HomeMy WebLinkAboutMiscellaneous - 275 WAVERLY ROAD 4/30/2018j
Date ......
0 T"
TOWN OF NORTH ANDOVER
PE RMIT FOR WIRING
This certifies that ............. �M
has permission to perform .....
...................
wiring in the building of ............. W .. .................................
at.....J.13 ..... .. WL ............... Aorth Andover, Mass.
Q—
Fee .... 5�r,. 4�- Lic. No. .7. & ...... . ..... C ........
Check,e
10657
-Er 2012 Massachusetts Electrical Code Amendments 527 CAM 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
K—, on the prescribed forin. After a pennit 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-deerned-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. . -
F1 The Permit Extension Act was created by Section 173 of Chaptef 240 of ths Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 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 extendingthrough August 15, 2012.
Permit/D.ate Closed: Note: Reapply for new permit,<
0 Permit Extension Act — Permft/Da-te Closed:
I
M
RMINEEMCoinntonwea& o f Vamaclume s Official Use Only
Apartment o� tire �ervicee Permit No. -Q 7
Occupanc
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] y and Fee Checked
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 ININK OR TYPE AL�L p�(IN�MA
FOR�_TION) Date: a l --I-r a
City or Town of. 6( i k Q6'P—r To the Inspector of Wires:
By this application the undersigned gives notice of his or her in/t�en �' n to perform the electrical work described below.
Location (Street & Number) a T J Y�
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Telephone No. 9-H --GB-()r,55
Yes ❑ No ® (Check Appropriate Boz)
Utility Authorization No.
Overhead ❑
Overhead
Undgrd ❑
❑ Undgrd ❑
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: Install residential security system
rr\\ rsuacn additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of ectric 1 Work: V (When required by municipal policy.)
Work to Start: 7' Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCES] BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRMNAME: Nightwatch Protection, Inc. LIC. NO.: 7 0 2 4 C
Licensee: Paul DelSignor Signature IC. NO.: 7024C
(If applicable, enter "exempt" in the license number line.)us. Tel. No. 888-722-9282
Address: 22 Briarwood Drive, Westford, MA 01886 Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. • . SSC00000969
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ 001
W.."u" � muuuuwln
taote m oe waived the Ins ector o Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No.—OF— Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
In-
Swimming Pool A ove ❑ ❑
No --- of Emergency -g mg
rnd. nd.
BatteEyUnits
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection-a-n-ff—
InitiatingDevices
No. of Ranges
No. of Air Cond. Togs
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Num er
Tons
KW
No. of a ontame
Totals:
_
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local -Municipal
❑ ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security S stems:*
No. o Heaters KW
of
o No. of Si
Ballasts
No. of Devices or E uivalent
Data Wiring:
s
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HPa
ecommumcations inng•
No. of Devices or Equivalent
OTHER:
rr\\ rsuacn additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of ectric 1 Work: V (When required by municipal policy.)
Work to Start: 7' Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCES] BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRMNAME: Nightwatch Protection, Inc. LIC. NO.: 7 0 2 4 C
Licensee: Paul DelSignor Signature IC. NO.: 7024C
(If applicable, enter "exempt" in the license number line.)us. Tel. No. 888-722-9282
Address: 22 Briarwood Drive, Westford, MA 01886 Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. • . SSC00000969
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ 001
t The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
~c 600 Washington Street
Boston, Mass. 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual) : /� 1 W aAc- Y fAeA U n C.
Address: 15D A MO l � W -D Y . 's P q
City/State/Zip: S_ U1 �% () 3O Phone#:_ 998 o� a - a o�
Are you an employer? Check the appropriate box:
1 >� I am an employer with _13
4. ❑ I am a general contractor and I
employees (full and/or part time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
r working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance. $
required]
5.0 We are a corporation and its
3! ❑ I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption perm MGL
insurance required] t
c. 152, § 1(4), and we have no
employees. [no workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. >�Other�)PL f ( S�
�_o w \I014a3 e
"My applicant that checks box #1 most also fill out the section below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If
the sub -contractors have employees, they most provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. I l � U I
Insutgnce Company Name:_ 14 ox T (A —ly-) 5, Cd . () � � + � 6_yt- )
Policy # or Self -ins. Lic. #: 4 Cp WE Ec
ujExpiration Date:
iT1 0��I �� • �if� pt l�)�Job Site Address: Aye_r`pNS City/State/Zip: JA
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date).
Failure to secure coverage as required under Section 25a of MGL 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under thr pains and penalties of perjury that the information provided above is true and correct
Date:
V
Print Name: ��yy�Uf-6-- Phone #:
Official use only Do not write in this area to be completed by city or town official
City or Town: Permit/license #:
Issuing Authority (circle one):
1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #:
La - 03
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
oil MA"r'/Y ROr46
1.2 Assessors Map and Parcel Number:
%
G 7j-
Map Number Parcel Number
/11��
1.3 Zoning Information:
,f I N /,y
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING 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:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT
Historic District: Yes NO
2.1 Owner of Record
flaw /LL fR,;Is c/` r>17S G✓fJl/E�'i L y /fa,4_0
Name (Print) Address for Service
Signature Telephone
2. caner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (AG.L. C 152 & 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
( /it/ LAb✓ ffi°/Dr9�T�rl�N "r' c S' ��t/C�LF FLadA° ��D�i
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
` t}FFIIALUSE'(fNY
1. Building
(a) Building Permit Fee
Multi lier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total -(1 +2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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
Signature of Owner/A lent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T11VIBERS 1 2 ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
DIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Y.- MORTGAGE INSPECTION PLAN
NORTHERN ASSOCIATES, INC.
401 SOUTH BROADWAY, LAWRENCE MA. 01843-3522 TEL:(978) 837-3335 FAX.(978) 837-3336
MORTGAGOR:. DONALD * JOAN WILLIAM5
LOCATION: 275 WAVERLY ROAD
CITY,5TATE: N ANDOVER, MA
DATE: 4/20/03
DEED REF:
G384/1 77
PLAN REF:
1 247
SCALE:
1 "=30'
JOB #:
203.044G4
WAVERLY KOAD
CERTIFIED TO:. MEMBERS MORTGAGE CO INC
Flood hazard zone has been determined by scale
and is not necessarily accurate.Until definitive Plans
are issued by HUD and/or a vertical control survey
is performed, precise elevations cannot be determined.
I
NOTE: This mortgage Inspection was prepared
specifically for mortgage purpose only and '+ "
is not to be relied upon as a land or property ®liP o2�
line survey, used jbr recording, preparing deed �.
descriptions, or construction. No corners were �'
set. Building location and offsets are
approximately located on ground and �` G.
are shown specifically for zoning determination no
only and are not to be used to establish property
lines. The matters shown hereon are based on' 3
mayclient-furnished injbrmation and may be subject
to further out -sales, takings, easements and right S 1
of way, and other matters of record and preserpii <a1;�lf 1
or other rights. Northern Associates, Inc. assumes S� q
responsibility herein to land owner or occupant, ,`►'Q•y-S;r�„;
accepts no responsibility for damages resulting fro s
reliance by anyone other than the said mortgagee a its assigns
in connection with its proposed mortgage financing to said mortgagor.
This mortgage inspection was prepared in accordance
with the Technical Standards jbr Mortgage Loan
Inspections as adopted by the Massachusetts Board of
Registration of Projbssional Engineers and Land
Surveyors 250 CMR 605.
I further state that in my professional opinion that
the structures shown conform with the local zoning horizontal
dimensional setback requirements at the time of construction or
ale exempt under previsions of M.G.L. CH. 40-A Sec. 7.
o t.Property/House is not in Flood Hazard,
O 2. Property/Nouse is in a Flood Hazanl Area.
[:1 3. Information is insufficent to determine Flood Hazard.
Flood Hazard determined from latest Fede Flood
Insurance Rap nel -
Date zone f
'T C,
This certifies
rtif e'
has permis
in tl )uj �n
at
Fee-:-�
p
I Or%Ydinst
.lo f
�17 T: 4..
Check # (!�) 1W
Ti 39
Date .... ... . .........
N 0 ORTH ANDOVER
r F:/GAS INSTALLATION
........ ..
n.............
... ..... . ..... ...
North A ndover Mas s
�3 46
GAg INSPECTOR
FlYTIIRF�Jf S .9
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
N
G�
City/Town: P iL41, MA. Date:. CJ Permit#
Building Location: a75 WCL(/er1,.f Owners Name: �� /�'✓jP.y�/Pi/�
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: P11, Alteration: ❑ Renovation: ❑ Repla ement: ❑ Plans Submitted: Yes ❑ No ❑
FlYTIIRF�Jf S .9
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachus0ts-r5aneral ws, and that my signature on this permit application waives thi requirement.
` heck -One Only
Owner Agent ❑
Signature f Owner or Owner's Agent
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or enteredl reoardino this annlinntinn arP trim and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Tvjpe of License: �o
By Plumber V4��
Title ❑ Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑ Master
City/Town []journeyman U�
APPROVED OFFICE USE ONLY) ❑ LP Installer License Number: 3366
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SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 1H FLOOR
5 FLOOR
6 1H FLOOR
7 FLOOR
8 FLOOR
54r- �
Check One Only Certificate #
Insta?'Ang Company
Name: �I
i CN U1
q,s
P FrC,
`y
Address: �3d�
01 \(A,r6i\(\
Sfi City/Town: I_ckje,
State:
AA ��, A
Afic
❑ Corporation
❑ Partnership
Business Tel:
9'N-
'?'Oy
-0530
Fax:
❑ Firm/Company
Name of Licensed
Plumber/Gas Fitter: IMl' OA \Lt5 S{--9 Jr.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachus0ts-r5aneral ws, and that my signature on this permit application waives thi requirement.
` heck -One Only
Owner Agent ❑
Signature f Owner or Owner's Agent
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or enteredl reoardino this annlinntinn arP trim and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Tvjpe of License: �o
By Plumber V4��
Title ❑ Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑ Master
City/Town []journeyman U�
APPROVED OFFICE USE ONLY) ❑ LP Installer License Number: 3366
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Samuel F. McCormack Co., Inc.
Insurance Adjusters and Appraisers
Samuel F. McCormack Co., Inc.
ADJUSTERS AND APPRAISERS
December 17, 2012
Town of North Andover
Building Inspector
North Andover, MA 01845
RE ASSURED:
Steven & Kayla Wieners
LOSS LOCATION:
275 Waverly Road, .North Andover, MA 01845
POLICY NO:
10164196
TYPE OF LOSS:
Water
DATE OF LOSS:
12/13/2012
OUR FILE NO:
12-05217
Gentlemen:
Claim has been made involving loss, damage or destruction of the above -captioned property, which
may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to
be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 36 is
appropriate, "please direct it to the attention of this writer and include a reference to the above -
captioned insured, location, policy number, date of loss and claim or file number.
Thank you for your anticipated cooperation.
Very truly yours,
William Manchinton
Adjuster
wjm@mccormackadjuster.com
cc: Board of Health
42 Holbrook Avenue ■Braintree, MA 02184
(781)-843-1222 ■ MA WATS 800-972-5399 ■Fax (781)-849-8191