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Home My WebLink AboutMiscellaneous - 28 WATER STREET 4/30/2018to Date . 7' ..'. `;'/... ..... . TOWN OF ORTH ANDOVER o _. • PERMIT FO GAS INSTALLATION o7 s : • o " "ISy 1 This certifies that ....f! j has permission for gas installation. � ; -V-�"�� ...... in the buildings of ...:- ........... ...........v ...... . at 1� ............. , North Andover, Mass. Fee .`... Lic. No..*.#W. .��✓:�..... . GAS INSKCI'OFi'� Check # 121 6792 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:. �L► Date: Building Locatic..., 1X1 - Type of Occupancy: Commercial New: Iteration•. Renovation: Educational iinj Permit# Owners Name: Industrial Institutional Residential Replacement: Plans Submitted: Yes No I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 1es :No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. ility 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent By checking this box ❑; 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 unper the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chaptgr �42 of the General Laws. By Title City/Town APPROVED (OFFICE USE ONL Type of License: Plumber Gas Fitter aster Jo an LP Installer Signature of Licensed mberlGas Fitter i% License Number: ` --� / LA FIXTURES U) w � Z L" Uj 0 X Uj m Of 0 La J X O U C0 F- Uf 1-- W Z H w Q w ZW < m F' fn X O W O F- Q 0 O O W Z F- Q U) U Z W ! f 0 0 W U) a- O F- < w o W = J U X n. E >�- v w z w O -� lW- z l= o z z tW� W O z I- -� O w W uF�J w w o 2 n U I O u_ Q i� C9 w ='= uaJ < J O d W W IW- >>3: Q<<_ O SUB BSMT. BASEMENT 1 FLOOR --2 'FLOOR 3 PD FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 11 `FLOOR 8 FLOOR Installing Company Name: Check One Only Certificate # Address: �'J? MiA'tiCils�h-� City/Town:A� State. - Partnership .1..... Business Tel: (1774 4-76-54adCell: Zip Coder Fax • ,� irm/Company Name of Licensed Plumber/GasFiitter:,... I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 1es :No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. ility 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent By checking this box ❑; 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 unper the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chaptgr �42 of the General Laws. By Title City/Town APPROVED (OFFICE USE ONL Type of License: Plumber Gas Fitter aster Jo an LP Installer Signature of Licensed mberlGas Fitter i% License Number: ` --� / LA Town of Andover Massachusetts (Office Hours 8:00 A.M.to 10:00 A.M.) Gas R Plumbing Fees Effective March 12, 2003 ❑ NFiv: New Construction and Additions ❑ RENOVATION: Plumbing within the existing system ❑ _REPLACEMENT: Removal and replacement of a fixture to the existing piping *ALL TENANT FIT -UPS ARE CONSIDERED "NEW" PLUMB NG FEES New Domestic Construction — up to 3 Uuits $100 plus $5 per fixture DNEW New Domestic Construction — 4 units or r :ore $200 plus $5 per fi=xture DNEW Renovation (Domestic) $50 plus $5 per fixture DREN Rep] acement (Domestic) Existing Fixtures ONL $10 plus $2 per fixture DREP Backflow Preventer (for boilers) $10 plus $2 per fixture DREP Backflow Preventer (for irrigation systems) $25.00 DBS{ New Commercial /Industrial $200 plus $5fixture CNE)AI Commercial — Renovation .Per $100 plus $5 per fixture CREN Commercial Replacement — Existing Fixtures ONLY $50 plus $5per' fixture CREP Backflow-Preventer (for boilers) $50 plus $5 �er fixture CIREP Backflow Preventer (for irrigation systems) $25.00 C AK Re -inspection Fee $25.00 TYSP GAS FEES New Domestic Construction — up to.3 Units $75 plus $5 pera S50lus $5 pera liance liance DNEW New Domestic Construction — 4 units or Bore 5150 plus $5 p6ra Iiance DNEW Renovation (Domestic) $50 plus $5 pera $25.00 liance DREN Replacement (Domestic) Existing Appliances ONLY $20 plus $2 perappliance- DREP Gas Boiler / Fumace / Conversion Burner (Domestic) $50 plus $5 pera liance DREN Ne' w Commercial/ Industrial $150 plus $5 pera liance CN -EW Commercial — Renovation $100 plus $5 per_appliance CREN Commercial Replacement — Existing Fixtures ONLY $50 plus $5 pera liance CREP Gas Boiler / Furnace / Conversion Burner (Commercial) $100 lus $5 era liance CREN MISCELLANEOUS Gas Lo /Fire Place S50lus $5 pera liance DREN Gas Stow/Heater $50 plus $5 pera liance DREN Utility / Bar Sinks $10 plus $2 per fixture DR -EP ' Capped Sewer Lines $25.00 SCAP I Re -inspection Fee $25.00 INSP ._ "`' ' ese-, fees are llsed It the pernjif tic for tnic xvnrl- ne,:v 'i flir, ,D� rnif includesc nith hart-� {-tel [� L f .. _ J - i �..J V ei pl UllA l/i�b YtiQl ll, ! fee charged will be the fixture fee z,,•hick appears under renovation, replacement or new work ($2.00 or $5.00) ' O 04P TIIriIII unwralt4 of Massar4uaetts Office Use Only Department of Public Safety Permit No. BOARD OF FIRE PREVENTION REGULATIONS 27 CMR 12:0091 �� Occupancy & Fee Checked,% 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with t Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INF/ORRMATION)) �J/� Date— City or Town of ti �� ! (/ Y f/(A V� To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) _ LV Owner or Tenant Owner's Address 2_ _ l / _/ / _ oef� �Q ulop, Is this permit in conjunction with a building permit: Yes I� No L� (Check Appropriate Box) Purpose of Building 1 / I L �f Utility Authorization No. t&` Existing Service /UD Amps ;20 / � / y Volts Overhead RrUndgrd F-1 No. of Meters New Service Amps Volts Overhead 101�Undgrd ❑ No. of Meters Number of Feeders and Ampacity t Location and Nature of Proposed Electrical Work S- 50016% OTHER: ),w— INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. YES ❑ NO ❑ ! have submitted valid proof INSURANCE ID"BOND ❑ OTHER❑ (Please Specify) ARK X 1 60 ' PdL16 y f CO 090Ya Estimated Value of Electrical Work $ U Wprk to Start I U -31D Inspection Date Requested: Rough Q Final Signed under the penalti s of eriury: FA 1�206T Date) FIRM NAME A) - t -E �~T G LIC. NO. -60( .Licensee — 'q Signature G LIC. NO. .006 3 6 Address � �' oda Bus. Tel. No. Alt. Tel. No. .OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that m�signature on this permit application waives this requirement, Owner Agent (Please check one) �P Telephone No. PERMIT FEE $ (Signature of Owner or Agent) TOTAL No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA 0 Above in 11rnd. ❑ No. of Lighting Fixtures SwimmingPool rnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets 19- J No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices. ' Heat Tota Tota No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices / No. of Dishwashers / 5 ace/Area Heatin KW Municipal ❑Other No. of Dryers 7, Heating Devices KW Local❑ Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: ),w— INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. YES ❑ NO ❑ ! have submitted valid proof INSURANCE ID"BOND ❑ OTHER❑ (Please Specify) ARK X 1 60 ' PdL16 y f CO 090Ya Estimated Value of Electrical Work $ U Wprk to Start I U -31D Inspection Date Requested: Rough Q Final Signed under the penalti s of eriury: FA 1�206T Date) FIRM NAME A) - t -E �~T G LIC. NO. -60( .Licensee — 'q Signature G LIC. NO. .006 3 6 Address � �' oda Bus. Tel. No. Alt. Tel. No. .OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that m�signature on this permit application waives this requirement, Owner Agent (Please check one) �P Telephone No. PERMIT FEE $ (Signature of Owner or Agent) SCG ( � r, w #,z— e9 k Z I7— CD"J '1,... db t 2?- 61v1� in k,�:,fl 0 ro aw jo 9�r azr Apxcz 0. A*oc P444Z oft A46 P2PP-04'oeX4T` Sw — asc Me-7ri2 "IV X900 94&- e L - &%w o to r� e4cow /� Date. PAC. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... �tr 6 ... " has permission to perform .q 1 %g ... 0.1 /3 . .. wiring in the building of.....�' .... ... P,644 6:1-W..j !.^............................................................ ' ... f rX-X...T ..... North Andover, Maass. Fee../ ...4 "Sq,Lic. No.,. ��.9. . .........................................,J {-......... ...... qgg ELECTRICAL INSPECTOR Check # JA� 04t (foin tmII1Z1 eatt4 of Massar4usPtts Offiic"e' Use Only Department of Public Safety Permit No. r✓ BOARD OF FIRE PREVENTION REGULATIONS 27 CMR 12:00.�� Occupancy & Fee Checked 3/90 (leave blank) / APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with t Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) j� Date. � D City or Town of / & r/ ' e/A/ re vcTo the Inspector of Wires: The undersigned applies for a permit to performtheelectrical work described below. Location (Street & Number) "�O fi` ,i Owner or Tenant G— l Sf� 00 0 Owner's Address In d /�J� �/-� _ _ Is this permit in conjunction with a building permit: Yes L J No ❑ (Check Appropriate Box) %J Purpose of Building EH r/ (f Utility Authorization No. . c;? f 6 3 3 / Existing Service / U� Amps /�� /, 0 / I (y Volts Overhead LJ Undgrd F] No. of Meters New Service Amps X � Volts Overhead Undgrd 1:1No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work kE)Q00,E E 5f_79V1(_T Fle, 119A1VR O/S(_CWV-C(f j OTHER: �f"� MAO` �J O °! INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ ! have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE E BOND ElOTHER❑ (Please Specify) YORK 60 � COL ICY 'A CoS oon3o�a j-63koc Estimated Value of Electrical Work $ 5-00 (Expiration Date) Wprk to Start D Inspection Date Requested: Rough a Final C Signed under the penalti s of erjury: FIRM NAME NLIE -`ECTG LIC. NO. ;�rT'0 063,0 Licensee m. s �(��Mz nature ly_ G- LIC. NO. 5D 06 3 G� Address / 0 �s. C) - Bus. Tel. No. 1 � a RkOOC% Alt. Tel. No. ,OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and thatm signature on this permit application waives this requirement, Owner Agent (Please check one) �9 Telephone No. PERMIT FEE $ MTV (Signature of Owner or Agent) TOTAL No. of Lighting Outlets 0 No. of Hot Tubs No. of Transformers KVA 0 Above In - ❑ ❑ No. of Lighting Fixtures Swimming Pool gmd. grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets 5— No. of Oil Burners Battery Units No. of Switch Outlets /0 No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and • Total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices. No. Disposals '' Heat Total Tota No. Pumps Tons of of KW No. of Self Contained Detection/Sounding Devices j No. of Dishwashers / S ace/Area Heatin KW Municipal 11 No. of Dryers 7. Heating Devices KW Local❑ Connection Other No. or No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massae Tubs No. of Motors Total HP OTHER: �f"� MAO` �J O °! INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ ! have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE E BOND ElOTHER❑ (Please Specify) YORK 60 � COL ICY 'A CoS oon3o�a j-63koc Estimated Value of Electrical Work $ 5-00 (Expiration Date) Wprk to Start D Inspection Date Requested: Rough a Final C Signed under the penalti s of erjury: FIRM NAME NLIE -`ECTG LIC. NO. ;�rT'0 063,0 Licensee m. s �(��Mz nature ly_ G- LIC. NO. 5D 06 3 G� Address / 0 �s. C) - Bus. Tel. No. 1 � a RkOOC% Alt. Tel. No. ,OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and thatm signature on this permit application waives this requirement, Owner Agent (Please check one) �9 Telephone No. PERMIT FEE $ MTV (Signature of Owner or Agent) Date. � �14� . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSAC� This certifies that �-' t. . V'X I ....... .......... ( 3haspermission to perfmA1C.•........ . plumbing in thebuildings of . '4' (�N ...... at . ?� h. v!� . ��...... ............... . North Andover, Mass. Fee. Lic. No..'2?/'?7tT ............................. . ,( PLUMBING INSPECTOR s Check # C-�J /jl( G1r-5)- MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location WA4 R `sl NIFORM/APPLICATION FOR PERMIT TO DO PLUMBIP Date )w er Name / / A AAIN ' D V (o1 A S Permit # Amount ofccuoancv Renovation � Replacement New 1:1 ❑ FIXTURES Plans Submitted YesNo ❑ (Print or type) Check one: Certificate Installing Company Name -TA M t S >? �� N� Pt ❑ Corp. Address 7q Rn Ay- sl Partner. :::361P M . A/ -{ 3071 Business Telephone' ( 90 3) q97- St s A�5 ® Firm/Co. r Name of Licensed Plumber: SA ft, S 61Z'C'N r ` Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ML4j 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 Owner ❑ 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 his application will be in compliance with all pertinent provisions of the Massact�e is State P1umflVg- arad-C--hapi r 42 of the General Laws. VED (OFFICE USE ONLY TjVof Plumbing License a I se Num �c�eum ❑ ser Master Journeyman Location C:�,; ` czf Z No. Ad Date MORTN TOWN OF NORTH ANDOVER • 4 0 9 + Certificate Occupancy of $ sACMUSE Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1,2 9,i r /\ f 7 k 2 4 /-Z:z B— ing Inspector ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCTREP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / DATE ISSUED: SIGNATURE: Building Commission for of Buildings Date - !�—o SECTION 1- SITE INFORMATION 1.1 Property Address: AG -),g T Assessors Map and Parcel Number: dt�i Map Number Parcel Number 16,kTH 4 A W 0( E k 1.3 Zoning Information: Zoning District Pr osed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RequiredProvided Required Provided 11 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 OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record LISA T)b (A= 6 --S 8 LOP -Ek &I : , AJ, A106 0 E R, Nathe (Print) I� a Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele one 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 PAV 1T) CkSTRU e NJ E Not Applicable 0 /0 �� / 0 Company Name ' I n� 0 O S u -7—T -6/V t5 I, S to i % F A A � Registration Number A ��•q2g—,l k2'" 7� t^ Expiration Date—� Signature Telephone 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 inpermit. -Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check afl a 6cable New Construction ❑ 1 Existing Building V I Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑ Accessory,Bldg. ❑ I Demolition ❑ I Other ❑ Specify t Brief Description of Proposed Work: sTpu P f KF- R,o o F I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Com feted by permit applicant I . 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 A�j 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH DING 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, V 1 S T -P f G p M ,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 'D 12 c. C-0 PPame N ( �i1-Q.. Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS 1 s 2 ND3 RD SPAN DEVIENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 0 ri Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 104569 Expiration: 7/1.4/2004 Type: Private Corporation DAVID CASTRICON£ RQbFING,.S inidr ravetastricone 7 Hillside Road Boxford, MA 01921 Administrator =-1• �� The Commonwewrth ofMassachusetts 4 Depantwnt of Industriaf ucidents Office ofInvestigations 600 Washington Street (Boston, 9KA 02111 Workers' Compensation Insurance Affidavit APPLICANT INFORMATION / Please PRINT Legibly Name: LISA D d (/t , L—A Location: Z/' -- 42.9 019 R 97—, City: N6, AkD d VEE Telephone #:_ 2 % ❑ I am a homeowner performing all work myself. ❑ I am sole proprietor and have no one working in my capacity ❑ I am an employer providing workers' compensation for my employees working on this job Address: Al I )Q n„ �E L =i2 Al ---S L, City: b f-T/J A/V 0a V F— 1k Telephone-#: Insurance Company: PUY, 1— g wU' AtLi /v Cj1 l Policy #: / k f 2 r d 6 ❑ I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: ` City: Insurance Company: 1. Telephone #: Policy #: Company Name: Address: City: Telephone #: Insurance Company: Policy #: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B 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 hereby certi under a pains and penalties of "perjury that the information above is true and correct. r � Signature: Date: f E� JA• Official Use ONLY - Do not write in this area City or Town: Permit/License #: P Check if Immediate response is required Phone # L� — z 4,,2, 0 ❑ Building Department o Licensing Board ❑ Selectmen's Office o Health Department ❑ Other INFORMATION & INSTRUCTIONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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 including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 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, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or, license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call'the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Fax # (617) 727-7749 Telephone # (617) 727-4900 ext. 406, 409, or 375 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-954 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: W A TTSK - l (Location of Facility) ST6 TE LiA1 % C 6 np-7-AW� SEEM IV& f Signature of Permit Applicant 1J1,/b � Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector / • O z 0 W TIP" C O = C H R ��L: y O m Z lo. 'O cm"o aCr .mor �cc Z O. ce CL 0 w o$ -0,r'CO z ca DI =4- O ti CXOw 'O V cm -0 C ®yon C O` Z .9 d 4- E V Z h p N C co m Cf C 0o 0 C N CD t 0 z O Q zoo z 0 w a �I CD O C■ _O CD z CL O y C C co C! i O O CA 0> ac h co 0 CD CL .0 O � 10 IS O d 2L cmcc S c� .FL O CD o a C.3 c ev e c— '� E c CLCO2 Ul 0 LLI U) 19 W W cc ujW U) w° >. cin w° a�' U w W w�' w GG w c9i w F+ w�' w W A x w W 6 z cn cn C O = C H R ��L: y O m Z lo. 'O cm"o aCr .mor �cc Z O. ce CL 0 w o$ -0,r'CO z ca DI =4- O ti CXOw 'O V cm -0 C ®yon C O` Z .9 d 4- E V Z h p N C co m Cf C 0o 0 C N CD t 0 z O Q zoo z 0 w a �I CD O C■ _O CD z CL O y C C co C! i O O CA 0> ac h co 0 CD CL .0 O � 10 IS O d 2L cmcc S c� .FL O CD o a C.3 c ev e c— '� E c CLCO2 Ul 0 LLI U) 19 W W cc ujW U) Location C26, No. .2 ' / Date / U Jai /car MORT1y TOWN OF NORTH ANDOVER O.�t�w y,tiO L • a . Certificate of Occupancy $ CMUst<�' Building/Frame Permit Fee $ D Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 0 C) Check # 14S—D i 7747 Hwy `b,- -� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR. RENOVATE,OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUELDING PERMIT NUMBER: a DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: S0+1. . 1.2 Assessors Map and Parcel Number: b b a Map Number Parcel Number Ayt" /0, ` � A6104, 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS fit Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.3. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zane ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT -� ;�r:c,r;c ;strict: Yes Nn 2.1 Owner of Record me tAddress for Service O 1415' 00Iv lot gni ignature Telephone 2.2 Owner of Record: Name Print Address for Service: Si re 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 t' Registration Number Address k Expiration Date Sigrmature _ Telephone MA SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check ao a cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: a 01 Ole of &ALC tbm6tna lfisKL at SECTION 6 - ESTMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by pern-dt applicant Oi?'h'ICLA]. USE ONLY 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 f G SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property 17WHereby to act on M b al ; in all rs rel rve to:wor;k;authoriLze�ildurgpermit applications`' r iatu a of elf 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/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS is 20 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DRAENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRvINEY 1S BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax Please print. DATE JOB LOCA Number Town of North Andover Building Department 27 Charles Street 'y� North Andover, MA. 01845NA111 iss4cHuSE� HOMEOWNER LICENSE EXEMPTION St, Q Map / lot 04-1 "HOMEOWNER I" AM 4 Name HoMe PhoneX ��l 3� Work Phone r PRESENT MAILING ADDRESS 2.8 Ai"" ` r `S -f - City Town State The current exemption for "home6wriers" was extended to include owner -occupied dwellings of two 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 108.3.5.1) 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 or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. 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 helshe understands the Town of No. Andover Building Department minimum inspection�rocedures and req, . ents and that he/she will comply with said procedures anc, requiy�,/ir ents. HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFF Zip Code The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 - Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # F-1 I am a homeowner performing all work myself. F-1 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 Comoanv name: Address City: Phone # Insurance Co. Policv # Company name: Address City: Phone # Insurance Co. Policv # 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 yell.as_civil..penaltiesinlhefmnd a..ST.OP.W. ORK..ORDER..and..a.fine.of.(.310.0.00.) allay 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town PermitlUcensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: �-Q m -o i'e. 1A�J-1f_&Vef1s .Al f� — (Locati of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector GI Y- 1) r� or') 7 ui c w- � c C CJ v .�� nc m c s E� ol CD O•Ey me E h O Lob y h = i h 00 ' �: •gip N Z Em ♦'� a o CJm � C C • m O m �. cmad,0 o vac b 0 CL c Lc� CL Q � y c •C = m ;ago s y�z8m w NJ O C_,,,LA- v.. H •w � = m C Z •E v � m O V m � � � C F• C* a m O� = W DO z �a�COD a F-;,4 Cf)* z 0 U U) U) 19 W W 19 W LUN o a a H w w w a � A vii w° U w w w w w r ra o z cn vii ui c w- � c C CJ v .�� nc m c s E� ol CD O•Ey me E h O Lob y h = i h 00 ' �: •gip N Z Em ♦'� a o CJm � C C • m O m �. cmad,0 o vac b 0 CL c Lc� CL Q � y c •C = m ;ago s y�z8m w NJ O C_,,,LA- v.. H •w � = m C Z •E v � m O V m � � � C F• C* a m O� = W DO z �a�COD a F-;,4 Cf)* z 0 U U) U) 19 W W 19 W LUN