HomeMy WebLinkAboutMiscellaneous - 28 AUTRAN AVENUE 4/30/2018 (3)fla
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This certifies that
DaW� 3/7. YO) -
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
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has permission to perform .... ...... .......
plumbing in the buildings of . .* ..... 0. : ...............
at ... (34�- f k4 -.V A ..... North Andover, Mass.
Fee. -)-o
20 ..... Lic. ....... ............. ..........
PLUMBING INSPECTOR
Check # I �- 5-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY � ; MA DATE PERMIT#
JOBSITE ADDRESS OWNERSNAMEL��-
POWNER
V
ADDRESS TELr =FAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW:E] RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NO[j
FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —1
CROSS CONNECTION DEVICE jJ7
_j
DEDICATED SPECIAL WASTE SYSTEM I J==
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN I
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
F— F—I
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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY D BOND [j
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: OWNER 0 AGENT F—I
SIGNATURE OF OWNER OR AGENT
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 !n cor�Wnce with all Perti t rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME —!]LICENSE SINATORE
IMP;4 ip 01 CORPORATION 01 #=PARTNERSHIPF—] # LLC
COMPANY NAME DRESSI
—71 AD
CITY JISTATE ZIP TEL
FAX CELL 30AIL
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ......
1 o
has permission for gas installation ... .. ....... ....
in the buildings of ... L. O.K1.5.0 ..............................
at c.). &-. . . . . . . . ., North Andover, Mass.
Fee..SA.. Lic. No.. . .......................
GASINSPECTOR
Check # (D-5 �
Ifim
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE PERMIT #
JOBSITE ADDRESS OWNER'S NAME
GOWNER
ADDRESS I TEq__ FAX
TYPE OR
PR1NT
OCCUPANCYTYPE COMMERCIAL E] EDUCATIONAL RESIDENTIALJO
D
CLEARLY
N E W: El RENOVATION: F -J REPLACEMENT: PLANS SUBMITTED: YES NO F -J
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE 1
FRYOLATOR
FURNACE . . . . . . . . . . . . F --J
GENERATOR JL I
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/ SPACE HEATER L
ROOF TOP UNIT
TEST
UNIT HEATER —A
UNVENTED ROOM HEATER
WATER HEATER
--dTHER
I
—j ___j
=1-- = — =1
-
91 111 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES)p No D
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY [j BOND
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: OWNER F—] AGENT
SIGNATURE OF OWNER OR AGENT
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 compliangovith all Pertine n of the
[Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE #E� �IGNAYURE
LPG]
IMP MGF [D JP 0 JGF CORPORATIONF71# E= PARTNERSHIP 0#= LLc D#=
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COMPANY NAME:F--J7,— J�--.- ADDRESS �2
CITY STATE &W ZIP TEL
FAX C E L L�f�' 'EMAILL_
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The Commonwealth ofmassachusetts
Department ofindustridAccidents
Offide of-rnVesagations
.600 Washington Sftwet
Boston, AM 02_111
www-mass.gov1dia
Workers' Compensation Insurance Afridavit: DuUders/Contra
ctors/Electricians/Plumbers
e -
Name (Business/C)rganizatioj)andividual): _7J_/A
- - - —Addrem
r
. _ . sl�_
City/State/Zip U2191(5� Phone PIS;�d) _t) "3
A you an employer? Check the appropriate boxt
am a employer with
4. 1 am a general contractor and I
employees (fall and/or part-time).*'
have hired the sub -contractors
2)0 I am a Sole Proprietor or partner-
listed on the attached sheet I
ship and have no employees
T.hesc sub -contractors have
working for me in any capacity.
workers$ comp. insuranc
[NO workers' comp. insurance
5. E]We area colporation e'
and its
required.)
3.EJ.I am a homeowner doing
officers have exercised their
all work
light Of exemption per MGL
myself. [No workers' comp.
C. 152, § 1 (4), and we have no
insurance required.] f
eMploYdes. [No *orkers'
comp. msuranci� required.]
Mustalso 1
Type of project (required):
6. R New construction
7. E] Remo deling
8..E] Demolition
9. El Building addition
10-FTElectrical repairs or additions
I IMPlumbing repairs or additions
12-M Roof repairs
13.n Other
— wu�
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new iffidavit indicating such.
'contractors that check this box must attached an additional sh-eet showing the name ofthe sub-contracton Bud their workers, coup. policy information.
lam a" employer thatsProv'dkg workers'cOmPensa&n insurancefor my employees. B I M —
informadon. I 1 0 1 is thepolicy andjob site
hisurance Compiny 1jame:
Policy # or Self -ins. Lie, #.-
R iration Date: /
Job Site Address: L., City/State/Zip-__aZd!��
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration da
te).
Failure to secure coverage as required -under Section 25A OfMCYL c. 152 can lead to the imposition of ermi =ial penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to $250.00 a day again§t the violator. Be advised that a copy of this �tatemcnt may be fbr�rarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cert!& uy4re)rthepains and
OfPeriujYthat the information provided above is true andcorrect,
Signature:
Date,
Phone#. -
h
re.
ce
the Pains andp, al -es ofperjuq that
FOfficial use only. Do not write in this area� to be completed hy ciV or town officiaL
C -ty or Town.
ity or Town: PermitfLicense
Issuing Authority (circle one):
L Bolard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Ins
6. Other
F pector 5. Plumbing Inspector
L Contact Person:— Phone A-
Information aitd Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is definc,-d as "...every pc--rson in the service of another under any coiltract of hire,
express 6r implied, oral or written."
An employer is defined as "'an individual, partnership, a*ssociation, 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 employe; or the
receiver or trustee of an individual, par�nership, association or other legal entity, employing e mployees. However the
owner of a dwelling house having not more than -three apartuents and who resides therein, or the occupant of the
dwelling house' of another -who -employs -persons to Ao -mainttmanceconstructioil or -repair -work -on-such dwolling-houso
or on the grounds 6r building appurtenant tliereto shall not because of such employment be deemed to be an employer."
MOL chapter 152,'§25C(6) also states that "every state or 10cal 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 coxUpliance with the insurance coverage required.77
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract fo.r the porformance.of public work iiatil acceptable G*Vidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicantis
.Please fill out the workers' compensation aff * i&vit c9rapletoly, by checking, the boxes that apply to your situation and, if
necessary, supply sub1contractor(s) name(s), address(es) and phone number(s) along with their certific�t�(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) wit�.no employees other than the
members or partners, are not required to ca.rry workers' compensation insurance. If an LLC or LLP does have,
employees, a ' policy is required. Be -advised that this affidavit may be submittedto the Department of Industrial
Accidents for confinnation of insurance coverage. Also be s7are to sign and date -the affidavit. The affidavit should
be, return edto the city or license is being requ*este4, not fn-- Do-partmeait of
or
Industrial Accidents. Should you have any questions regarding flae, 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 oflavestigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be -used as a referencenumbor. In addition, an applicant
that must submit multiple permit/license applicationsin any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the, applicant should writ-_ "all locations in _(city or
town)." A copy of the affidavit that has been offici�lly stamped or marked by the city or town ni�Ly be, provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be. fined 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 licensf, or permit to burn.lea.yes etc'.) said person is NOT required to complete this affidavit.
The Office of Investigations woulflike to thank you in advance f6r your cooperation and should you have any questions,
please do niot-hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusats
Dopartmont of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0,2111
Tel. # 6.17-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 6.17-727-7749
Location (:9, (a f-) 0 AU
No. 416 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
C)
MU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# e,4
'16/-78
(j2
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
'0 OW
BUILDING PERNUT NUMBER:
DATE ISSUED:
SIGNATURE: Z�Ay �c���
Building Commissioner/Ins=tor of Buildings Date
SECTION I -SITE INFORMATION I
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
q 'g C - ;� k
Map Number Parcel Number
1.3 Zoning Information:
Zoning DiMrict Proposed Use
1.4 Property Dimensions:
Lot Area (so Frovitage (R)
1.6 BURDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide ReqWred
Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 13
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
� \./0 zq
Name �Print) Address for Service
Signature Z_ Telephone
M Ownefof Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
149AIA,110 :77 RL"5-,rq
Lice�sed Construdtion Supervisok
/�/6/ '416C IeE�1.1�lc
ss
4e2q!0__ e", Fri Y��
Sjgt;at,%06 10�/' ;oll Telephone
Not Applicable 0
License Number
C,
Expiration Date
3.2 Registered Home Improvement Contractor
/ a IV14 21.4 :r- fi,/
Not Applicable 0
Company Name
Registration Number
AAdress
U,4o4a2ir �I:Z -71T 3 �e.2,7
Expiration Date 7
OL
S — v- - e �
gn re Telephone
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I SECTION 4 - WORKERS COM[PENSATION (NLG.L C 152 § 25c(6) I
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 ....... 11
SECTION 5 Description o Proposed Work (cheTck ApplIcable)
New Construction 0
Existing Building 0
Repair(s) [I
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 11 Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE' ONLY
I . Building
(a) Building Permit Fee
Multipl er
U
2 Electrical
(b) Estimated Total Cost of
Construction
.3 Plumbing
Building Permit fee (a) x (b)
.4 Mechanical (HVAQ
5 Fire Protection
.6 Total (1+2+3+4+5)
Check Ntunber
SECTION 7a OWNER AUTHORIZATION TO BE CONIPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT
1, 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
1, 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/Aient Date
�7 - �—y V
YEE
NO. OF STORIES SIZE
BASEMENT OR SLAB
S17 -E OF FLOOR THVMERS Isl 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
f MIGI-IT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUJI.DING CONNECTED TO NATURAL GAS LINE
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Town of North Andover
Building Department
27 Charles Street
North Andover MA 01845
Tel: 978-688-9545
HOMEOWNER LICENSE EXEMPTION
Please print.
rl A 7 C
JOB LOCATION C:�R
Number Street Address Section of Town
"HOMEOWNER ?—, —
Number Home Phone Work Phone
PRESENT MAILING ADDRESS I;::;. ;> _.%^ -_
City Town State 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 HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one to six family dwelling, attached or detached structures ac-
cessory to such use and and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official,
a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFI
Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0 Construction Control.
OFFICES OF:
APPEALS
BUILDING
CONSERVATION
HEALTH
PLANNING
MADE BY: _1)tu .
of
Town of
NORTHANDOVER
DIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN 11.1'. NELSON, DIRECTOR
'A/_ 6IV6_10�
120 Main Street
North Andover,
Massachusetts 0 1845
(617) 685-4775
DATE -plov ze_l
ADDRESS: —TEL. ee-e�-X&"
NATURE OF COMPLAINT
% AIZI 1%
p
4
91--
.01
1%
LOCATION: OCCUPANT.
OWNER ADDRESS.
DO NOT WRITE BELOW THIS LINE
h DATE OF
REFERRED TO- " Am/
RESULT OF INVESTIGATION 0 --)'& __a_4v-��
RECOMMENDATIONS:
ACTION TAKEN:
INVESTIGATION
C
Date.,.��. er-.
,N2 4417
0
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�811---'- I D
This certifies that ... N CA ...................
has permission to perform .... .............
"plumbing in the buildings of
.................
'at X ..... North Andover, Mass.
Fee. ...... Lic. No ......
P L U �1�1 �G INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (,f
(Print or Type) 070,
IN
&2o A &i-c)n vel-. Mass. Dat xi Permit #
Building Location-Z�, A A ve Owner's Name L(DLsok,,q Z- Loij G 0
TypeofOccu 16/y/
Pi7New C3 Renovation C3 Replacement s Submitted- Yes El No C3
FIXTURES
Installing Company Name "'A 0 t'�Ee-r 'j,4 al M 4 T A e -0 Check one: Certificate
Address
0 Corporation
6 TW 1,'j5 -A) - Yr f4 0 a �A/ 0 Partnership
.Business Telephone k1f, Z -'-/ q 7 1 9-A"/Co.
Name of Ucensed Plumber
INSURANCE COVERAGE:
I have a current flabillity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Er No 0 10
If you have checked ves. please indicate the type coverage by checking the appropriate box
A liability insurance policy Other type of indemnity 0 Bond 13
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature his permit application waives this requirement.
Check one:
56nature of Owner or Owner's Aaent Owner 0 Agent 0
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
knotMedge and that all plumbing work and in lation� ormed under the permit lssu!pl�for this application will be in compliance with all
lum ��,
pertinent provisions of the Massachusetts StatelP a apter of the erall Laws-
Titl e SLOMre of Licensed Plumber—,
City/Town Type of Ucense: Master gjj-�' Journeyman
APPROVED (OFF—ICE-USE ON Ucense Number 3
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BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
OOR
7TH FL,,d
8TH FLOOR
.0
Installing Company Name "'A 0 t'�Ee-r 'j,4 al M 4 T A e -0 Check one: Certificate
Address
0 Corporation
6 TW 1,'j5 -A) - Yr f4 0 a �A/ 0 Partnership
.Business Telephone k1f, Z -'-/ q 7 1 9-A"/Co.
Name of Ucensed Plumber
INSURANCE COVERAGE:
I have a current flabillity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Er No 0 10
If you have checked ves. please indicate the type coverage by checking the appropriate box
A liability insurance policy Other type of indemnity 0 Bond 13
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature his permit application waives this requirement.
Check one:
56nature of Owner or Owner's Aaent Owner 0 Agent 0
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
knotMedge and that all plumbing work and in lation� ormed under the permit lssu!pl�for this application will be in compliance with all
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pertinent provisions of the Massachusetts StatelP a apter of the erall Laws-
Titl e SLOMre of Licensed Plumber—,
City/Town Type of Ucense: Master gjj-�' Journeyman
APPROVED (OFF—ICE-USE ON Ucense Number 3
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Date..............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... a. 'I I . d . "e . ........... ... i .. ,- ... C .....................
...... ... . ..... ..... ..... ... ....
t k -Q WA U
has perTission;to perfo .... .......... t .... A.�-
. .... . .......... ......................................
wiring ift the building of ......... ��"J.3.. 0 ....................................................
0 A L) i V-,:' ^2 0.!�.f . ............ . North Andover, Mass.
at ... Q� ............. I ...............................
Fee ... Lic.NoJk.��a..De&.I.A../...
Check # 513 S-Q3c( ELECMICAL INSPECTOR
4439
TBECOAMONWEALMOFAMS4CHUSE77S Office U I
DEPARTAffAT0FPUB0CS4FE7Y - Permit No.
BOARDOFFMPREVEMONREGUIA7YONS527CM]2 00
4 Occupancy & Fees Checked
APPLICATIONFOR PERMM TO PERFORM ELE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Da S-03
Town of North Andover To the Inspector of Wires:
ne undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) ry a- 14 �� 0,1 AV
Owner or Tenant L51
Owner's Address
Is this perinit in conjunction with a building permit: YeSEZI-No (Check Appropriate Box)
Purpose of Building P14 Utility Authorization No.
Existing Service Amps Yolts Overhead Underground M No. of Meters
New Service Amps Volts Overhead Underground r --J No. of Meters
Number of Feeders and Ampacity I
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
5
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
e ow
Generators
KVA
Unrl
aro [::]
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Bu ers
FIRE ALARMS No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. ofDetection and
No. of Disposals
No. of Heat Total Total
Pum s
Tons-
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal r ---J
F7Connections;
Other
No. of Dryers
Heating Devices KW
L --J
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER-
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INSURANCE BOND OIFER ?=se Spxfy) 14,1,Z4 �-V
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and d-Aniysigmkueonftpemtapphcmmvm'vesftieqa*ffmncm
(Please check one) Owner r7 Agent F-1 Telephone No. PERMIT FEE 3�
Signature ot Uwner or Agent
The Commonwealth of Massachusetts
Department of IndusMal Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
r—Name Please Print
Name:
Location:
cily Phone #
I am a homeowner performing all work myself.
I 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
Phone
Insurance. Co. Policy #
Company name:
Address
CibL Phone
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 $1,5W.00
andfor one yearr.'iniprisomnent-as-weU-as-chM,penaftiesiolhelxxmjdA-STOPYdC)RK-ORDER-and-afkw-d-($IjUDM)-aAayAgairamm.- I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
do hereby certify undgr the pains and penafties of pedury that the information provided above is ftie and corred.
Signature Date
Print name Pho e.#
Official use only do not write in this area to be completed by city or town official'
City or Town Perrrd1licensinq
Build
Ing Dept
[]Check t immedibie response is required .0 Licensing Board
E] Selectman's Office
Contact person. Phone#.- E] Health Departrnent
Other
Date. �/ -. x�. .,- .-I
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING.
This certifies that . P,�' e, F)/) L. 4 ^7 //
........... ! ..... ...... I
has permission to perform ... �-q. �., .". : . ! ..............
plumbing in the buildings of . .......................
at ... � ... AV: ............. North Andover, Mass.
Fee. Lic. No./.). . ....... L .......
tPLUMBING INSPeCTOR
Chedk # / I/ '/ /
5579
1� 3 Z -9 -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
WHIAGIA91TAW11
e of Occupancy 's / /y 6 L' 6�
Date
Permit #
Amount
New E] Renovation 031"- Replacement 1:1 Plans Submitted Yes 1:1 No 1:1
(Print'or type)
InstallingCompanyNam
Check one:
Corp.
Partner
r7V'11
Firm/Co.
NameofLicensed Plumber: b1q(jMKA1
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Er Other type of indemnity El Bond
Certificate
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
SignEure Owner n Agent []
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 win be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By: SignaLure of Licens
Type of Plumbing License
Title / 1 6�--2 / 61
City/Town License Numoer - Master Journeyman
APPROVED (OFFICE USE ONLY I
V
15
(Print'or type)
InstallingCompanyNam
Check one:
Corp.
Partner
r7V'11
Firm/Co.
NameofLicensed Plumber: b1q(jMKA1
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Er Other type of indemnity El Bond
Certificate
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
SignEure Owner n Agent []
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 win be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By: SignaLure of Licens
Type of Plumbing License
Title / 1 6�--2 / 61
City/Town License Numoer - Master Journeyman
APPROVED (OFFICE USE ONLY I
V