILING ADDRESS 9-) LACA Lay)r_
Work Phone
9
oy� &t�e V, VYW\_ I — C) 041 --
City Town State Zip Code
The current exemption for "home6wners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner' certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he>� will
comply with said procedures and reqq"entsq /1)
HOMEOWNER's SIGNATURE
APPROVAL OF BUILDING OFFICIAL
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Permit No..
Eepmt=W erf Vablic tidetq occupancy A Fee Checked
0eave blank)
BOARD OF FIRE PREVeMON REGUUTIONS 55V CMR 12:00 6-Z)73
OR 7�-
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W K W fua
All work to be performed in accordance with the Massachusetts Electrical Code, 52ff MR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date k4wvu , �-�q
(%*or Town of NORTH MOVER TO tpCi—nspector of ires:
The udersigned applies for a pi�rmit to,,pertorm Spe electrical work described below.
Location (Street & ��Per)
Owner or Tenant
Owner's Address
'—L; -""'No (Check Approo ate -8
Is this permit in COnju t' n with 4 building permit: Yes ;-*-- ri elT�
Utility Authorization Nd`,�.
Puraose of Suildina
Existing Service Amps Vaits Overhead Undgmd No. of Meters
(4ew Service &2!�L Ampsl&)-j :2 10its Overhead No. of Meters
t t42-
Nurricer of Feeders anc Ampacity
Locaticn anc Nature of Proc.o.sed Eec-rical ',VCrK
I No. of �0' 7-s No. at '7ransformers iota'
No. of L;gnting Cuttets 7 1 - - --- KVA
I Swimming P*zci Accve— In- —. KVA
No. at Lighting Fixtures ;-no. — gma. Generators
0 T H EP :
INSURANCE CCVERAGE: Pursuant to the recuifements at Massacnusers ;enerai Laws
I have a current Uaoiiity Insurance PoliCY inc:ucing Czrr.=!eteC Ccerations Coverage or 'Its substantial ecuivaient. YES :: NO
have submitted vaisd proof of same to the Offics. YES = NO = If you nave checKeto YES. ptease indicate the type of coverage --y
criectiting 'he aoproortate 00x.
INSURANCE = BOND = OTHER = (P!ease Scec-!�41 (Excitation Date)
Estimated Value of Electrical WorK S
WCrX *0 Stan
Signed unce of pe,%ur
Fi FIM t4AME
Irtsciecuon Cate Recueszec: Rougn Finai
f
LIC. NO.
Bus. 7eifNo.
Address Alt. 7el. No.
OWNER'S INSURANCE WAIVER: I am aware trial tre ---censee coes not nave the insurance coverage or Its substantial ecuivalent as re
autrec by Massachusetts General Laws. and -nat -ny signa-,ure an =3 zermit application waives this reautrement. Owner Agent
(Please cnocx one)
cSiq—.ature of Owner or Agent)
'79teanone No. _ PERMIT FEE S
1-4565
No. of Emergency Lighting
No. of Receoracte Cutlets
No. of Cil Burners
Sartery Units
No. of Switc.n Outlets
No. --t Gas Surners
FIRE ALARMS No. of Zones
No. of Cetection and
No. at Ranges
No. c4 Air C--r:c.
initiatinc Devices
No. of Oisoosais
No.of Heat '7cai
Purncs 10 n s
—iotai
K11v
No. of Sounding Devices
No. of S it Contained
No. of Disnwasners
ScacetArea �4eannc
DemcnoniSouncing Devices
No. of Orvers
Heaunia Oev;ces
KW
munlc;oal
Locaj ;—. —. Other
Connect;on
No. at '140- at
Low Voltage
No. of Water Heaters
KW Sicns Bailasm
Winnc
No. Hvaro Massace '7uCS
No. of Motors -ota;
HP
0 T H EP :
INSURANCE CCVERAGE: Pursuant to the recuifements at Massacnusers ;enerai Laws
I have a current Uaoiiity Insurance PoliCY inc:ucing Czrr.=!eteC Ccerations Coverage or 'Its substantial ecuivaient. YES :: NO
have submitted vaisd proof of same to the Offics. YES = NO = If you nave checKeto YES. ptease indicate the type of coverage --y
criectiting 'he aoproortate 00x.
INSURANCE = BOND = OTHER = (P!ease Scec-!�41 (Excitation Date)
Estimated Value of Electrical WorK S
WCrX *0 Stan
Signed unce of pe,%ur
Fi FIM t4AME
Irtsciecuon Cate Recueszec: Rougn Finai
f
LIC. NO.
Bus. 7eifNo.
Address Alt. 7el. No.
OWNER'S INSURANCE WAIVER: I am aware trial tre ---censee coes not nave the insurance coverage or Its substantial ecuivalent as re
autrec by Massachusetts General Laws. and -nat -ny signa-,ure an =3 zermit application waives this reautrement. Owner Agent
(Please cnocx one)
cSiq—.ature of Owner or Agent)
'79teanone No. _ PERMIT FEE S
1-4565
2 3 -3 9
ORTol
0
Date..... ...... J.: .............. /-1
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... L—. ....... ........ ................. C. -I ........
has permission to perform ........ ....... ...........................
wiring in the building of ....... ...... ..............................
at .... . /.-.7 .... ....... . North Andover, Mass.
Fee -..C' Lic. NO,'./.
I/ ............... i�'E*C'T'R"1*C* A*'L'*1'N-S'P-E*C-T'0-R- * ...............
1-04
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File