HomeMy WebLinkAboutMiscellaneous - 275 APPLETON STREET 4/30/2018K)
C, m
—4
0
z
0 cn
C, .-I
40 m
0 m a
jo m
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
t5form4.doc- 11/12
State
State
Telephone Number
Zip Code
Zip Code
1. Date of Pumping - I �- I(H 10 2. Quantity Pumped: sno
Date Gafl—ons
3. Component: El Cesspool(s) EJSeptic Tank El Tight Tank [-I Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? 0 Yes E] No
5. Observed�condition of component pumped:
6. System PunTped By:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Sign �eof H a u I �er
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
— � �--1 �--L (C::,
Date
Date
System Pumping Record - Page 1 of 1
A. Facility Information
Important: When
filling out forms
on the computer,
1 . System Location:
use only the tab
6o 5
key to move your
Address
cursor - do not
North Andover
use the return
key.
City/Town
01�
2. System Owner:
vs��=A
Ppd 0--0
Name
Address (if different from location)
City/Town
B. Pumping Record
t5form4.doc- 11/12
State
State
Telephone Number
Zip Code
Zip Code
1. Date of Pumping - I �- I(H 10 2. Quantity Pumped: sno
Date Gafl—ons
3. Component: El Cesspool(s) EJSeptic Tank El Tight Tank [-I Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? 0 Yes E] No
5. Observed�condition of component pumped:
6. System PunTped By:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Sign �eof H a u I �er
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
— � �--1 �--L (C::,
Date
Date
System Pumping Record - Page 1 of 1
Date ...
. ..... ... ....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... :5) .. e4L ........ C
....... ...
has permission to perform .... . ....... 6.ee!�A.�
wiring in the building of ....... 0
..... ........... .......
at
......................... ............................
Fee4-) ................ Lic. No. ................
Check4t
1.2985-/
............................................................
!�. ..... ...................
North Andover, Mass.
..................................................
ELECTRICAL INSPECTOR
K113
(f0Mjno9W0a1a 0/ Ma.MaAUJA
BOARD �OF FIRIE PREVENTION REGUI�LA TIONS
timclai use timy
Permit No.
Occupancy and Fee Checked
[Rev. 1/07] (leave blank) -
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
'PLEASE PRINTIN INK OR TYPE ALL INFORMATION) Date: December 10, 2015
—City or Town of: North Andover, NIA— To the Inspector of Wires:
3y this application the undersigned gives notice of his or her intention to perform the electrical work described below.
�ocation (Street &Number 275 Appleton St
3wner or Tenant James Phelan TelephoneNo. (978)685-2066
3wner's Address 275 A1212leton St
[s this permit in conjunctio th a building permit?—Yes 0 —No 2) (Check Appropriate Box)
?urpose of Building_ Z&ijal Utility Authorization No.
Zxisting Service Amps Volts Overhead 0 Undgrd 0 No. of Meters
14ew Service Amps Volts Overhead 0 Undgrd 0 No. of Meters
14umber of Feeders and Ampacity
�ocation and Nature of Proposed Electrical Work:
Installation of a low-voltaize, wireless burglar alarm 5ystem.
Completion of thefollowing table may be waived by the Inspector of Wire
qo3of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
io-i'of Luminaire Outlets
No. of Hot Tubs
Generators KVA
io. of Luminaires
Above C] In
Swimming Pool grnd. grnd.
No. of Emergency Ligbting
Battery Units
io. of Receptacle Outlets
No. of Oil Burners
FIREALARMS
Fo.ofZones_
io. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
4o. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
io. of Waste Disposers
Heat Pump
Totals:
umber
IN
ons
IT
rw
No. of Self -Contained
Detection/Alerting Devices
4o. of Dishwashers
Space/A I rea Heating KW
Local 0 Municipal D Other
Connection
io. of Dryers
Heating Appliances KW
Security Systems: * I
No. of Devices or Equivalent
lo. of Water KVV
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
io. Hydromassage Bathtubs
IN o. of Motors Total IIP
Telecommunications Wiring:
No. of Devices or Equivalent
)THER:
Attach additional detail if desired, or as required by the Inspector of Wi?4'
�stimated Value of Electrical Work: $850.00 (When required by municipal policy.)
"-<
Vork to Start: December 10 �2O 15 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
N11
NSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
.ie licensee provides proof of liability insurance including "completed opemtion" coverage or its substantial equivalent. The
nd,ersigned certifies that such coverage is in force, and has exhibited proof of same to the pennit issuing office.
H ECK ONE: INSURANCE 9 BOND 0 OTHER 0 (Specify:)
ceilift, under thepains andpenalties ofperjuly, that the information on this lication is true and complete.
'IRM NA 12 e 71>--- LIC. NO.: -C 13 55
.icensee: gnature C. NO.: D 434
�fapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 800-689-9554
kddress: 3750 Priority Wa S Drive, Suite 200, Indianapolis, IN 46240 Alt Tel. No.: 866-502-3559
PerM.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic.No. SSCO-001258
)WNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
,quired by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner 0 owner's agent.
)wner/Agent Telephone
,ignature No. [PERMIT FEE: $ ge5-
)22-12 31 L,< ae'r W V -,Y\ vo -
I
I
c _J
Address: 3750 Priority Way S Drive, Suite 200
Indianapolis, IN 46240 Phone #:
Are you an employer? Check the appropriate box: Type of project (req'uired):
1. 1 am a employer with 3 4. [:] I am a general contractor and 1 6. r_1 New construction
employees (full and/or part-time).* have hired the sub -contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub -contractors have 8. Demolition
__I�!__ r__ __ :_ _1 emt)lovees and have workers' -
[No workers' comp. insurance
required.]
3. El I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
comp. msurance.t
E] We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comi). insurance reauired.1
I 0.1g Electrical repairs or additions
I LEJ Plumbing repairs or additions
12f l Roof repairs
13.El Other
*Any applicant that checks box #1 mustalso fUl out the section below showing their workers' compensation policy information.
I Homeown= 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 a I n additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. Ifthe sub-contractDrs have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers'compensadon insurancefor my enTloyees. Below is thepolicy andjob site
information.
Insurance Company Name:
IVIJ Insurance
Policy # or Self -ins. Lic.#: TCJUB1116LO3015 ExpirationDate: 07/01/2016
Job Site Address- -7 Ap
City/State/Zip:
Attach a copy of the workers' compelsation 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 thePains andivenoes ofperjury that the information provided above is true and correct
Phone#:
Official use only. Do not write in this area, to be completed by city or town ofticial.
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
lilt.
600 Washington Street
�4'
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aimlicant Information
Please Print Legibly
Name (Business/Organizationdndividual): Defenders, Inc. dba Protect You r Home
Address: 3750 Priority Way S Drive, Suite 200
Indianapolis, IN 46240 Phone #:
Are you an employer? Check the appropriate box: Type of project (req'uired):
1. 1 am a employer with 3 4. [:] I am a general contractor and 1 6. r_1 New construction
employees (full and/or part-time).* have hired the sub -contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub -contractors have 8. Demolition
__I�!__ r__ __ :_ _1 emt)lovees and have workers' -
[No workers' comp. insurance
required.]
3. El I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
comp. msurance.t
E] We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comi). insurance reauired.1
I 0.1g Electrical repairs or additions
I LEJ Plumbing repairs or additions
12f l Roof repairs
13.El Other
*Any applicant that checks box #1 mustalso fUl out the section below showing their workers' compensation policy information.
I Homeown= 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 a I n additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. Ifthe sub-contractDrs have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers'compensadon insurancefor my enTloyees. Below is thepolicy andjob site
information.
Insurance Company Name:
IVIJ Insurance
Policy # or Self -ins. Lic.#: TCJUB1116LO3015 ExpirationDate: 07/01/2016
Job Site Address- -7 Ap
City/State/Zip:
Attach a copy of the workers' compelsation 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 thePains andivenoes ofperjury that the information provided above is true and correct
Phone#:
Official use only. Do not write in this area, to be completed by city or town ofticial.
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
AILTH OF MA
COMMONWt SSACHUSETTS.,
1LE CTR I Cl ANS
ICENSE A
ISSUES THE. FOLLOWING L If,
T
A. REG 1. STERED SYSTFEtl CONTRAC 0
R
DEFENDER SECURITY CO PROTECT Y
\i
STEPHEN,& EHRLACH
3750 PRI,ORITY WAY,...,SOUTH
lu
STE
�.20.0
-1ND 1 ANAPOL I S I N 46240-3815
1355 C 07/3 I/A 38220
ELECTRICIANS.
.ISSUES THE FOLLOWING L1 CEN
A:,R,:E0-I'ST'ERED SYSTEM TECHNICIi
STEPHEN C EHRLICH
369 CENTRAL STREET.:'. �z
UN T
1 �9-
-O'ABOROUGH �-�:MA 02035-2637
434--D O7/3,.I/"1,6-:,,�.1.:- 4556o
L- Jl�
Mt1-111
1
SSCO-001258
STEPHEN C EHRLICH
3750 PRIORITY NVY S DR 4200 IbN
INDIANAPOLIS IN 46240 -Ad'
CONTROL#
IMPORTANT
If your license is lost, damaged or destroyed; is inaccurate; or
needs to be corrected, visit our web site at mass.gov/dpi for
instructions to ensure the proper mailing of your Renewal
Application and any other corriaspondence.
This license is subject to Massachusetts General Laws and
regulations. Your license is a privilege, and cannot be lent or
assigned to any person or entity under penalty of law. Keep this
license on�vour person or posted as required by law and/or
regulations�
CONTROL# i U
IMPORTANT
If your license is lost, damaged or destroyed; is inaccurate; or
needs to be corrected, visit our web site at mass.gov/dpi for
instructions to ensure the proper mailing of your Renewal
Application and any other correspondence.
This license is subject to Massachusetts General Laws and
regulations. Your license is a privilege, and cannot be lent or
assigned to any person or entity under penalty of law. Keep this
license on your person or posted as required by law and/or
regulations.
Employer: DEFENDER SECURITY COMPANY
12/03/2016 For DPS Licensing information visit: wwW-1Vlass.Gov/DPS
,7 q- , 1-1
NOTICE OF COMPLETION OF ELECTRICAL WORK
Pursuant to M.G.L. c. 143, § 3L, Stephen Ehrlich hereby provides written notice to the
inspector of wires that the electrical work outlined in the preceding permit application has been
completed.
EO
D
160OOsgood Street
Building 20, 2035
No hAndoverMA01845
lel:
Fax: 978-688-9542
COMPLAINT FOR INVESTIGATION
DATE: Tel #:
FROM:
ADDRESS:
\c
Complaint Against:
ELECTRICAL:
GAS:
BUILDING CONTRACTOR:
Signed:
0308 ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .. .. .... ....... ...................
has permission to perform .. . .. .......
................... ..
.. . .........
wiring in the building of .... ....... .............................
2 7 �— li
.......... .......... ........ ".* .... Mass
at North Andov'e'r, Mas�,
Fee.f ...... ............. Lic. Noo- ..... . .. .... .......
LE I
Check #
Commonwealth of Massachusetts Official Use Only
Permit No. Z .-!r
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date: I- Z, -7,.- - /)
City or Town of- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of hi r h r J t tion to perform the electrical work described below.
Location (Street & Number) 114 -
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a bufldin r it? Yes El No Z (Check Appropriate Box)
Purpose of Building &,5,10& 13aj Utility Authorization No.
Existing Service _Amps —Volts
New Service — Amps Volts
Number of Feeders and Ampacity
and Nat9fe of Proposed Electrical Work:
Overhead Undgrd No. of Meters
Overhead Undgrd No. of Meters
Completion of the followinz table mav be waived bv the Inspector of Wires.
N, o. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
[i
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
lNo. of Luminaires
Swimming Pool Above o In-
grnd. grnd.
N—o. ToT Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. 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
1.N4R!4fT..1.To.n.s
..........
1.!�yy
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [I Municipal 0 Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
I Signs Ballasts
I No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total UP
Telecommunications Wiring.
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: I pections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: [Unss waived by the owner, no pen -nit for the performance of electrical work may issue unless the
Ity
licensee provides proof of liabili nsbrance including "completed operation" coverage or its substantial equivalent. The undersigned
I su
c;ertifies that such coverage is in rce, and has ex hibited proof of same to the permit issuing office.
e, 0
W:HECK ONE: INSURANCE BONDE] OTHER E] (Specify:)
-'N certify, under thepains andpenalties ofperjuiy, that the information on this aflPlicati is true and complete.
FIRM NAME: LIC. NO.:
Licensee: 145911heqj4 110J0,011a,11. Signature LTC. NO.: �7
(If applicable, enter "ex t"i th licens9nt4nbyrline.),,.,f L/
)J,
0 Bus. Tel. No.:
Address: Al LY41-f o.: 7L
Alt. Tel. N 97r -,f
*Per M.G.L c. 147, 9. 57-61, security work require� Department Zif Public Safet3r"S" License: Lic. No.
OWNER'S INSURANE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required
by law. By my Sig below, I hereby waive this requirement. I am the (check one) 0 owner F1 owner's
Owner/Agent PV --
Signature 6� Telephone No. FPERMIT FEE: $
� - -. s� `/
��y
�.
SI
d
�� � �
�,
rhe
'0' "'0�0
epqlz 71;Peq11h'
41ellf 0
0
lid,
AD O'ke 61,9 0-rZ, 411
D 'rs' C, v
11ca t 4; "',pest, - C'Cia
evf
Dfor sati 0 0
'Vto
'Vanle On
Musinessl 'ranec' h�whl 1% freet
'V
0
Addrc,ss: n/ 4frid.,qt..
w1d,
it Istate
trac.t
4rey 1P.- -A! ors/ti,
1. cl 0 111 1 ectril -
1 jj)&��l r? C cla'q
Clib 'b Se �""'Jbber
2. 0,17ploy, Ploye'r eck the Int
lain Cesmill, With apprO
a Sole an( t Phone
,shiPRT?d, proPrittlo'rP
orki aveno Or 4.
n or C).
[No w g for,-, . ernp pa cr- a general
orke., 1 0 in an ecs ha V'e hir� con
3.[3'equ - ca , . ed tbe S., Ir
1 arn 'Pcd] COMA i cz C, "Sted
a horn St"tanc, 7, ese on tbe att, -coactor and
h nlr 0
"I.Yself ach ac
institan. w Slib-cont., COI tolts f
NO COW" eP doi [3 Orkeps, 6 Ir r,
work ng,71114 dcto IV, 1 1 1, 1, ri
cereqtjir, CTS'c comp - Ts ha v'C 7 ew cons I I red):
d , 0 are a . Insitrance tru lion
"y appir. 'mp. Ork Off,-Cerg h Corporat . c
1110�7?c cant th 101) Odelin
�C.o own at Ch -rightof, aveexcrc. and] g
n4ractors erg wh ecks b C. x Is
0 sUbInit tholc 152 eq)Pt - Ised their� -9� Itio
th at checl, § 1 (4) 'On n
th 15 at" '11, 1172p], , Per Af, IQ Id -
4F/I is b, in c Vy and VVI. I Gi- C3 _pl, '-09 addition
di OTP 0 W
&If e4� St 'es, rave
or it
p, 117 a ace catin Oct, ectri a
fta/10", d 9 they 'On bCj -IRS11 Ork, 1 .00 1 . c
suran add - - are C/o, 0 W Sh Tapce ers I [jP'1b - 'repair
117 Cc C /Spro nlonaZngaliw� OwinI reql",rcd 12 Cj,& Ingrej)a. sOradditio
0'r)7 eel S IT
e --s ho winork and then b. Orke's 13 Vs
Pany Atan g tire n (1, ire 011tsid Compensatio .0 oof-rePairs' ttsoradditio
Policy# 0 Self - Of Other Vs
T e: C01w,
1'0s.j 10 - 'he Sul, Contra n Policy -
JobS. ic. -&T4fq' �Contr C I" 1niattio
Ite A dd &C'e tops rnust slib 0
.4 tt ress: -for their rnitanew.
.7 Col woriker" avit lea
)y 0r con, ind -
to sec 0 Pol ' , 'Y Info tin. - Ueb.
Inc lip t tire cov Ir the rniation.
of lip t' 0 $i's Or
ve 0 00.00 age as
s . $2s000 QW10 _required 11111111� In Pol '-'Vpiration '7"0'joh site
ligatio 0 1 day ' "VO -ye, . Undo, CY decle, Date:
V's f the'o against . sect,* rati---
h 0
ji� the v- OnIne 1725,4 Of on C* tylst
for . -101ator t, as We A n page I atel
elehy Ins 1'(31 (S'bowin ;;,-
cc co 11 as C. . C. 15 'WP.
V'scd 2 can I g tj)e Poijej,
Ve - that "Vilpenalties . Cadt n
PL �"flca 'PY 0 th
n 'cc
0 "t'O Of this sta 'n the f, e Iniposi.4-111 I! pirat.
�Cjnejjt --]n ex�w �—.
r n7a Of a STOP Of c1rim, . 0al 101) date).
INV Y fo 0
4fse be I�Vaajtj - CS
owy. '60 arded to tbe oplotb Ofa
City Or 'r &0/ 1prife -propia, Ofrjc ` and a flne
issIlin A Own . . 11114 17 -eq ea, ?hoi,, Of
I ,, 9.411tbor, -40 he IS 114fe
6 �Qard offt COIWP/l "O'co
Othe
r 2. by
contact ilding 1) 1101
per'I
Person: epartMent 3. A %icense
jerk 4. electrical Inspector S pill,
Phone In, bing I
"'Pe'tor
top
Location P/ -)c/ E 222x/ 5
7
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
*-1,\ Other Permit Fee
�-010 Sewer Connection Fee
$ ,-- Ix-, 0 - 0
Water Connection ee $
T% $
Q r
41 building inspector
Div. Public Works
-eERAITT, XID. -
I
4
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
I -AGE I
M -i
AP -40.
LOT NO.
2 RECORD OF OWNERSHIP DATE
I
BOOK 'PAGE
ZON E
SUB DIV. LOT NO.
LOCATION
PURPOSE OF BUILDING
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS
fo t -
j :57_1
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME leP- A (2)' Foo Ls
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET i (o 0 1
1. POSTS
DISTANCE FROM LOT LINES - SIDES (.3 -3o REAR
0 100' 4
GIRDERS
AREA OF LOT 4/6 FRONTAGE
,177
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER;AL OF CHIMNEY
IS BUILDING ALTERATION
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 OUT SECTIONS 1 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 Fdaj:f- le,
RE OFAWPft)t,6R AUTHORIZED AGENT
E
PERMIT GRANTED
ig 92 --
OWNER TEL. #--!��ZQ�
CONTR. TEL. #-3-6-6,j5�ff y
CONTR. LIC. #---Q Z
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST 1 _57 oc C)
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
777:7`la�m
I
OCCUPANCY
NGLE FAMILY
S-ORIES
ULTI. FAMILY
MICES
'ARTMENTS
LAVATORY
FIN. ATTIC AREA
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
)NCRETE
HEAD ROOM
MODERN KITCHEN
)NCRETE BL K.
11 �11E
4 WALLS
9 FLOORS
ICK OR STON E
H
1
2
ERS
DROP SIDING
�
PL, 45TER
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
D-RY WALL
CONC. OR CINDER BLK.
WIRING
3 BASEMENT
10 PLUMBING
AREA FULL
FIN. B M T AREA
14 1/2 1/1
LAVATORY
FIN. ATTIC AREA
tLO B M T
FIRE PLACES
NO PLUMBING
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
1
2
3
DROP SIDING
CONCRETE
EARTH
HARD\'-' D
COMMCN
ASPH. TILE
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STIRS. & FLOOR
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
5
GABLE
�5AMBRE
� TA _T
ASPHALT
ROOF
10 PLUMBING
I HIP
BATH (3 FIX.)
TOILET RM. (2 FIX.)
WATER CLOSET
LAVATORY
KITCHEN SINK
NO PLUMBING
6 FRAMING
WOOD JOIST
TIMBER BMS. & COLS.
STEEL BMS. & COLS.
WOOD RAFTERS
7 NO. OF ROOMS
I I HEATING
B'M*T 2�d 'ECT� C -------
_'__'liET0 �EA511G
I st I'Td I
4J
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.
09915
ORT
C2
Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . .(�6 I I &.� !�.� .......
has permission to perfonn T/ -P
plumbing in the buildings of . ................ I ........
I- North Andover, Mass.
�.5� ............ )
FeeZ�... Lic. NoCil Z .... . 0.0 ..................... .
PLUMBING INSPECTOR
Check 4
11
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING
CITY [_jZdZaL-&4
MA DATE
PERMIT #
JOBSITE ADDRESS L22
/0/
OWNEFrSNAMEI,,, &
P OWNERADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL FJ RESIDENTIAL
PRINT
CLEARLY NEW.0 RENOVATION:jd REPLACEMENT:0 PLANS SUBMITTED: YES [I NOW
FIXTURES -1 FLOOR- I BSM I 1 1 2 1 3 1 4 1 5 1 6 1 7 8 1 9 1 10 1 11 12 1 113 1 1-41
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS[OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DRINKING FOL
FOOD DISPOS
FLOORIAREA
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
IG MACHINE CONNECTION
HEATER ALL TYPES
WATER
I have a current liability nsurance policy or Its substantial equivalent which meets the requirements of MOL Ch. 142. YES [] NO jj
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY [j BOND
OWNEP INSURANCE WAIVE ama to that the licensee does nothave the Insurance coverage required by Chapter 142 of the
MRS Otis loon wrL iwws and that gn*ure on this permit application wilm this requirement.
r07� CHECK ONE ONLY: OWNER jj AGENT
—M--
SIG4ATURE 0 0 N R OR AGdEt,(r
I hereby cerIlly, that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knovAedge
and that all plumbing work and Installations performed under the permit Issued for this application Y411 be In 9"lance vAt"qertInent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 11
PLUMBER'S NAME %---� U SIGNATURE
LICENSE #
MID iz/ ip C ORPORATION E3# FARTNERSHIPEJ# LLC E3
COMPANY NAME I ADDRESS 1 /,9-- /=,yx /2 V-A,- 4V
C I TY 1-115A ........... — STATE ZIP TEL , -f-Jf- ,
MAIL 10,&f K oy- , 2!�
FAX CELL za/"M �4,��j_ej
ke,
Y)
IN,
t
3,C)" S-?)-
The Commonwealth ofMassachusetts
Department of]ndustrialAccid�nts
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legib
-4+
Name (Business/Organization/Individual): e�2,zz& 10Z�,
Address: fi-t/ cy
City/State/Zip: '�Y'$teYJ Phone 4:
Are you an employer? Check the appropriate box:
1111 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
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3.0 1 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. n New con.struction
7. E] Remodeling
8. E] Demolition
9. E] Building addition
10. n Electrical repairs or additions
ILE] Plumbing repairs or additions
12.E] Roof repairs
13.ri 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 aie doing all work and then hire outside contractors must submit a new 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 insuranceformy employees. Below is thepolicy andjob site
information.
Insurance Company
Policy # or Self -ins. Lic. 9;
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 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 erely �wrtjfy un qer4li Opains an dpen alfies ofperjury th at the information pro vided 7b ove it true an d correct
Phone#: Coo
Official use only. Do not write in this area, to he 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 ofhire,
express or implied, oral or written."
An employeils 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 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 cons truct 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 subdiv! . sions 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 (LLQ 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.
Pleas ' e 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 pennit/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 fille.d 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 p* ermit 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 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 021 It
Tel, # 617-727-4900 oxt 406 or 1-877�MASSAFE
Revised 5-26-05 Fax # 617-727-7749
__Www�mass,gov/dia
Al
Date ........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
.70 -)
This certifies that.. a;�qi�7 .....
has permission for gas installation
- An
in the buildings of -7 ................ I ......
North d
at ... ........... An over Mass.
Fee.J9�-�� Lic. No.14KZ7.
GASINSPECTOR
Check# ?Zw
7863
mllmlllxi
6ow--
b 10
SUB BSMT.
BASEMENT
1'5'FLOOR
2 No FLOOR
4'" FLOOR
6 "' FLOOR
Fff -F- L 0-0 R
ff—FLOOR
Uff FLO—OR
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO
A
City/Town: MA. Date:
Building Location: 75 tqeflp __S 7- Owners Name:
Type of Occupancy: Commercial Educational El Industrial
New: El Alteration: 0 Renovation: El Replacement: Ej
FIXTURES
GAS
Permit# *
Institutional El Residential
Plans Submitted: Yes Ej No F1
Installing Company Name: 0 —t
Address:ako —16(cwv�s Cityffown-AG-9-9� State: HA
Business Tel: 21&&Ellak�o— Fax:
e of Licensed Plumber/Gas Fitter: CLA�e CAA,"
Check One Only Certificate #
El Corporation
0 Partnership
D Firm/Company
INSURANCE COVERAGE:
1 have a current liability insurance policy or 1 . ts substantial e uivalent which meets the requirements of MGL. Ch. 142 Yes 0 No
If you have checked �Les
, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Ul--' Other type of indemnity E] Bond n
OWNER'S INSURANCE WAIVER: I am aware that the licensee sLoes _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
Signature of Owner or Owner's Agent Owner El Agent
By checking this box E]; I hereby certify that all of the details and information I have su mitted(orentere I 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 pro7i 1
jp 0
— - - .4 'yf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of Ll e
nse:
Sig nature of Lice
S um r.
By A —&4v El Plumb( c ' 'I .
?r
Title El Gas Fitter
. F1 Master Signature of Licensed Plumber/Gas Fitter
City/Town Djourneyman
r License Number:
APPROVED (OFFICE USE ONLY) El LP Installer A262--�—
W
z
W
I
C0
Ig
I 1
Q
I
2:
W
W
0
W
Lu
0
U
Cl)
z
W
z
Wonww
0
W
0
ZI
z
6
W
W
:3
1XI
W
01
1.-1
=I
Q
65W
>
V)W
111
gmo
1--
uj
b
0
<
W
X
%
W
1--
Cl)
M
0
Z
UJ
M
LU
W
0
0
<
W
W
1--
W
a
X
.
LL
I L
V
>
z
ULU<
111
5'
zo-jl.-�-Oz-jou-
U)
_j
W9
V)
W
r
X:Zujwm
W
0
www
in
=)
<
R
0
<<Wwozo
W
W
>
0
9
0
co
W
t
z
z
z
W
l'-
T
I--
LL
0
m
re
I--
=)
=)
>
0
Installing Company Name: 0 —t
Address:ako —16(cwv�s Cityffown-AG-9-9� State: HA
Business Tel: 21&&Ellak�o— Fax:
e of Licensed Plumber/Gas Fitter: CLA�e CAA,"
Check One Only Certificate #
El Corporation
0 Partnership
D Firm/Company
INSURANCE COVERAGE:
1 have a current liability insurance policy or 1 . ts substantial e uivalent which meets the requirements of MGL. Ch. 142 Yes 0 No
If you have checked �Les
, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Ul--' Other type of indemnity E] Bond n
OWNER'S INSURANCE WAIVER: I am aware that the licensee sLoes _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
Signature of Owner or Owner's Agent Owner El Agent
By checking this box E]; I hereby certify that all of the details and information I have su mitted(orentere I 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 pro7i 1
jp 0
— - - .4 'yf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of Ll e
nse:
Sig nature of Lice
S um r.
By A —&4v El Plumb( c ' 'I .
?r
Title El Gas Fitter
. F1 Master Signature of Licensed Plumber/Gas Fitter
City/Town Djourneyman
r License Number:
APPROVED (OFFICE USE ONLY) El LP Installer A262--�—
ffs--4�
NW—E
comMo ALT14
wwrnm
IT.T
R
-�IICENSE D AS A,JOURNEYMAWPLOMB
:�GE�SE
Assti E-STH&AB V,E��
A�
R IE
114-IRO'BERTS Ria
0, '921 2
-.20488
„rCOMMONWEALTH70F MAS$ACHUSET.TS
,,,X--l!CENSED ASAMASTER"PLUMBEFt
�NSE 0
ISSUESJHE ��VE LIG
fN
H A RIL E S "'A C A S H
-`ROBE�
RTS--,�RD
IMA,`01921-...,
OXFORD If '8
V.- "1. -7952-
"'ll - �;� -TO 6 7 7 -�95/01/12_,;A, --
-S
CC)MMbfiWEALTWOFMA!� -ACHUSETTS
A 'JOURNEYMA
S.A
,
'SWES T -HE AbOVE-,3(tENSE T.,
ARE.,A
-1 E_
S RD
�14 �ROBE
RT
4”,
�65/01/12
..204
06
Location 7,,5-,d 74-olv
No. Date
&011TN TOWN OF NORTH ANDOVER
AL
10 Certificate of Occupancy $
0
Building/Frame Permit Fee $
C"
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check
2 4 4 16
)Auirding Inspector
it
it
knd
.Permit
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Permit NO: O?�
f
Date Issued: P/ _//1
IMPORTANT: Applicant must complete all items on this page
Age Q
Y If
LOCATION c
P :fiu
t
PROPERTY 0 ER T 9,
Print
MAP NO: eo'S'PARCEL: ZONING DISTRICT:- Historic District yes 0
Machine Shop Village ye no
no
100 year-old structure ye 6
OFIMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
0 One family
0 Two or more family
0 Industrial
0 Addition
0
0 Alteration
No. of units:
0 Commercial
epair replacement
R p
0 Assessory Bldg
0 Others:
Demolition
0 Other
ws-
TRI N�M -7-
(Identification irtease JLYPU UF J[_ I 1HL %-IUUX -,Yl Phone:? 7
OWNER: Name: M,�,
Address: 6&k&_P9_A0
CONTRACTOR Name: 4�ecf �� 9— e_!J Lovtn Yhone:
YOE
Address: '/ 7 ZY0y7r ( c--) I - 4' 1 c---' I u L' r'
Supervisor's Construction License: X`7�- -3 a_&__Exp. Date: -9 nap
Home Improvement License: /0 _10 5-a Exp. Date:
ARCH ITECTIENGI NEE Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: FEE: $
Z13 el Receipt No. -
Check No.:
NOTE- Peryons tr tin unregisteredcontractors nq ve,7a ss otheguarantyfund
n vimpri
Fl.
Lo
Ffi
COP
Plans Submitted D
13uilding Depa,tMe"t ermit to be obt-ained.
s to be filled out for the Ppropriate P
The following is a list of the required form PerMits
Rooting, Sidingi Interior Rehabilitat7lon
Building Permit Application
Workers COMP Affidavit 0, C.S.L. Licenses
photo copy of H.I.C. And
copy of ContraC, ed interior Work oducts issuance of Bldg
Floor Plan Or PrOPos . eered Pr Department Prior to
jineering Affidavits for Engin
En� mpster permits require sign off from Fire
No-rE, Ali du
AdditiOn or Decks
Building Permit Application
Certified Surveyed plot Plan
Workers Comp Affidavit L. Licenses
photocopy Of H.I.C. And C.S. With Sprinkler Plan And
COI)y of Contract i wntion Plan Of Proposed Work
Floor/Crossectlon/E:- qco- (if Applicable)
Calculations (if Applicable)
Hydraulic Compliance Report
mass check Energy 'ered products prior to issuance of Bldg
Affidavits for Engine Department
Engineering rmits require sign off from Fire
NoTE- All dumpster pe -ywo FamilY)
New Construction (Single and
Building Permit Application
Certified proposed plot plan
0 1 C. And C.S.L. Licenses sprinkler Plan
photo of - - t
Workers, Comp Affidav, -ro Be Returned) to Include
5 of Building Plans (one
Two Set! pplicable)
oydraulic Calculations (if A
Copy of Contract gy Compliance Report
Mass 'check Ener Engineered products r to issuance of Bld�
,ering Affidavits for Fire Department PrlO
Engine r permits require sign Off from u the -Board 01
NoTE: All dumPste ist stamp the decision fro' and proof oJ
mit was required the Town 'Clerks office nit eds. one coPY
orded at the Re?
,Istry of De
In all cases if a variance or special per en get this rec
. d -s over. The applicant must th
that the appeal perio I the building application
must be submitted with
D.... Dol.-Build'ngpennit pevjsed200gmi
Dimension
t - 14 1 ; ' � - I
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Sectio , n 21 A —F and G min.$100-$l 000 fine
NOTES and DA
U Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Plans Submitted El Plans Waived Certified Plot Plan Stamped Plans
E—O�FSEW�ERAGE KDISPOSAL 0
ing pools
El Swimming Pools El
Public sewer El Tanniining/Massage/Body Art F1
[I I s j ] aging/Sales 70
'h TEF woomd MPa ck
El Tobacco Sales El Food Packaging/Sales El
Well permanent Dump - ster on Site F1
Private (septic tank, etc.
- 1 7'
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED
F1
DATEAPPROVED
P
ONSERVATION Reviewed on Si �natu�re'
COMMENTS f\J-P
'HEALTH Reviewed on r -1111
COMMENTS
Zoning Board of Appeals: Variance, Petition No:----�Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comment -
Conservation Decision: Comments
Water & Sewer Con nectio n/siq nature & Date Driveway Permit
DPW Town Engineer: Signature: Loc6t6d 384 asgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes. no
Located at 124 Main Street
Fire Department signature/date
cOMMENTS
%16
N
ri;
WD
W
E�
COD
�E
LU
C-3
BE
I--
CD c
0
�2
C/)
0
or -
co
:3
LE
.9
u
x
0
co
di
—ca
Cc CD
—Ctj
;L4
aj
U)
0
C/)
COD
�E
LU
C-3
BE
I--
CD c
0
C/)
P-4
m
I
I
I'Look,
s
0
Cl
E
CD
CD
cm
co
CD
co
.9
CD
CD
Cl
Go
CD
u
ca
CD
C.3
cc
ca
L
0
ca
CO
Q
CD
cc
CD
.0
CD
cc
CD
Z
CD
0.
w
ui
U)
19
ui
w
W
ui
ui
to
CD
c
CD
Cc CD
=.CD
. .
. CD
E MCC
CF
Mm
EE
T
cm
IE --
wo s
CD
CL -
Me
ca
cqo
CD
m
C*l
ID
E S*
cm
CLC-.�
G:,D,
CD
Le c D
=
CM
I CIM
Ca m
03
CD
cm
CD
w
a
I..
co
-
C2
.0
52
=Cu !.s
C=a CCD
, CA
co
42
ca CM
cm !E
CL.
CD
.0 0
cm
CD I -M
:.*- CL - cc
—
>0
0
C/)
P-4
m
I
I
I'Look,
s
0
Cl
E
CD
CD
cm
co
CD
co
.9
CD
CD
Cl
Go
CD
u
ca
CD
C.3
cc
ca
L
0
ca
CO
Q
CD
cc
CD
.0
CD
cc
CD
Z
CD
0.
w
ui
U)
19
ui
w
W
ui
ui
to
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.go.v/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(GKUB-010SN30-0-11) 02-OG-li TO 02 -OG -12
POLICY NUMBER EFFECTIVE DATES
EASTERN INS GROUP LLC 233 WEST CENTRAL ST
NATICK MA 01 7GO
NAME OF INSURANCE AGENT ADDRESS PHONE#
WEISENBORN, EUGENE R 44 NORTH STREET
METHUEN
MA 01844
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
000674 W20PIG02
Ltj
CD L -Li
xj!
U)
All
I'c >
T T LIJ
oul
CD,
LO n
9)
®R
C�
Of
0
I
CA
0
Information and Instrueflons
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 an), 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
Z,
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 theremi, or the occupant of the
dwelling house of another who employ's 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 erhployment'be deemed to Se an employer."
MGL chapter 152, §25C(6) also states that "ever
y state or local licensing agency shall withhold ihe 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 the' certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with n1ro 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 ofm'surance 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 inforniation (if -necessary) and under "Job Site Address" the applicant should write "all locations in Z-- (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be prov�ii-dedto 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 questions,
please do not hesitate to give us a call.
The Departrnent�s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investications
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax 4 617-727-7749
www.mass.gov/dia
The Commonwealth of Massachusetts
Department qf Industrial Accidents
Office of Investiqations
600 Washington Street
Boston, AL4 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Build ers/C ontractors/Electricians/plum bers
Applicant Information Please Print LeEiblv
Name (Business/organization/Individual):
e
Address: /V V X/
, ^,44 t
City/State/Zip:_&
0/ S' Y 4 Phone #: '-) ' � '
?ga-
-x:
(0 a
Are you an employer? Check the appropriate bo
91 am a employer with
4. 1 am a general contractor and I
Type of project (required):
employees (Ul and/or part-time).*
have hired the sub -contractors
6. New construction
.0 1 am a sole proprietor or partner-
listed on the attached sheet.
7. Remodeling
ship and have no employees
These sub -contractors have
S. Demolition
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. m'surance.+'
9. El Building addition
required.]
5. ED We are a corporation and its
10. El Electrical repairs or additions
1 am a homeowner doing all work,
officers have exercised their
I I - El Plumbin- repairs or additions
myself. [No workers' comp.
insurance t
right of exemption per MGL
12.D Roof repairs
required.]
c. 152, § 1(4), and we have no
employees. [No workers'
l3&OtherReFj
comp. insurance required.]
---------------
*Anv 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 indicatina such.
Icontractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and state whether or not those entities have
,employees. If the sub -contractors have employees, they must provide their workers � comp. policy number.
I am an employer that isprovidin,-, workers' compensation insurancefor tqj� employees. Below is thepoliqj, andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. 9: tj �3_0 Expiration Date: q2
Job Site Address: 1p"?
City/State/Zip:WAJ Z)Ve_ 4�", 0
Attach a copy Of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required und . er 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 agaist 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 herety cVond"e pains a allies of perjur
I n1`p �, y that the information provided above is true and correct
Official use on�y. Do not write in this area, to be completed 417 cify or town official
City or Town:
Issuing Authority (circle one):
el
I. Board of Health 2. Building Department
6. Other
Permit/License
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
el
Contact Person: Phone#:
6o;l i -Wo H3 0 Al I i i 6)
am
or. -icensa
�4ceps C S' 42328'
Restricted to., 001.
EUGENE R WEISLNBORN
44 NORTH ST
METHUEN,. MA 01844
!i'�- 'Aw
Expiration: 12/9/2011
Ti-�: 11114
Restricted to: .00
to
ow—
jiMe
5 b A4
::s- V4 -14
0"
Failure to possess a current editi n' of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to:; --'-'W-WW.Mags.Gov/DPS
�L" Consumer Affairs & 140sines
's'
YxgulaifiGIR
M--,.HOWiEIMPROVEMF-NTCOI�l-IfRAC*R
On: '10, 12
;.'Type:
pirati n: 702012 ladividual,
Eug&!O.Wel!�enborn'..'
4,fqorth St,
01844
-.�indivjo ys"aly
se4ar, Ire Al
gistration valid; f6r
2
bef coui-ad -rOh'im:4 . 0'*.
i i'; '. -'r;1"' - A0i
_0
1'0 P'r�
_j
'tost�',
'%�N witholpt-si qabwe
— - .9 —.
Restricted to: 00
0 d", VO
IG
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer. to:;,—WW, -.Mass.GoWDPS
License or. re i ration valid-W',indi viijiji,kise�'oply
gist
befoi� -the'ex0i ratio n dat& � If found itturnVi-
;-, , 7
Offite-6 , -6w�u mer Akaids' 'a nd.iffus;j n�'e'�: w lOiA,
,--Boston, MA 62116.
11 ,
0 -�Vithod, S oature
Eugene Weisenbom
Weisenbom Builders
44 North St.
Methuen, MA 0 1844
(978) 618-4083
Customer Information
Jim & Ellen Phelan
275 Appleton Street
North Andover, MA 0 1845
PROJECT DESCRIPTION
Estimate
DATE
ESTIMATE NO.
7/15/2011
1080
Replacement of deck according to plans by (Thom McMullen, Landscape Architect). Removal of
existing deck, install new footings to accommodate new design, placement of weed barrier and
gravel under deck.
Deck framing to be pressure treated material, decking to be composite materials - 5/4 x 6"
timbertech XLM river rock with concealed fasteners, railing system to be composite Radiance
white, all exposed frame to be covered with white PVC,all sides to have PVC privacy diagonal
white lattice.
20 riser lights (white)
Existing balcony deck - replace railings, deck boards, lower support posts ( use existing footings),
lattice at ground level with access gate. Product to match new deck.
Price includes materials, labor and clean up/ removal of all debris.
1/3 Deposit, 1/3 at framing, balance upon completion.
Tentative starting date of July, 27,2011 estimated time to complete is approx. 15 days (weather
permitting)
The above estimate is based on typical construction methods. In the event of any unforseen conditions, such
as, but not limited to, insect infestation, structural rot, or pre-existing sub standard work, it is my intent to
correct/upgrade said issues during the construction schedule to comply and meet current building
practices/requirements. Such defects if found will be completely discussed and identified with the client and
removed, repaired and/or upgraded as needed at a cost no greater than what is required to meet current
building coftcompliance.
MA Construction Licence # 042328
Home Improvatent # 103052 TOTAL
The above prices,specifications and conditions are satisfactory
and are hereby accepted. You are authorized to do the work as SIGNATURE
specified. Payments will be made as outlined above.
PROJECT
Deck
TOTAL
28,397.00
0.00
$28,397.00
2r 9 5 0
Date.
TOWN OF NORTH ANDOVER CL
0 0 PERMIT FOR GAS INSTALLATION 8
This Certifies that ........................
hois permission for gas installation ................... C—n
in the buildings of ... Z' "'.7 k ............................ :>
at /k-- ...... North Andover, Mass.
Fee...I�-'. Lic. No ........... ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
T7
MASSAC E T-7
'Rec r*d,
E-1 V E D
dAR 8 2091
OEPhdo p do(I Wj toll') �o
10,
1 ry
--)RTH ANDOVER
Faclll�y ln.forMaftn
c:2
n
m M �w
Own o r,
QvIfff')l 11W "vQn)
C�;7 Q-. ,)
Ppumpino
X3
Y� (e M:
0 Ih
oo F11(o( p
,(P,�onr7 Yo5 CD No
m
N.P11 I
Lm 4,.�
Y
T
Qu Qn. Wh o (Q',;
i UX h, i v
M a
(SvW
P0c Tan,, '7
Yes
----------
New Renovation Replacement Plans Submitted
(Print or type) Check one: Certificate Installing Company
Name My-, V t 10 Vn. F1 Corp.
Address a 16 n Y, �3,?6 Partner.
AWQ��, /90,
Business Tefephone I Firm/Co.
A
Name of Licensed Plumber or Gas Fitter
IN§URANCE COVERAGE Check one:
I I-'R,,ve a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked M, please indicate the type coverage by checking the appropriate box.
L4ility 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:
Siiinature of Owner or Owner's Agent Owner E] Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to tne
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
I
compliance with all pertinent provisions of the Massachusetts Stato-6-4 Cod;�"er 142 of the General Laws.
-., 1 `117 �-
I
ity/Town I
VED (OFFICE USE ONLY)
Sijnature of Licensed Plumber Or Gas Fitter
Plumber 4j2-)-76-
Gas Fitter License Number
r77 Master
L."
C:r Journeyman
z
z
2-
a�
G
z
z
z
z
z
z
C
SU B -BA SE M E NT
BASEM ENT
IST. F L 0 0 R
2 N D F L 0 0 R
3 R D F L 0 0 R
4T H F L 0 0 R
5T 5 F L 0 0 R
6T III F L 0 0 R
7T 11 F L 0 0 R
,8'r [I IF 1, 0 0 R
(Print or type) Check one: Certificate Installing Company
Name My-, V t 10 Vn. F1 Corp.
Address a 16 n Y, �3,?6 Partner.
AWQ��, /90,
Business Tefephone I Firm/Co.
A
Name of Licensed Plumber or Gas Fitter
IN§URANCE COVERAGE Check one:
I I-'R,,ve a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked M, please indicate the type coverage by checking the appropriate box.
L4ility 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:
Siiinature of Owner or Owner's Agent Owner E] Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to tne
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
I
compliance with all pertinent provisions of the Massachusetts Stato-6-4 Cod;�"er 142 of the General Laws.
-., 1 `117 �-
I
ity/Town I
VED (OFFICE USE ONLY)
Sijnature of Licensed Plumber Or Gas Fitter
Plumber 4j2-)-76-
Gas Fitter License Number
r77 Master
L."
C:r Journeyman
z
,'-
r
,�
�'.. A.
.j
d
Date.7.7x,;.�
3827
oRr#j
-TOWN OF NORTH ANDOVER-
qz
ERMIT FOR PLUMBIN
C us
This`�eftifies t a
aspermi LA
,h' rm
issio-h tb fo ..........................
...........
4
-1 �eo -fi'Andqver-,..M
.,a t No"rf ass
F60 54. o.
C.
. ...........
"PLUMBING INSPECTOR
- 09 14-30,
14,
—4—",
:WHITE: Applicant - 'CANARY: Building bept. -.PINK:'Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PER IT TO DO PLUMBI7
(Type or print) 1�1 '9, �)�
0 NORTH ANDOVER, MA Date
Cr Permit # 7 eg 7
4,�W
Building Locations AV
I F
Owner's Name
New F1 Renovation Replacement fi2 Plans Submitted ri
FTXTTTRF,S
C
(Print or type) heck one: Certificate
installing Company Name 0� Corp.
Partner.
Address El
tusiness T61eplione FirmJCo.
Lme of Licensed Plumber:
ins ur-ance Coverage: 1ndicate the type of insur-ance c6v6rage by 'checking the appropriate box: Bond
Liability insurance policy Other type of indemnity
Insurance Waiver: 1, the undersigned, have been made aware tffai� the licensee of this application does not have any one of the above
three insurance
Signature Owner 13 Agent Cl
bm of my Amawle* and t= aU plumbing vxxk and insm1Wfims, ed 11,nr�115� 'or tl�5 zmi�
mpliance with all pertinent provisions of the Massachuscus 54te =11lum im e and Chapter 142 of the General Laws.
By: -S—igT4we oT Licensea riumDer
P1 cemw
Title I
City/Town License Numoer Master Journeyman
APPROVED (OFFICE USE ONLY __j
6li—
= C)
B?"v
9
LL
rmmmmmmoq
O -LI *
to
to
z
1%
of
qo
Ink -
Cho
M.s
:4-4
0 W)
LU
CLM C6
0)
A
qx
L.
40
C�
CL.
Ix
11)
40
CL
oc
c
rA 2�
:2
cv)
> LLJ
2 X
cm LLJ
>
LLJ
z
0
V)
Lf)
::D
MQ
FT
.0
CL
E CL
v <
bw
CL
CL
Ewi
r.
W
z
CL 0 W
4)
cc
DO
c
bm
0
W)
c
be
c
9�
CIO
0
0
0
log
z
z
0
LU
z
z
of
L6
o
Co
96
uj
-a
Ac
E
0)
:1 '@
LU
3
c
0
0
0 S .
0 4)
0 S
E
CC
0 U-
rr U-
cc V)
cc U-
CD
U,
1%
of
qo
Ink -
Cho
M.s
:4-4
0 W)
LU
CLM C6
0)
A
qx
L.
40
C�
CL.
Ix
11)
40
CL
oc
c
rA 2�
:2
cv)
> LLJ
2 X
cm LLJ
>
LLJ
z
0
V)
Lf)
::D
MQ
FT
.0
CL
E CL
v <
bw
CL
CL
Ewi
r.
W
z
CL 0 W
4)
cc
DO
c
bm
0
W)
c
be
c
9�
CIO
FORM U - LOT RETAP.ASE 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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: -I-AM05 'P4V-LP'k) Phone 6:9-5- 0066
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street -76 4WLI6AU 15,; 0 7
- Z 11 St. Number
************************Official Use Only************************
RECO14KENDATIONS OF TOWN AGENTS:
-X\C se a4ion �Admi�nist�rato�r�
Date
Date
Approved
Rej ected
Town Planner
Comments
Health Agent
Comments
Public Works - sewer/water connections
driveway permit
Fire Department
Received by:Building Inspector
Date Approved
Date Rejected
Date Approved
Date Rejected
Date
a
e
uj
in L
ir
uj
0
14, m:3 &:,x4j
RIM`
,
mg z
uj S?
w ul,
b -P uj
z
z
TA C.9
HOW
1p
I