HomeMy WebLinkAboutMiscellaneous - 278 WAVERLY ROAD 4/30/201887-,0 Date.
4
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... 90.w. Yy� &* ....... TVA .................
has permission to perform .......
plumbing in the buildings of A ................
L1. .... . NorthPAndWpve,. , ass.
at ... 6), ......
F e ' f 0 -w
ef��.;.P9. Lic. No. ( .. ...... �%Aj
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
�(�1/%—/ Date
Building Location /�lJ Owners Name �� Permit #
Amount
Type of Occupancy
New Renovation ri Replacement L� Plans Submitted Yes No
(Print or type) _I� Check one: Certificate
Installing Company Name��M#.4&4W �XJ / iGd!`� Corp.
Address W -y
Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner 11 Agent r
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach s Stat 1 bing a and ter 142 of the General Laws.
By: Licensed um er
Title
ype of Plumbing License
� _ 0City/Town License um er Master ourneyman ®---
APPROVED (OFFICE USE ONLY
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(Print or type) _I� Check one: Certificate
Installing Company Name��M#.4&4W �XJ / iGd!`� Corp.
Address W -y
Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner 11 Agent r
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach s Stat 1 bing a and ter 142 of the General Laws.
By: Licensed um er
Title
ype of Plumbing License
� _ 0City/Town License um er Master ourneyman ®---
APPROVED (OFFICE USE ONLY
The Commonwealth ofMassachusetts
Departnwnt of Industrial Accidents
Office of Investigations
600 kirrzchin; ton Street
Boston, MA. 02111
www_numpv/dia .
Workers' Compensation I=, ince Affidavit-. Builders/Contractors/Electricians/Plambers
colic Mt Information
Name
Adc7res�. cry •-V.4,1.4 U Ani--
City/State/Zip: l� Phone #: .
-----------
You an employer? Check the appropriate box:
'� L❑
[am a employer with 4. Type of project (required):
❑ 1 am a general contractor and I
nyees (full and/or part-time).* have hired the sub -cont maors 6• ❑ New construction
2. I am.a.sole proprietor or partner- listed on the attached sheet = Z. ❑ Remodeling
ship and have no employees These sub -contractors have
working for me .in any capacity. workers' comp. insurance. 8. Q Demolition
[No workers' comp. insurance 5. ❑ .We are a corporation and its 9. ❑ Building addition
required.] officers have exercised their 10•Q Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.[] PIumbing repairs or additions
Myself. [No -workers' comp, c. 152, § I(4), and we have no
insurance.mquired.].t em to ees. 12.[] Roof repairs
P Y [No woriCers
comp: insurance required..] 13.❑.Other
*Airy applicant that checks bol#1 must also fill out the section below showing their worketc' compensation policy information
t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a naw affidavit indioatiag such
;Contractors that check this box must attached an additional sheet showhrg the name of the sub -contractors and their worimrs' comp. poli- infonnazioa.
! am can employer that is Pr?ri&nng:worhers' compensation insurance or
infornurfion. -f' eMP�Yees: Below is the pofiry and job site
Insurance Company Name: '
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address;
City/stat izip.
Attach a copy of the workers' compensation policy declaratiou page (showing the policy number and expiration dated .
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 res 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 cerci Vh—d—er t
a e 0fPe1jmY chat the infnrmatioR provided above is 5w a3d correct
Sr tore Date: �tJ � f�
Phone #:
[Contact
al use only. Do not write in this area, to he comPlet�d by city or town. o rxa(
r Town: Permit/License #
g Authority (circle one):
rd of Health 2. Building Department 3. City/Tovvu Cleric 4. Electrical Inspector S. Plumbing Inspector
er
Person:
" Phone M
Information a nd In's'tructions
Massachusetts General Laws chapter 152 requires all emp Ioyers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enterprise, and includirig the legal representatives of a dec cased employer, or the
receiver or bustee of an individual, partnership, association, or other legal entity, employing employees. 'However the
owner of a dwelling house having not more than three apa3-trnerrts 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 imannee 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, MOL 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 compii. ce with the insurance
requirements of this chapter have been presented to the cora racting authority."
Applicants
Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply .sub -contractors) name(s), address(es), mind phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not rmiuiredl to carry workers' oo Tnpensation insurance. Ifan 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 requited to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-ir-s ed campaniess sheuid ents-w d,er i
self insurancelicense number on the'appropriate.line. - --
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hes 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 -ill 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
poiicy'information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license; or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of LndustriW Accidents
Office of Investigations "
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
vvww.mass.gov/dia
7399
Date. . e0pin .......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
SAC HU
This certifies that .... .............
has permission for gas installation ...... 1-1� � ..................
in the buildings of ..... av! YA q�L f
.......................
at North A
,ndoyer,.Mass.
................
Fehrj-,Q;� Lic. No.
4S��IN�SP�EC�T�OR
Check #
1" FLOOR
2FLOOR
3R " -FLOOR
R
4 LF OOR
FLOOR
OR
6 FLOOR
7 FLOOR
8 FLO RO
Installing Company Namee�:``cv.�Sv/U�iJ�/
Address: City/Town: State: 0 /¢
Business Tel: P7`l —A&7 Fax:
Name of Licensed Plumber/Gas Fitter: !lI pt7da vt,ailill j
Check One Only Certificate #
❑ Corporation
❑ Partnership
❑ Firm/Company
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes -2 0 ❑
If you have checked Yes, please indica a the type of coverage by checking the appropriate box below.
A liability insurance policy Other tvne of inrfamnit., n r-1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent F7
By checking this box Q I hereby certify that all of the details and information I have submitted (or entered) 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 provision of the Massachusetts State Plumb a"pter 112,04#*
-(Neral Laws.
By Type of License:
lumber
Title ❑ Gas Fitter
City/Townurneyman
APPROVED OFFICE USE ONLY ❑ LP Installer
:fiatOre—of Licensed Plumber/Gas Fitter
License Number: 13
il
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: /t✓Q�I ��L ,�L ,��, MA. Date:
Permit#
Building Location: � Ilie� 1% Owners Name: %bQ,)-A&T
Type of Occupancy: Commercial ❑ Educational ❑
Industrial ❑ Institutional ❑ Residential [�—
New: ❑
Alteration: ❑ Renovation: ❑ Replacement: 21' Plans Submitted: Yes ❑ No �—
FIXTURES
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1" FLOOR
2FLOOR
3R " -FLOOR
R
4 LF OOR
FLOOR
OR
6 FLOOR
7 FLOOR
8 FLO RO
Installing Company Namee�:``cv.�Sv/U�iJ�/
Address: City/Town: State: 0 /¢
Business Tel: P7`l —A&7 Fax:
Name of Licensed Plumber/Gas Fitter: !lI pt7da vt,ailill j
Check One Only Certificate #
❑ Corporation
❑ Partnership
❑ Firm/Company
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes -2 0 ❑
If you have checked Yes, please indica a the type of coverage by checking the appropriate box below.
A liability insurance policy Other tvne of inrfamnit., n r-1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent F7
By checking this box Q I hereby certify that all of the details and information I have submitted (or entered) 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 provision of the Massachusetts State Plumb a"pter 112,04#*
-(Neral Laws.
By Type of License:
lumber
Title ❑ Gas Fitter
City/Townurneyman
APPROVED OFFICE USE ONLY ❑ LP Installer
:fiatOre—of Licensed Plumber/Gas Fitter
License Number: 13
il
I
.1
Date ......
........ ....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ ...... e, ........ . ..............................
4 /,,- ;0
has permission to perform .........
wiring in the building of
...............................................................................
......... 'Pr.a . . ....... . North Andover Mass.
""I U'
Fe�� .............. L i A a ............. . .... . .. .. ..
PLECMTRICAL INSPE R
Check #
8781
-4� Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. Rf %,pl
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked �<S
[Rev.l/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 PRINTININK OR TYPE ALL INFORMATION) Date: 5-30-o,9
City or Town of. NORTH ANDOVER To the Inspector of Wires:
or her in ion to perform the electrical work described below.
By this application the undersigned gives notice of his
Location (Street & Number) c'f 78 �e 4 vel^ �e,i ad
Owner or Tenant R o ber Q v l ti
Owner's Address L178 Lie%Uer e
Telephone No.q %o- 68�-?K'ga
Is this permit in conjunction with a building permit? Yes
❑ No � (Check Appropriate Box)
Purpose of Building RQSI k4 +,.r, Utility Authorization No. f �/6 y 2
Existing Service Go Amps Zfj / I orb Volts Overhead Und rd r
g ❑ No. of Meters
New Service J 00 Amps 2 (F / 010 Volts Overhead
® Undgrd ❑ No. of Meters
Number of Feeders and. Ampacity
Location and Nature of Proposed Electrical Work: �' %nQn�P S'�y I � C,/,�
1OnA�S - s
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
ti► No. of Receptacle Outlets
No. of Switches
v
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water KW
Heaters
No. Hydromassage Bathtubs
OTHER:
the ollou n table maybe waived bv the Ins ector of Wir
No. of Ceil: Surp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool si`nd e ❑
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. Tc
Space/Area Heating KW
Heating Appliances KN
No. of o. of
Signs Ballasts
No. of Motors Total HI
'
No. of Total
.
Transformers KVA
Generators KVA
nd.
0.0 mergency ig g
Battery Units
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices .
No. of Alerting Devices
KW._ -
No. of Self -Contained
Detection/Alertin Devices
Local ❑ Municipal
❑ Other
Connection
Security Systems:
No. of Devices or E uivalent
Data Wiring:
No. of Devices or Equivalent
>
Telecommunications Wiring:
No. of Devices or E uivalent
/Attach Attach additional detail f desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Wor J (When required by municipal policy.)
Work to Start S 3 0 - 09 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: INSURANCE ❑ BOND ❑ OTHER ❑ (Spec
I certify, under e pain s and pens lies o er'u )
t2J .fp ry, ��ff at the information on this application is true and complete.
FIRM NAM LizdwE�eCT/�� LIC. NO.: / 036
Licensee: Signature,,/
(If applicable, enter "exempt 11 in the :cense ny� ber line.) q_ LIC. NO.:
Address: �% �2 /y► lj 1 Gw t� Neo r /gin X10�o f � t( Bus. Tel. No.:
*Per M.G.I. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt L cl No
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. �%B�yy y signature below, I hereby waive this requirement I am the (check one) ❑ owner �
Owner/Agent owner's agent.
/��"-/ ` „ �G�/ v
Signature Telephone No.
Cf/
e 14 �, ,
N
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 ffashington Street
Boston, NIA 02111
c , www.mass.gov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
rlinlieanf Tn&v-r_. +:....
Name (Business/OWizadon/Individual):_
Address: 5 (-n V eco)
bti IrIt ) tv I
AV4P_
City/State/Zip: N or4k And 0 yer, #A o fpy 5phone #:_ S"a8 - _ / /-),q3
Are you an employer? Check.the appropriate box:
I.m a employer with �
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. K I am .a.sole proprietor or
have hired the sub -contractors
listed
partner_
on the attached sheet. $
ship and have no employees
These suis -contractors have
working for me .in any capacity,
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.)
3. ❑ 1 am a homeowner doing
officershave exercised their
all work
right of exemption per MGL
myself [No-worke'rs' comp,
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required..]
•Anv. wnnlb-...r .0.... ..�..._t._ t�__. �..
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. ❑ Building'addition
I 0.,KElectrical repairs or additions
11 1-0 Plumbing repairs or additions
12.[] Roof repairs
13.❑ .Other
t H .._, dbu lug ou[ ine section below showing their workert' compensation policy information.
omeowners who submit this affidavit indicating they are doing all work and then hire outside con
4Cotractors must submit a new affidavit indicating such
ntrsators that check this box must attached an additional sheet showing the name of the sub -contractors and their —rk=' comp. policy information.
fain an employer that is providing; workers ' compensation u7surance for m employees:
information Below is the Policy and job site
Insurance Company Name: '
Policy # or Self -ins. Lie. #:
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 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 s 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 cern under the pains a penalties of perjury that the information provided above is true and correct
Si lure: �v�fL=��
Date: S 28 --O 9
Phone k S09 ---/Qa — %L,- L/ 3
Of xiaf use only. Do not write in this area, to be completed by city or town. official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5
6. Other . Plumbing Inspector
11 Contact Person• Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, t -
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the .
receiver or trustee of an individual, partnership, associatiotn or other legal entity, employing employees. 'However the
owner -of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insurance 'coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public woric 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 -contractors) name(s), address(es).and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cavy 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, nottthe 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 numberlisted below. Self-insured companies should enter their
self insurance- license number on the appropriate line.
City or Town Officinis
Please be sure that the affidavit is complete and printed legibly. The Department hes 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 NviII 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 "ail locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT.requimd to complete this affidavit
The Office of lnvestiptions would hike to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 east 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-77491
www.mass.gov/dia
6
Location.
N6. /W10, Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ J
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # IV: -t-)
' 4 '%0
1 5,-,, U
Building Inspe6to/r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
PPLICATION TO CONSTRUCT REPAIR. RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
[ JI LDING PERMIT NUMBER: DATE ISSUED:
`GNATURE:
A�
Building Commissioner/I for of Buildings Date
:CTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
1
r— / ^�
C` �- - .�
ensed Construction Supervisor:
z7 /)c VeP1
Map Number Parcel Number
License Number
1.3 Zoning Information:
1.4 Property Dimensions:
ning District Proposed Use
�j'
/L7 11
Lot Areas Frontage ft
i BUILDING SETBACKS ft
Expiration Date
Front Yard
Side Yard
Rear Yard
Required Provide
Telephone
Required
Provided
ReqWred Provided
Water Supply M.G.L.C.40. 5 54)
1.5.
Flood Zone Information:
1.8 Sewerage Disposal System:
dic ❑ Private 0
Zone
Outside Flood Zone 0
Municipal ❑ On Site Disposal System ❑
:CTION 2 -.PROPERTY OWNERSHIP/AUTHORIZED AGENT
Owner of Record �'. I .. i `%_ �t _
( �`', v !. ! 1 r i �. %L�� 64 -1 -`� i— • J
me (Print)
Address for Service
;nature
Telephone
Owner of Record:
Jame Print
Address for Service:
nature
Telephone
CTION 3 - CONSTRUCTION SERVICES
Licensed Construction Supervisor:
Not Applicable ❑
npany Name
ensed Construction Supervisor:
z7 /)c VeP1
14
License Number
Tress ,
_T n
�j'
/L7 11
l C ./ ::; ,,:' 72 .r 1_. -
o C ✓ `'
Expiration Date
nature Telephone
Registered Home Improvement Contractor
npany Name
cress ✓
_T n
tature
Telephone
Not Applicable ❑
Registration Number
L -
Expiration Date
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work(check all applicable
New Construction 0 Existing building. 0 Repair(s) ❑ Alterations(s) Addition 0
Accessory Bldg. ❑ Demolition 0 Other 0 Specify
Brief Description of Proposed Work; Z x
n
I SECTION 6 - ESTiMATRn ('ONSTRTTCTTnN Cn.QTQ I
Item
Estimated Cost (Dollar) to be A¢w
Completed by permit applicant
1. Building
(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
6 Total 1+2+3+4+5
Check Number
p.. NEL. HUN is UWINEK AU 1HVFJZA11O1N "1U BE COMPLETED WHEN
r OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
'f"` iill r �,� �'/Z_ J ��- as Owns /Authorized Agent f 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/ uthorized Agent ot}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/ Al
1 Signature of Owner/Agent"
-- �� Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
I)EIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name � c. f L L e.. h _�- Z #C- i7 �� .5 CIL
,
Location: (� AA/ i,/ (f
City /yoRra-/ /+ /2 l)e--V`:
am a homeowner performing all work myself.
EI -am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance Co. __ Policy #
Company name:
Address
City Phone #:
Insurance Co Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under thelpains and penalties of perjury that the information provided above is true and correct.
Signature- ��.-�� L`��t__ t.�-z.__ Date
Print name i t .. A- rZ J /� Phone #
Official use only do not write in this area to be completed by city or town official' ❑ Building Dept
❑Check ff immediate response is required Building Dept ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone #: ❑ Health Department
❑ Other
FORM WORKMAN'S COMPENSATION
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978)688-9545 Fax(978)688-9542
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a.
The debris will be disposed of in /at: /
Facility location n
Signature of Applicant
A- /Dk-) ; L 3 6� C:--) c)
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
BOARD OF BUILpING REGULATIONS
L. )License: CQNSTRUCTION SUPERVISOR
Number CSS 040927
Blrtl-didi�
957
{{ pI
io44/29,01 Tr. no: 8479
Jw
11 R tr�cted To:.,00
ROBERT W ALLEN;; (F
86 ANDOVER ST 1
N ANDOVER, MA 01845/
inistrator
-07464 Date.
"0RTN 11 TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that ...........
has permission for gas ins - tallation ...................
in the buildings of ... . . . . . . . . . . . . . . . . . . . . . . .
at ... K:�-! x' North Andover, Mass.
Fee.,45 ..... Lic. No..,? ........
ASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
' �f
��U / ��d✓1F� . Mass. Date 6-40_.,2 t o Permit # 3 V C c(
C4�
Building Location_. �%� J�,[a/ y Owner's Name[/,(�77�L
Type of Occupancy �.
New jo Renovation ❑ Replacement E] Plans Submitted: es❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone -687-1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one: Certificate #
XJ Corporation 1862
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability insurance policy K Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner'sAgent Owner❑ Agent ❑
hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and aocu�gte to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application WillLwn&mpliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. i
T of License: �Fl
Plumber Signature of Licensed r or Gas
Title Gasfitter
9
(Qty/Town Master License Number 8697
APPROVED O FIC S . ONLY Journeyman
Y
•
HER
■■
. ...
■EMENEENEEN����n�n��■
EN
..
MEN
EMEMENNEM
MEN
SEEN
ON
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone -687-1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one: Certificate #
XJ Corporation 1862
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability insurance policy K Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner'sAgent Owner❑ Agent ❑
hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and aocu�gte to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application WillLwn&mpliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. i
T of License: �Fl
Plumber Signature of Licensed r or Gas
Title Gasfitter
9
(Qty/Town Master License Number 8697
APPROVED O FIC S . ONLY Journeyman
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Location v Aa,
U
No. D a t e
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
6 �,�
Check #
13676
$
s
Building ln�Oector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
lOg=#�b!' illClBi .U9C
BUILDING PERMIT NUMBER:DATE ISSUED:
SIGNATURE:
it n ommission for of Buildings Date v -D
SECTION 1-tMTE INFORMATION
1.1 Property Address:
.279 z,,,yaGYru AO/
1.2 Assessors Map
Map Number
and Parcel Number:
Parcel Number
1.3 Zoning Information:
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
R red
Provided
Re red Provided
1.7 Water Supply M.G.L.C.40. 34)
Public 0 Private ❑ Zone
1.3. Flood Zone Information:
Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
P
Address for Service
Signature
Telephone
2a2 Owner 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 (NLG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil 'ng permit.
affidavit Attached Yes ....... W No ....... ❑
—Signed
SECTION 5 Description of Proposed Work check applicable)
New Construction ❑
Existing Building V
Repair(s)
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SX) 0/:�a 06-0 ROy%i
`p
4-00 S10106 670 Q r2 5jP& G'jgt?& --
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE. ONLY
1. Building
t'�rJ
(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
6 Total (1+2+3+4+5) , Q
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT CONTRACTOR APPLIES FOR BUILDING PERMIT
JOR
I, �7- 44(O , 5 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, I ( 4oz- '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
ni 5
Print
Si afore of Owner/ t Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR THVMERS 1 ST2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DINvIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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BUILDING DEPARTMENT'
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL -C'40 S 54, a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in:
Location of Facility
Signature ofternlit Applicant
i Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of
the Building Inspector
Name
Name:
The Commonwealth of Massachusetts
Department of Industria"ccidents
Office of lnvesti_aations
Boston, Mass. 02111
Workers' Compensation Insurance Affi;davit
Please Print
Lccaticn: ��— ` kJ�l
City v Vlln �. Phcre T
aI am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacib/
CI am an employer providing workers' compensation for my employees working on this job.
Comoanv name:
Address
CiN: --Phone-"--
insurance
Phone"'
Insurance Co. Policci
Comoanv name:
Address
Phone T-
�ylnGuranca Co Folic,,/ T
Failure to secure coverage as---awrec under Section 25A or MGL 152 can lead to the imcositien of cnmir.al penalties cf a fine up to 51,5C0.cc
and/or one tears' imprisonment as Neil as c:vii penalties in the form cf a STCF INCRK ORCE= and a Fine cf (5100. CO) a day against me. I
understand that a copy of this statement may be forwarced to the Ot ice of Investieaticns cf the GIA fcr coverage verification.
I co hereby cet-, y uncar the gains and penalties or perjury that ;he information provided accve is 'rue and correct.
Signature
nate
Print name Phone 1r
Official use only do not write in. this area to be comcleted by city crown cmcai
City or Tc,,vn Permit/Lcensirc
❑Check ,r immediate response is required
Conracr Berson: Fhone r.
❑ Building Dept
Licensing Board
❑ Se!ectman's Office
I^'ealth Department
Other
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Location 170 WASA::*-!�
No. 309 Date 9-6 – 24—
TOWN OF NORTH ANDOVER
0
16.
Certificate of Occupancy
$
-37-
4L
Building/Frame Permit Fee
$
Foundation Permit Fee
$
CHU
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$ '39
Buildinglhs�e`ctor
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0
-81092
Div.
Public Works
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HOME IMPROVEMENT CONTRACTORS REGISTRATION
Board of Euillding R*gulationa and ��andard�
One Ashburton Place - Room 1301
Boston, Massaclhusatts O27,lO6
HOHE IMPROVEMENT CONTRACTOR
Registration 104608 Expiration 07/I4/94
INDIVIDUAL
Robert M. Lyons
12, Theresa Ave.
Salem NH 03079
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LYONS HOME IMPROVEMENT
MA Contractors License 12 Theresa Ave
# 104508 Salem, NH 03079
(603) 898-1352
RESIDENTIAL CONTRACTING AGREEMENT
Read this agreement and make sure you understand it before signing it.
This agreement has legal force and effect and binds those who sign it.
Notice: All home improvement contractors and subcontractors engaged in home improvement contract-
ing, unless specifically exempt from registration by provisions of Chapter 142a of the general laws,
must be registered with the Commonwealth of Massachusetts: Inquiries about registration and
status should be made to the Director, Home Improvement Contract Registration, One Ashburton
Place, Room 1301, Boston, MA 02108.
Designated Registrant's Name: 4/nr im "Co, 6,OL 't"rT}
Registration Number: U
Salesperson's Name:
This agreement is made on may"% Y ;fir y between Af.�
(DATE) (CONTRACTOR)
of
(ADDRESS) (PHONE NUMBER)
hereinafter called "Contractor" and
(OWNER)
of %�j /✓'42:
(ADDRE (PHONE NUMBER)
hereinafter called "Owner".
I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the following:
d0/X) //,�/ 27 A& 1-,,,2ZL-
Lr�li�, �'i�' G>7 ra[f 6--11-11-L 51 ; �l ( 20M :X :!56 >, ,72 v- elk - Y .Siff 5
DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the following:
%C�/L � A i�, �L✓)T�'T�Z, 115?ad9 57 Ul>7 L 31►,i ht"
Il. PRICE
Contractor agrees to do all work described in Section I for the total price of $
III. PAYMENT
Payment will be made as follows:
w
3[ 3 1/31 % (S / LTC . ) upon signing Contract;
%($ LCiSL.% ) upon completion of
upon completion of ,
and the remaining % ($ ) upon verification of
the work by Owner and Contractor as having been satisfactorily com-
pleted, which verification shall take place promptly after completion.
Notice: No agreement for home improvement contracting work shall require a down payment (advance
deposit) of more than one-third of the total contract price or the total amount of all deposits or
payments which the contractor must make, in advance, to order and/or otherwise obtain delivery
of special order materials and equipment, whichever amount is greater.
IV. COMMENCEMENT AND COMPLETION OF WORK
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless
specified here in writing. Contractor will begin the work on or about _tel 6 /,OY (date). Barring delay caused by
circumstances beyond Contractor's control, the work will be completed by 5bo � (date). The Owner hereby
acknowledges and agrees that the scheduling dates are approximate and that suA delays that are not avoidable by the Contractor
shall not be considered as violations of this Agreement.
V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of the times specified in Section III (Payment) above for the reason
that he deems himself or the payments to be insecure. If, however, he deems himself to be insecure, he may require, as a prerequisite
to continuing the work described herein, that the balance of the payments under this contract that are in the control of the Owner,
shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner for withdrawal.
VI. INSURANCE
Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself, his
employees or his subcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to carry
insurance to cover such damage or injury.
VII. SUBCONTRACTING
Contractor agrees that, notwithstanding any agreement for materials and/or labor between Contractor and a third party, Contractor
is responsible to Owner for completion of all work described in a timely and workmanlike manner.
VIII. CONSTRUCTION -RELATED PERMITS
The following construction -related permits will be necessary in order to complete the scope of work included in this Agreement:
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction -related
permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory,
permit granting or inspectional agencies, authorities or individuals.
Notice: If the homeowner obtains his own construction -related permits for the work described under this
agreement, the homeowner is hereby advised that in the event of a dispute, judgment and
nonpayment of the contractor, the homeowner will not be entitled to make a claim to or collect from
the guaranty fund established by Chapter 142A, M.G.L.
IX. MODIFICATION
This Agreement, including the provisions relating to price (Section II) and payment schedule (Section III) cannot be changed
except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance
with the Notice of Cancellation (annexed).
X. WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period
of n ,'i following completion and shall comply with the requirements of this Agreement. In the event
any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is
discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith
remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or
workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such
equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturers' warranties, the Owner
maybe required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate
such warranties. The Owner's failure to mail in or register such documentation, which failure voids the manufacturer's warranty,
shall not create any responsibility for the Contractor to warranty such equipment.
This warranty gives the owner specific legal rights, and owner may also have other rights which vary from state to state. Under
Massachusetts law, sales of goods carry an implied warranty of merchantability and fitness for a particular purpose.
XI. COMPLETENESS OF AGREEMENT FOR EXECUTION
The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked
as void, deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated herein are
attached hereto.
XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement iS governed by the Laws of Massachusetts. It must be executed in duplicate, and an original signed copy hereof
given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and
transmittal to the owner of a copy thereof.
Aikin I a 1 V l n11q%-L' L
The owner may cancel this agreement if it has been signed by the owner at a place other
than an address of the contractor which may be his main office or branch thereof,
provided that the owner notifies the contractor in writing at his main office or branch
by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
third business day following the signing of this agreement. See attached Notice of
Cancellation.
HOMEOWNER:
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner's Signature Date Signed
`4
Contractor's Sig re Date Signed
H - GG 25M 6/92
p
Mll�
MMy",
"'NEW. IIWMPSHIR
R R L ONS
72.,! H RE A AVENUE
1-fLEM NH
3079
OPERATORi
LJOEME NUMBERI LICENSE EXPIRES
06LSR53011 06-01-96
SOCIAL SEC. mo. ;'IT- GATE
031-44-37119 -01-53
RESTRICTIONS W- WY. SEX TYPE
6-01 180 M
[WArLlft,
Date .......
N2 2963
R711
0
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
................................
This certifies that ...... ........... C/
11
has permission to perform ......... ........ ... ..................
-K
wiring in the building of ........ /� ...........................................
....................... . North Andover, Mass.
at ................. ...... Z K� ... �A)n..��'OW 6/
Fee Lic. No.
',,,�CMICAL INSirWMR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Office Use Only
01(�4e t'iommunwealo 1f3,55a[4n1 efts Permit No. (P
Mepartment of Pubiic F'Af l Occupancy & Fee Checked
l BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3i90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12 .00
PLEASE PRINT IN INK OR TYP+ ALL NFO_(R�M�ATION Date D
( City or Town of 1y�l ) To the Inspecto of Wires:
The udersigned applies for a permit to perform the 71ectrical w rk desc 'ed below.
Location (Street & Number)9y�'�'d�
Owner or Tenant 1b LA
3
Owner's Address
Is this permit in conjunction with a building permit: Ye No ❑ (Check Appropriate Box)
Purpose of Building , 1 7 Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work /2�y
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures 2
Above In -
Swimming Pool
❑ ❑
grnd. grnd.
Generators KVA
No. of Emergency -Lighting
No. of Receptacle Outlets
No. of Oil Burners
I Battery Units
No. of Switch Outlets 3
I No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
No. of Ranges
No. of Air Cond. Total
tons
Initiating Devices
No. of Disposals
I No.of Heat Total Total
Pumps Tons KW
No. of Sounding Devices
No. of Seif Contained
No. of Dishwashers
Space/Area Heating KW
Detection/Sounding Devices
Local Municipal
❑ ❑Other
No. of Dryers
Heating Devices KW
Connection
No. of No. of
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. Hydro Massage Tubs I
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES `$' NO ❑ 1
have submitted valid proof of same to the Office. YES 2Q• NO ❑ If you have checked YES, please indicate the type of coverage by
checking the appropriate box. ��,14d4-
INSURANCE X BOND ❑ OTHER C3 (Please Specify) N
Estimated Value of Ele t fc Work $ (Expiration Date)
Work to Start Inspection Date Requested: Rough Final
Signed under the Pena tie of pedury. T
FIRM NAME _— _ G ZIC C� 1�1G LIC. NO. 6' 33
Licensee 5. �./vfA . T2 Signature LIC. NO. AS%. 3
� ��� ,m�us. el. No. �3 , ��3
Address .y_-1 Ci1/ee15-Z/Ya- Yt-rJ . Z� 46&2 JOZZ2 Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent
(Please check one)
Telephone No. PERMIT FEE $
(Signature of Owner or Agent) x-3565
I . N2 4791
r,
Date. . Ix—'. - -`�f /'
TOWN OF NORTH ANDOVER
-PERMIT FOR PLUMBING
This certifies that
............................................
has permission to perform. . . ......
plumbing in the buildings of ..... ...............
at . C'�'7i .......... North Andover, Mass.
�_Lic. No .......... ......
Fee./W ...........
PLUIVIBING� SPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
1-9
�f
MASSACHUSETTS UNIFORM APPLICATION . �
9 Panic � FOR PERMIT TO OO PLUMBING
46
,Print or Ty*� - �a/-/
/ ,�/ /
A10,, RAJ J Mass. Oahe - �/
Sulkft owner: N&W I eCyi A/ /I � �' �'' "
L / /Q % Type at occupancy—
Yes
Ren�rdlon O � d1(p�ns�Subattilted: O No C3
New D
FIXTUR�,
Insudang CMWY Name K MARTTN P + P TWt' _ CQ Oonpoorpo rdlon 2one:. 1Ryicte
Address i z�i ABBOTT ST 3- 3 ��,
LAWRENCE, MA 01843
O Partner"Sualnesatelephone D hmVM.
Name d Lioensed Plumber KERRY
INSURANCE COVERAGE:ett which meets the d MGL Ch. M
I hairs a current UWAy insurance pollc y or Its subdsntial etAYW
Yes q No ❑
If you have checked yam. please Wlade the type covaape by ehedit the aPProPrWft boos
A lis AW Insurance policy 9 other type d IndatutM O . Sond D .
OWNER'S INSURANCE WAIVER: I am aware that the Ifoensee�do� ot hm. Ow Pew ��� �� this
Chapter 142 of the Mass. General taws` and that my sgnatune Check own .
Owner D Aged O
1 Eby GAM W as of the dstais and kftM W I ha» subeitbd fa w t.ndl in above appkatbn an we and somVe m rim bast of my
aawledpe and that as Flunbiaq work and mons p wbnmd WNW the PGM* i:s this sppb o hon wM be in owoft G Wit all
pertinaat poorissbm of Vo Mossadaasntfs State Robing 000 saw Chapter W oil Laws. W v
0 Type of License: Woor [ Jaui+ey,nan D
a�ryRawn
t;oense Number 9� 0 ....
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