HomeMy WebLinkAboutMiscellaneous - 275 CHESTNUT STREET 4/30/2018 (2)m
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed forin. After a permit application has been accepted by an Inspector of Wires appointed pursuant to m. aL c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time oforigoing construction activity, and may be -deemed -by -the -Inspector -of -Wires abandoned-and-inv.alid-ifhe--
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
ThePermit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence' during the qualifying period beginning on August 15, 2008 and extending�ffirough August 15, 2012.
Permit/D.ate Closed: 2 "V Note: Reap'ply for new perm
El Permit Extension Act — Permit/Date Closed:
'This certifies that .... J) .6. 1�)---FA� ....................
has permission to perform
.. .......................
wiring in the bui�ding of . tlr*�PO 0 V) ta/ 0 ....................
at . . e.4 r.—. ............. rth Andover, M ss
00
h, , Am 4 . . .
Fee 4-� .... Lic. No. . .. ..
ELEkCTTRICAL INSPEC OR
b -
Check# t/l
j * 12 ;'-) I
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
/.-Z
Permit NO. , �5 /
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 (NEC), 527 CMR 12.00
(PLEASE PRWT)ATHK OR TYPE ALL DWORAM TION) Date: I I -?_ 9 _y_1
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location PIRtreet Number) 2 _7'S - 0V4P;e,,T-AmW- 9-T,
U
. 5156
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes No (Check Appropriate 13ox)
Purpose of Building Utility Authorization No.
- Existing Service
New Service
Amps -volts Overhead Undgrd
Amps Yolts Overhead Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Comnletion ofthe following table mav be waived bv the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Lurninaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In- D
grnd. grnd.
No. of 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
HeatPumP
Totals:
J.KW ...........
...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalD Municippl El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
0.0 No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Eguivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Ecjuivalent
OTHER: J VQ
,-- J ktach additional detail iftlesired, 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 I�IEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation' 'coverage or its substantial equivalent. The
undersigned certifies that such covero is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE D/ BONDE] OTBEREI (Specify:)
I certify, under thepains andpenalties ofperjury, that the information on this a plete.
,pplication is true and com
FIRM NAME:. ;�Vs Q0 LJ i LIC. NO.: 35 o
Licensee: SignattvA,-Jt4,,(/,pW'j,�� _41C. NO.: 7FA7, 5 ' 't'7D'7
(1fapplicable, enter "exempt" in the license number line.) 07 -1 -
Bus.Tel.No.
Address:,A Av_(Z) IjM 'DR AltU5 0"A Al JA Alt. Tel. No.:
*Per M.G.L &_ 147, s. 57-61, security work requires Departihefit of Public Safety �'9" Licensi: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (che one) [I owner [] owner's agent.
Owner/Agent I PPIMIT FEE: $ III -e-0 I
Signature Telephone No. /-,D — I
I -Z
17 W171,C_A_ 1-h
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012, The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
• Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pas
Failed
Re- Inspection Required El
\V
lnspprtnr-z Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass n?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass F?1
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
DEBWEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizati6n/Individual):_
A"
I - W
�,4
City/State/Zip: Phone#: 1? 76 -4l-fl- 3 - qf 0?
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
(full and/or part-time),
have hired the sub -contractors
Kemployees
2. 1 am a sole proprietor or partner-
I
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
.
require
officers have exercised their
3. 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. El New construction
7. E] Remodeling
8. E] Demolition
9. n Building addition
IOTJ Electrical repairs or additions
I LFI Plumbing repairs or additions
12.E] Roof repairs
13T1 Other
kny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such'
0
�ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy and* b site
Jo
!formation.
isurance Company Name:,
olicy # or Self -ins. Lic. #:
)b 'Site Address:
Expiration Date;
City/State/Zip:
.t!ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
LVCstigations of the DIA for insurance coverage verification.
do h ereby cqtify un der th e p a iSs,��s o�p erju ry th a t th e inform a tion pro vided ab o ve is trit e an d correct.
Official use only. Do not write in this area, to be completed by city or town official,
City or Town:
PermitUcense ft
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 defmed as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in 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 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 perfomiance 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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
town)." A copy of the affidavit that has been officially stamped or marked by the city of town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to 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 Judustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
evised 5-26-05 Fax # 617-727-7749
www,mass,gov/dia
This certifies that .....
............. 1.9 ........................
has permission for gas installation . . ........
in the buildings of. ......................
at ........ rth Andover, Mass.
Fee Lic. No.
Check # GASINSPECTO
U
-n
w
1�
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS RTTING WORK
I
CITY MA DATE PERMIT
76 0611
JOBSITE ADDRESS 61 qS- C/jfS4l-J1-t ST JO�LNAMEJ '10M FIA)eCh I /+a I
GOWNER
ADDRESS TELI IFAXI
TYPEOR
PRIN7
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL/
CLEARLY
NEW/ RENOVATION: REPLACEMENT* PLANS SUBMITTED. YES NO['
APPLIANCES I FLOORS— BSM 1 2 3 4 5
6 7 8 9 10 11 12
M R
BOILER
BOOSTER
CONVERSION BURNER
COOKSTOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
.FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HUT-E—R
ROOF TOP UNI
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER!
INSURANCE COVERAGE
I have a current liabilWinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1/� OTHER TYPE INDEMNITY I I BONI)
OWNEWS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
KECK ONE �ONLY-- WN7 AG
SIGNATURE OF OWNER OR AGENT Z,
1 hereby certify that all of the details and information I have submitted or entered regarding this appk:alkn are true aw:W� le t m
and that all plumbing work and Installations performed under (be permit Issued for this application will be 1 nce
Massachusetts State Plumbing Code and Chapter 142 of the General Lmvs.
J
S
PLUMBER-GASFITTER NAP� Gr r4llpcl 1 LICENSE #Vf 3 6 SIGN�PME
MP 1/1 MGF I I JP I I JGF LPGI CORPORAT'ONK# 13 '1 q-� I PARTNERSHIP [ 191 LLC 1#1
COMPANY NAMEt'/(�-0� (Itij Plk- Lid I ADDRESSI PC f-.�6t -? �c)
CITY h I STATEIIA-T7 JZIPJ 01,.�tr ITELI 9?e
FAX CEI-L� VNOMIX� �/
9( Y&� (6
C- 04�1 1 0q
/AQ�V�V
V,
v.
CD
ui
a. nt
w
Lu
w
z
0
w
W6
Ike annitenlivelth OfmirSSOC1111sells
Departmint ofludastdalAccidents
0 witunangoiNla
We 001111"49011011S
600 WaS1,111glol, Smeet
Roston, AM 02111
Wedtatl Compeasadoit histit ance Affidavift DiiildordCoiitractorstfliceiricians/Plititibers
1,18,11ii, a anployer willi 4. 1 ant a general contraclorand 1
jWAve all el"1110)VO Check file appropriate box:
Tylic, of"project (requiredy.
6. [INewconstraction,
employees (fall andf" pail-finic).0
how lifted the sub -contractors
7. Remodeling
211 I am a sole pmprielororparfacr,
listed an the attached shecl. I
ship and havotio, catfiloyces
These sub-con(ractors have
S. Demolition
walking formelannycapactly.
[No %%vikere conip. fitsuranct;
%%vjk-eFe collip. Insurallm.
S. AMe, arc a corporation and Its
9. Building addition
requirvd.]
officers havoexerclsed their
to.[] lilectricalrepalisoradditions
311 lamultoitie(nviterdofisgittl%vwk
right ofecemplion per M01.
I Q] Mouthing mpairs or additions
inyselE (N*,,mkcrs' couip.
c. 152, fl(4). and wo have no
12.[] Roorrepifis
hintionce required-] t
employees. (No workere
13.[] Other
conip. Inguancerequited.] a
I
*AnyqvIkad Conigxwgion policy Iniolnutio.L
1 110twouiw %%UA Sul-Mitifils effAnit Indiw6kv their tie ".-011uoikerA
It WAIMM"ith It A&LAM-avrma WiNtOm aUkkmA Owt slou&T,& a uw of thit 111-ir IwAme Ckw1krolicylvilk,0113fiak
firM eittviti�to)-eritiallsprorlditig Beloit- Is theliolley widjob site
Policy It or Sdr-fils. Mo. IT. Expiration Dato�—
Job.SitcAddttw, IVOLTre- �j - a4—� - —Fivistlicizil):�—
Attach n copy of the i%xithers' compensation polleydeelaratfoll [Mgt (SholirIng file policy number n"d expinfloll da(e).
Pallare, to secure comage its required ituderSectlim 25A orMOL c. 152 can lead to (he Imposition orcrimliml ptualties, ofa
filit lip lo�s��wdlor one-year as civil penatfles fit tho form ofn STORAVORK ORDER and a film
VMS0.00ndayik;ikist1hoy*a1or. BoWiscftb"col)yot(hissinteiiiaititiaybetonvaTded(olho0frictof
I & h Crehj.
Ike hjforjnatloitproddewlabo#� h trite judcox
I.,.. // 1-2o / 261
Offleld ime oii&. Do nor trAle /it flits area, to be rontlifeled by do- or foliv, offletal
C11yet-Town: Perinif/lAccuseff
Issuing Authorily(circle, one) -
1. Marti of Health 2. 11alkling Dtillirfuttrit 3. Cilyfirown Clerk 4. Electrical Inspector f% Phuntilng Inspector
6. Other
Contact Person:
Information and Instructions
Chapter 152 rMires all eniplOym to provide,%vorlefs, In theiremployew.
Pursuant to thisslaftit% an enoojw is CqUipek4atiort r
defined at'% -P-MyVerson in the service 060oifi� tin 'Contract
e-quess; orihiplied, orafor xvriftea?s . . der any i . - � of hire,
All t"'Flowiis deli4ed -afi illidividtial; partnership
of the forego' - "I&SOP. coriftation orotherlegal endW, 0ranyt%yobrjjjore,
1119 engaged in a jO%t cutWh% and hichOUg lhe- legal ripresentatives of a deceased employer, or gle
receiver Or ftllstee ofan individual, partnership. association or other jegil en(i4., empi - . .
olviler of a dwelling househavirig notinow than three apartments an 60118 employees. However "to
d%relling house ofanother.vdlo d who jasides therek or (he ocwpa[)t of(he
o'"Pley' li�'rsous to do BlaiRIC881IM- Construction or repair Avork on such divil Junft
Or Oil the grounds or building appurtenant thereto shall not because orsuch employment be deemed to be a . 1109
n employer.,,
VOL chapter 15�, §25C(6) a6 slates that -everY Wle or local lka�§ljlj agency stuill withh4itthe issuance or
renewal of R license Or POrnilt to operate a business or to Construct buildings - fit tile coullnertlyegill, filIr ally
-oPPliclint WhO 11119 110f Produced nceepiable evidence of Pliallce-Imb-ole, Insurance covejagd required?,
AdditionalV MGL chapter 152, §25C(?) states ,Neither earn
the contmorrivealth Many ofits Political subdivisions AaR
enter into RRY contract for the performatim orpublic workuntil necepablo evidence ofCompliance Ivid, ho insuran6d
requirements Offills ChaPW have been presented to lite conlraciing authority.'-
Applig4jils
Please fill oil 11 ' bik," -2 -
101v ',em WiTellsation. affidavit cothpldely, by che&ing the boxes that apply 1�-ioar Situation arld, if
insurance, Limited Liability Companies (LLQ orLimitedl.libilityPannerships (LLP) will, no enilayees other than file
ruernbers or parlilers, are 1101 MIAW to Carty %yorkers' compensation insurance, Won LLC orux does have,
employees, apo)icyisrequired. Be advised thattlills affidavit may be submitted to the Dep tof
Accidents for coartnuation, of insurance coverage, artmen Industrial
Also besure, tosign and dote Hie affidAvit- 111caffidavitillould,
be returned to tile ciqr or tolva that tile application for [he pennit or license is being requested, not file Department of
Industrial Accidents. Should you. luive, BUY questions regarding lite low or iryou, are required to obtain a workew
Compensation policy, Please call lite Department at the number listed below. Self-insured companies Should cater their
lf-insurarice license number on theq'
Vropriate, line.
Ci(yorTown officials
Please be sure dint the affildavit is 6 -1plole and printed legibly. Vic Department lias provided a space at the bolt6n)
of the affidavit for YOU to fill Out in file event the ONICC ofinvestigations has to contici yott regard e li It.
Please be sure to fill in the permitAicense number urfilch Avill be Used w a r0krence riumben Inad ing th opp cat
that must submit multiple permlMicense gppl dition, ark applicant
icAlions in any given year� need only submit one affidavit ludicaling entreat
Policy information (iffleceSsary) and Under '7ob, Site AddreW, (he applicant should Avrild N11 locations In _(city or
toxvn)?'A copy of the offidavit that has been officiil ly,slil raped or marked by the cl ty or tavai nwW be provided to the
applicant as proofthat a valid affidavit lion file fili-fidure Permits, of licenses. A newaffidavit inust 6e filled but each
Year. IM= a home owner or cilizen, is obtaining a li
icense or permit not Mated to any busf
(i.e. a dog fice= or liermit to bum leaves etc.) said Dim or commercial venture
Person is NOTrquired to complete this affidavit.
The Office offfivestigations would liketo thank you in *idvauce 1bry9�trcoWM!ioa,aud sJuJuld you have any tpostiolls,
Please do not hesitate to give Its a call.
7110 DCpartment's address, telephone and fax mu".
71id CDmm9lkXvea1t11 OfAla�Fsachjiscft
Departniwit of Industrfal AccideAlts
offipe of flivestigAttong
600 Avasllingtoli-$tm-4
BOS1011i MA 02111
Tel. # 617-7274 1 00,oxt 406 ot 1-877-MASSAr.B
Rc,Viscd S-26-05 A110-617-721-7749
Ninvw-Inass,govidia
11
jl�
jil�
AN -110�01111
DATE:
LOCATION: 711- Cle4 J.
�� Lk+,
OWNERS NAME: Q Y'l :091 1
GENERATOR kw
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR:
PHONE NUMBER:
ELECTRICAL
RESIDENTIAL
I
Iff-Tvi
COMMERCIAL TEMPORARY
LOCATION OF GENERATOR:
*ZONING DISTRICT: 1� �
-�7 (c)) o , -Z, o
I
*CONSERVATION APPROVAL,.��A
Town of North Andover
V
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Selection 11 Legend Localtion X
Select
(show all)
-FP;�o ID
. . . ....... ... P
'FINOCCHIARO, THOMAS D'098.C-0004-0
I selected To Mailing Labels To Spre.
iia,
Ownerl FINOCCHIARO, THOMAS
Owner2 JUNE E FINOCCHIARO
Address 275 CHESTNUT STREET
PropertyID 098.C-0004-0000.0
Lot Size 2.41 A
Fiscal Year 2013
Land Use 101
Code
Last Sale 11/19/1984
Date
Book/Page 1894
Total $707000
Valuation
Wilding CP
Type
Year Built 1986
---, I— -- –
11/13/2012
Town of North Andover,
Page I of I
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�L FINOCCHIARO, THOMAS DLM&C-0904-1]
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Ownerl FINOCCHIARO, THOMAS
0wner2 JUNE E FINOCCHIARO
Addrew 275 CHESTNUT STREET
PropertyM 098.C-0004-0000.0
Lot Size 2.41 A
Fiscal Year 2013
I.mW use 101
Code
Last Sale 11/19/1984
Date
Book/Page 1894
Totall $707000
Valuation
Buillcling CP
Type
Yew Built 1986
11/19/2012
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GENERATOR APPLICATION
DATE:
LOCATION: e ckrj
OWNERSNAME:__
-GENERATOR kw
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR:
PHONE NUMBER:
ELECTRICAL
RESIDENTIAL
GAS
COMMERCIAL , TEMPORARY
LOCATION OF GENERATOR:
*ZONING DISTRICT:
o
*CONSERVATION APPROVAL
Location c9
No. Date
,40RTN
TOWN OF NORTH ANDOVER
41
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
7 7 7
Building Inspecl6i
rl
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIJ RENOVAT& OR DEMOLI SH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: LIw
Buildilti Commissioner/ln�eEtor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
Avbo &//C—
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (fl)
1.6 BUnDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1,7 Water Supply M.G.L.C.40 54) 1.5. Flood Zone Information: 1. ' Sewerage Disposal System:
P"fic 0 Private 0 zone — Outside Flood Zone 0 Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Uistrict: Y(zs
2.1 Owner of Record
Ffn1oQ;#-1Nm-- /"IVZ,/ t
Name'�Print) Address for Service
Signatu Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Lice sed Construction Supervisor:
7)
ess t
Signature Telephone
Not Applicable
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (MG.L. C 152 § Acc�(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 (chweck applicable
New Construction 0 Existing Building 0 Repair(s) Alterations(s) 0 1 Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
- &Etq.'2 A./00,b --- aAP '0A0 'Q90F
I SECTION 6 - FSTIMATRI) CONSTUITCTMN CnQTC I
Itern Estimated Cost (Dollar) to be
Qqrnpleted by permit applicant
OFFICIAL USE ONLY
I . Building
Z)d
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
1+2+3+4+5)
Check Number
1. - 1. -� �w A LL�rw'.�JLJMJVI JLW Dr, %-%J1VJLrJLZ Im" W HAIN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUIILDING PERM[IT
as Owner Authorized Agent of subject property
Hereby authorize to act on
My behalf, in1!L2!2gers; relative to r4pthwi-ed by thVbuildu'ig permit application.
(-7
Signature of Owrier Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
of Owner/.
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOREIVIBERS �Tr 2ND- 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
IVIGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: —Est. Cost
Address of Work r�,9,5_ C&E�M6/2�7
Owner Name:— b wo n____111_M1 /10
Date of Permit Application: /) — y _&O Y
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Pernit No.
Job under $1,000 Date
Building not owner -occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND UNER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
4Z
bate Owner Name
Location
No. Date
R-1
TOWN OF NORTH ANDOVER
T,A Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit FeQv-��T) $
Sewer Connection Fee $
Water Connection Fee $
TOTAL L $ - /,�-
Building Inspector
Div. Public Works
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Town of' North Andover
BUILDING DEPARTMENT
Homeowner License Exemption
'Lease print)
DATE
JOB LOCATION–
Number. Street Address-
)MEOWNER"_'20MAS FINDCC
,6V,*/QQ
Name home Phone
RESENT MAILING ADDRESS
City/Town
State
bection ot town
8-3— 5
E;zC–.
Work Phone
Zip code
The current exemption for "homeowners" was extended to include owner
-occupied-dwellings of six 'units or less and to allow such homeowners to
engage an!individual for hire who does not possess a license, provided
that the owner acts as'supervisor. (State Building Code, Section 109.1.1)
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to
reside, on which there is, or is intended tq,be-, a one to six family dwell-
ing,,.aftached or detached structures accessory t.o such use and/or farm
.;tructures. A person who constructs more than one home in a ff two-year
period shall not be considered a homeowner. Such "homeowner shall submit
to the Building Official, on a form'acceptable to the Bulding Official,
that he/she shall be responsible for all such work performed under the
buildi.ng permit. (Section 109.1.1)
Ir
1he undersigned "homeowner" assumes responsibility for compliance with the
State Building Code and other applicable codes, by-laws, rules and
regulations.
Fhe undersigned "homeowner" certifies that he/she understands the Town
,orth Andover Building Department minimum inspection procedures and
12quirements and that he/she will comply with said procedures and
eauirements.
IOMEOWNER'S SIGNATURE
\PPROVAL OF BUILDING
of
'4ote: Three family dwellings 35,000 cubic feet, or larger, will be
_C�quired to comply with State Building Code Section 127.0, Construction
�untrol. ,
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