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Home My WebLink AboutMiscellaneous - 280 CANDLESTICK ROAD 4/30/2018 (4)m C6 'I This certifies that ...... P')" has permission for gas installation ... in the buildings of ... at . �29& - - �- Fee . Lic No Check # —jxs�- 8720 ................ .......... North Andover, Mass. GASINS4PECTOR Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... P')" has permission for gas installation ... in the buildings of ... at . �29& - - �- Fee . Lic No Check # —jxs�- 8720 ................ .......... North Andover, Mass. GASINS4PECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE JA,:� 3 CITY L_LV _1 Q j PERMIT# JOBSITE ADDRESS �'��OWNER'S NAME GOWNERADDRESS I TEL FAX TYPE OR OCCUPAN TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: 7RENOVATION: Ej REPLACEMENT: PLANS SUBMITTED: YESFJ-j N 0 APPLIANCES I FLOORS- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 1 13 14 BOILER BOOSTER CONVERSION BURNER ..... . . . . . . ------ COOK STOVE DIRECT VENT HEATER A DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR . . . . . . GRILLE INFRARED HEATER =F= -=j FF --- LABORATORY COCKS MAKEUP AIR UNIT OVEN . . . . . . . . . . . . . . . . . . P OL HEATER ROOM / SPACE HEATER RODF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER . . . . . . WATER HEATER '-j 6TH -ERF J I INSURANCE COVERAGE MOL. Ch. 142 YES ffN'O I have a current liabilily nsurance policy or its substantial equivalent which meets the requirements of I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY B 0 N D F --j1 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 .0-1 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 wil in mplian it 11 P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LICENSE# PLUMBER-GASFITTER N� SIGNATURE KAP El MGFE--JI J P OR ORATION C]4 PARTN ERSH I P D# LLC [-]'# JGF Gl� C� COMPANY NAME: 'iADDRESS STATE ZIP ]TEL CITY E' 2- -2j�� FAX CELL AILL GOD 0 El Z r-1 co� cn co w co pro co z 0 rA co t.- LL rA 0 u w P-4 rA n 0 , The Commonwealth ofMassachusetts Department of JndustrialAccWnits Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizatiordfndividual): Address: 4 (,1 e_ 1_\ ,5 1 Phone#: 64!�� 3 3 '7 F�� City/State/Zip: 411 Are you an employer? Check the appropriate box: I - El I am a employer with 4. F1 I am a general contractor and I e oyees (fall and/or part-time).* have hired the sub -contractors 2.1 am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3. 1 am a homeowner doing all work E] right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. E]New con.straction 7. FJ Remodeling 8. E] Demolition 9. F1 Building addition 1011 Electrical repairs or additions ILEI Plumbing repairs or additions 12.F] Roof repairs 13.[i Other *Any applicantthat checks box#1 mustalsofill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employ er th at is pro viding workers ' compensation insuran cefo r my employ ees. Belo w is th e p olicy an djob site information. h / / 4 Insurance Company Name; Policy # or Self -ins. Lic. 9: Job Site Address:. Expiration Date; �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 requiredunder 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 imprisomnent, as well as civil penalties in the fonn 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 certW hnd4, the that the information provided above is true and correct. Official use only. Do not write in this area, to he 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. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire express or implied, oral or written." An employer; is defiried as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivi '-sions 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 out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents. for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate Eno. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennit/license applications in any given year, need only submit one, affidavit indicating current policy information (if necessary) and under "Job Site Address?" the applicant should write "all locations in -(City or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit iion file for future permits or licenses. A new affidavit must be fille�d 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 faxnumber: The Commonwealth of MaSSae ,_hV S p _,ttS Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 __WWW-Mass.goV1dia Date ...... 4 � � //..v .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... k.L.� ........ (.?V I/I.-C .... ....... ............. has permission for gas installation ... in the buildings of. ................ ................ Lic. Check# 9.334 ..................................................................... ............ . No b Andover, Mass. ...... . . ... ..... .................................. 01 4i�OR IN�NSPE MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY t�= MA DATE 14 4 JJPERMIT# JOBSITE ADDRESS �OWNER'SNAME GOWNER ADDRESS TE _=FAX[ TYPE OR PRINT PE COMMERCIAL EDUCATIONAL RESIDENTIAL OCCU P CLEARILY NEW. ;7RENOVATION: El REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO [3 APPLIANCES -1 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOKSTOVE ---J. DIRECT VENT HEATER ----- ..... ..... DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS . . . . I . . . . . E -:Z3 MAKEUP AIR UNIT OVEN POOL HEATER A II ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER INLINVENTED ROOM HEATER WATER HEATER I--- J —dT—HERF . . .......... ... ..... r-1 f I INSURANCE COVERAGE I have its the MOL. Ch. 142 YESPN'O D a current liability nsurance policy or substantial equivalent which meets requirements of I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Fj—.1 OTHER TYPE INDEMNITY Ej 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 0 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 complia ewilhallP n ng t�he �p r4 Zi�of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. K) --" A - PLUM BER-GASFITTER NAME LICENSE SIGNAI IRE MP El MGF El JP 'JGF LPGI CORPORATION PARTNERSHIP El#= LLC E1# COMPANY NAME: ADDRESS CITY ZIP TEL STATE[� FAX CELLE7] k rA 0 F] z F, Of) ui IL u w X W Cl) CL LU 0 i� LU V) z 0 Lf) IL a- 00 LLJ LL. rf) The Commonwealth ofMassachusetts Department of JndustrialAccid�nts Office of Invesilgations 600 Washington Street Boston., MA 02111 kvi www.mass.gov1dia Workers' Compensation Insurance Affidavit: BuildersfContractors/Electricians/Plumbers ApOcant Information Please Print Legib NaMe (Business/Organization/Individual): c, /, I -C 'e, Address: 1.4 ec-��wt Z4 e4C_)(_ City/State/Zip: M Phone D4 Are you an employer? Check the appropriate box: 1. a ployer with 4. El I am a general contractor and I e =es (fall ancVor part-time).* have hired the sub -contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. F1 New con ' struction 7. n Remodeling 8. E] Demolition 9. F1 Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12.0 Roof repairs 13FJ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aire doing all work and then.hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' information. 1J " Insurance Company Name:. ri 4 L Policy # or Self -ins. Lic. #; insurance for mv ein I ployees. Below is thepolicy andjoh site Expiration Date: Job Site Address: _,Citv/State/Ziv: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 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 h ereby certify u4def the palq ailft eglills, ofperjury th at th e information provided ab ove is true and correct Information and Instruction -S 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 ofhire,- express or impli4 oral or written." An employer'Is defined as "an individual, partnership, association, corporation or other legal entity� or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity� employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local lie-ensing 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 subdivi , sions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contraotor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. he affidavit should be returned to the city or town that the' application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas ' a be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one, affidavit indicating current policy information (if necessary) and under "Job Site Address"' the applicant should write "all locations in -(City or town)." A copy of the affidavit that has been officially stamped or marked by the city 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 p* ermit to bum leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations . would Eke 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 1\41assach-usetts Department of Industrial Accidents Office of Investigations 600 Wasbington, Stmet Boston, MA 021 It Tel, # 617-727,4900 oxt 406 or 1 -877 -MSS AF Revised 5-26-05 Fax # 617-727-7749 This certifies that -.e ... ............................ has permission to perform . . h�'. -. �� ..... ��': / ................ wiring in the building of .... A,� ............... at.;?.,�� . . ....... , North Andovet� Mass-?, Fee P- Lic. No. 32:2,lerXE7. . -r .. ... eTolE�ECTRICAL INSP /CTOR Check # 11098 <L Official Use Only Commonwealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM E E MI^AL WORK All work to be performed in accordance with the Massachusetts Electrical Cod� C) 5277 12.00 (PLEASE PRINTEVINK OR TYPE ALL INFORMATION) Date: CityorTownof. NORTHANDOVER TO the inspectorof Wires: By this application the undersigned gives notice of his or her, tention to perform the electrigal work described below. Location (Street& Number) Z-80 ��Mes�IC4 Ro Owner or Tenant 1t1,06,, 4 Telephone No. Owner's Address r-tv- Is this permit in conjunction with a building permit? Yes jn� No (Check Appropriate Box) Purnose of Buildine Utility Authorization No. - Existing Service Amps Volts Overhead 1:1 New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead 11 Undgrd Undgrd No. of Meters No. of Meters Completion of the following table may be waived bv the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of 'rotal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above El In- Swimming Pool grnd . grn No. ot Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo. of Zones No. �of Retection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices Hea ........... No. of Self -Contained No. of Waste Disposers .).er J.KW ........... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW [:] MunicipFl n Other Local Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices o.r Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: Attach additional detail i(desired, or as required by ine spectur vi es. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCf -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 cov undersigned certifies that such s in force, and has exhibited proof of same to the )ermit issuing office CHECK ONE: INSURANCE BONDE] OTHER [I (Specify:) e I certify, under th insand e alfielo I I ��Iylsa�p'!Iica ton ids ueandcompl V, M�ft a t I * rfi rination on i t;7 2a45 .0 FIRM NAME: LIC. NO.-. Licensee- Signature7,60J y�goh LIC. NO nt. Owner/Agent Signature Telephone No. PERMIT FEE.- $ C'w C;�' /,a - _ EVEM 9SA- h8pactore Die la ?111.14 VJ-4 fo— V-apv eafore fflpaftwa - 3ao Wff als) --- pate, -ia-sicaL (-7411 7 - L, C -t Date ;. MAP, MOM -WROCTION. )),ate. OAM CAI 'Y'R, -D WAUTONM� C-90-131; NAME: Pate actoys, . covame.ats. 2-/j 4 - Zc, 9�—IJ, n*R TA 0-.q A'PV. MTV A-r%Tn W.W.are n*W.QTTV. W Tnw. AP.*W,& rVa TIV, MqP'P.PrP-O:n T.9 vn7l The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers vi)licant Information Please Print Legibl, Name Address: vo- City/State/Zip: Phone #: (3 e� Are you an employer? Check the appropriate box: El I am a employer with 4. El I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2/<l am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3. 1 am a homeowner doing all work E] right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. R New construction 7. E] Remodeling 8. E] Demolition 9. R Building addition ME] Electrical repairs or additions I L R Plumbing repairs or additions 12.E] Roof repairs 131� Other *Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 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. f do hereby cer% under the pains an alliesy ormation provided above is tuy and correct ,O,p� fperjury that the inf Phone #: Official use only. Do not write in this area, to he 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. Plumbing Inspector 6. Other Contact Person: Phone M 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, 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 br other legal entity, employing employees. However the owner of a dwelling house having not more than three'apartments and who resides ther'ein, 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 commonwealthnor 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this afFidavit may be submitted to the Department of Industrial Accidents for confirmation of *insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or town)." A copy of the affidavit that has been officially stamped or marked by the city 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. I 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 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia This certifies that. has pennission for gas installation ... eock� (?..,a ......... .in the buildings of. . . ........................... at..2 . . ....... .... North Andover, Mass. Fee Q-0 ZD Lic. No. .................... ... GASINSPECTOR Check 4 -� I -S I t- %- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE __IIPERMIT# J013SITE ADDRESS OWNER'S NAME GOWNER ADDRESS TE FAX TYPE OR OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL Eli RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 01 PLANS SUBMITTED: YES F-1 NO F-1 APPLIANC ES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER Ej COOK STOVE DIRECT VENT HEATER =A= DRYER FIREPLACE F-,. FRYOLATOR L—j FURNACE L --j ji GENERATOR GRILLE IL INFRARED HEATER LABORATORY COCKS IMAKEUP AIR UNIT . . . . . . . E -J -A OVEN I j POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE MOL. Ch. 142 YES JER 'NO D I have a current liability insurance policy or its substantial equivalent which meets the requirements of I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY B 0 N D Ell OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the IMassachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [:] 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I LICENSE KGNAVRE IMP MGF [---]I JP D JGF [: LPGI 1] CORPORATION PARTNERSHIP 0#= LLC [-If'# COMPANY NAME: ADDRESSF - jj --------- - CITY STATE�ZIP ]TEL FAX CELL MAIL )OW t- %- rA 0 u rA 4 91 0 z U) CL u w w 3: Ln w co CL 9 w m 0 co z 0 rn CL a_ < co COD The Commonwealth of Massachusetts Department of lndustrialAccWnils Office of Investigations 600 Washington Street Boston, MA 02111 Ut www.mass.gov1dia Workers' Compensation Insurance Affidavit: BuildersfContractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name Address: /2_51' -5 A -z-5: - City/State/Zip: o ?2rrt 4�7-0;12� 4,F�2d Phone #: Are you an employer? Check the appropriate box: 1111 am a employer with 4. 0 1 am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. T ship and'have no employees These sub -contractors have working for me in any capacity. S�rs' comp. insurance. [No workers' comp. insurance 5. B'Ve are a corporation and its required.] officers have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4). and we have no insurance required.] t employees. [No workers' .comp. insurance required.] Type of project (required): 6. E]New con.struction 7. E] Remodeling 8. 0 Demolition 9. E] Building addition 1011 Electrical repairs or additions ME] Plumbing repairs or additions 12.E] Roof repairs 13.[] Other A��W- *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjoh, site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: 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 requiredunder 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 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 certify under the pains andpenalties ofperjury that the information provided above is true and correct. 2,�-- �K,5- 4,, Official use only. Do not write in this area, to be completed by city or town offt"cial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:- Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enaployees. Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhire, express or implied, oral or written." An employerIs defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. ihe affidavit should be returned to the city or town that the' application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that m ust submit multiple penniVlicense applications in any given year, need only submit one affidavit indicating current Policy *information (if necessary) and under "Job Site Addrese" 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 p* ermit to burn 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 Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Teel, # 617-727-4900 oxt 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 __Www�mass,gov/dia 0 COMMONWEALTH OF MASSACHUSETTS 1BERVAN6.' A G- A, 714GENN 8 S S T U E'A OVE LICENSE CHR .1- ' 0� :0 s f"APA'DO 0)UL "475 ES AVE: 6* 'At t 14:0i 6' 9764 Date ... //- 1,4-16.2 ............................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ / .................................................... has permission to perform ............... r1k4 .............................. wiring in the building of ........... IAP&A..sen .......................................... at .... AR A4.4-.,5�.f ��K. 141 North Andover, Mass. Fee ... D�.. Lic. No.�2.e.f5� /,� ........... 1��L iN;�EC&R Check # S -F ( 7 I Commonwealth Of Massachusetts Department Of Fire Services leimit No. 7 rml FOccupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev -1/07] (,�_.,_IA 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 PRW IN NK OR TYPE ALL INFORAM TION) Date: I b City or Town of- NORTH ANDOVER To the 'Ior of Wires: By this application the gives notice of hi::� 11 "lier �intention to perform the electri . cal work described below. Location (Street & Number) Owner or Tenant �> V,-\V%L) ��o Telephone No. Owner's Address — Saw Is this permit in cOnjullction with a building permit? Yes El No F] (Check Appropriate Box) Purpose of Building S'� "\Sy- �- -) Utility Authorization No. Existing Service Amps volts OverheadEl Undgrd N—e- of �Meters New Service Amps ____L_Volts Overhead Undgrd No. of I Meters Nlvwnh. f r . � eeders and Ampacity Location and Nature of Proposed Electrical Work: > T)e�anr L No. of Recessed Luminaires No. of Luminaire Outlets of Luminaires of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers ---------- No. of Dishwashers No. of Dryers Heaters KW No. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above d. 0 No. of Oil Burners No. of Gas Burners No. of Air Cond. Tc Space/Area Heating KW Heating Appliances KW No. of No. of — Signs Ballasts INo. Hydromassage Bathtubs ---[!-O---Of ---Motors 101 �t�abvlenmray �bbewaived �by the �Ins ector —of Wires. iLransiormers KVA Generators KVA ALARMS INe. of Zone-. Of Alerting Devices tion/Alerting Devices -1municipal Connpetinn El Other No. of Devices or :a Wiring: No. of Devices or Total HP i ejecommunications No. of Devices or Attach additional detail Vdesirea, or as required by the Inspector of Wi Estimated Value of Electrical Work: -'7 02)0 S — (When required by municipal policy.) res. Work to Start Iri-Tections 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 licenseeprovides 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 23 BOND [3 OTHERE] (Specify. I ce?Wfy, under the pains andpenaldes o erjury, that the information on this application is true and complete - !fp FIRM NAME: CCZ j,C), C- k e ct-. t LIC. NO.: ao IED -0 Licensee: -, cc !()C) Signature (If applicable, enter "exempt,, in the license number line) LIC. NO.: Address: 1�-� &f -C -j SAC) 0 Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, Alt. Tel. security work requires Department of Public Safety 'IS,, No.: Ll 4 01 License: Lic. No. OWNER,s INSURANCE WAIVER: I am aware that the Licensee doe not hav required by law. BY my signature below, I hereby waive this requireme S e the liability misurance coverage normally Owner/A-ent nt. I am the (check one) [3 owner [:] ownes agent Signaturell Telephone No. PE"IT FEE. $ L, ri V/ The Commonwealth of Massachusetts Department of rndustrial Accidents Office of 1nvestigations .600 Washington Street kip Boston, AL4 o2111 www.mas&govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers App1icant Information Plea.se P - Name (Business/Organization/Individual): Address:- I jfaflp N�;�� City/State/Zip: SC�Us�j k --,f `�� Phone Arq you an employer? Check the appropriate box - I IJ54-ain a employer with L4 4. [] I ' am a general contractor and I employees (full and/or part-Vdine). have hired the sub -contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. workers' cOmP. insurance [No workers' comp. insurance 5 required.] 3-0.1 am a homeowner doing all work myself [No workers' comp. insurance required.] t *A-'. T;-_,+1 +_U - El We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.) Type of project (required): 6. F] New construction 7. El Remodeling 8. Demolition 9- Building addition 10 -0 Electrical repairs or additions I I - 13 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other -nowing _uun ve!ov� their woa-kemls� compensation Policy Homeo%-m= who submit this' afE-- —�'ie`_ davit indicating they are doing all work and then hire outside contractors must submit a ewaffi vit di ng such. -contractors and their workers' comp. i fo a 0 �Contractors that check this box must attached an additional sheet showing the name of the sub n da in rati Pol cy in rm ti n am an employer that is providing workers' compensation ursnrancefor my eMployees. Below is the policy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. # Lr7A_ Expiration Date: —1 u Job Site Address: C-r_-V<)(p City/State/Zip: L 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 M'GL c. 152 can lead to the imposition of c . riminal 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 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 certi under the pains and Penalties ofperjury thirt the information provided above is true and corre C_�) rr- — ct. Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Piumbing Inspector 6. Other t, ��C) 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, 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, §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 coxnpliance with the i'surance 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 work unlil acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town the, the applicationfor the perrait or license is being requested, not the Departme-wt of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' ' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city 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 Industrial Accidents Office of Investiagations 600 Washington St=t Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 wvm7.mass-gov/dia Date ........ . ... ....... ORTH TOWN OF NORTH ANDOVER 0 6 PERMIT FOR WIRING Leoxlq lej) ........................... This certifies that .............................................................. has permission to perform .... To-�*U ........ wiring in the building of ................... ..................................... . ............ ...... North Andover, Mass. Fee .... O�.5 .......... Lic. No..3YI� 7 kz�— ............ .................. i!!� ....... ........ ........ / ...... ELEcrRICAL INspEerc;R Check# 3 /40 cl 7398 ... Official ij.�c U1417 pt,. Occupancy and F CA Cheokdd [We,v I leave blatilt &I or-rUILATiONS 19-c" 011 BOARD OF FIRE pRF-VEN I TV M ELECoTRICAl- W"I'l APPLICATION FOR PERMIT T 0 PERFORI code 21CMR12.00 the MafiSaohl,,grttS fjCQtri9A — 7 rfortnedina,ccordaricc'"h Ali work to be PQ Date,. 1AIFORMA TION) To he Inspector of Wires' TYPE ALL 11, ,, ! (pL.6,4S,r pPjNT [IV INK QIR 0 n the Olecl work described bellow or ToWKk Oft I Tf T" 11010 1111� 111)'i ��11' *Fe� city e Ol WS Or e BY t1jis application the undersigned gives '10tic 0 Telephone et & Ntil Locating (Stre ... ro h C/ 09vuer or Tenant --------- .0t, ApPrOPIrla" 801) owner' a Address 111jildlyl permit? V ea No fk (rhe 1. rinfilmation With A 11tility A10007,eltlon 4 tilts perlm", Purpose 9t Building volts OverlICAd wrmatingServ,01 Amp" V010 overhga4l El AMP$ and A-111UP111-10 e— PIC o 4 ei� Numo [It vvork; pullf o r -e f P WO.—Of Recessed Luminaires No of L111131GRIM 011i1c"ta 'ro To No. of 1,uminalres Nor. of Receptfl Ontle" Ile No. Of r1witclics _ No. of Ranges I, IN .0 FA"l No. of CRII.-SM, ------- No. of Plot R 13 Pon -nd. No. Of 01 No- Of CAR ur ota No. of Air Cond. Tons t - — or ons No, of Waste Displ)flerl A.,S6 Space/Arfg fleeting KW No. Of 01shwAshers fleeting Applignelts KW No. Of Dryel's 0. o .toy l(W 401', ro_M�0;(Olt _J l'ool HP tubs NO-ofMO tOrs U.,J. Mal No. of Misters No, Of Mete" KVA .j., all 11k el,gll- y g I Ag atte units KRE ALARMS NO- of Z"W" In. of Alerting Devices 0. 0 0 � onto ne )Qt tion A r Devices "n c 001" AMR, vices or NO. of ic Data vviriog; INO, j OTHEW r of Wil olicy.) (When required by mililiciPA) P ulc 10, and Upon completion. Egimeted Vall1c Of jectrical Wo& rdance with MEC R work MAY issue unless Inslpections to be requested in WO for tile perfoirmaricc of electrical Work to Start: tial equivalent. The — . jiilga$ waived by %be owner, no p1wrillit subst4n INSURANCIAOMMA . on" coveXABO Or itq the licensot provides Proof of liability insurAnce includi"B "cOrnfitv"tcd OPOTat' I rMit issuing office, -in force, and has exhibited Proof Of 34mc to t le ' - Oil low r r u r qn Oe undorsigned certifies that such 00CM OT14ER C) (SPOcify:) true and,complam jNq URANCF, Cl,"13OND f Perjj4ry, �hal Ile j1!f0rjA4 an a" 1his applicaliftil is LIC. NO-. 197 CHECK ONE Pis and penaldes Q —LY -12 I rertb% ander the P40 LIC. NO,,. FIRM NAME: Signpliuce us. TO, Licensee: -------- — -------- wl_�� PH ap, Aft, Tel. No�:— (1fapplicable. enter re Pe the 11011.0c " b Lie. No, License: Address' Publi SafctY -once coverage normally *Per M.G,L, c. 57-61, security wOrk mqulrcs Dop doe, not have the liability insui r owner's a ont. oWNERIS INSURANCF, WAIVER, I aM More tilat the L'censef ent, I am the (aheck OnO Owne required by 1AW BY My SiPaWre below, I liereby waive this rcqulrcm PERMIT F EE-' owncriAgont Telephone No ------- Date ...... .... (14-n. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ......... ....... ........ ........................................ has permission to perform . .................................... wiring in the building of ...... ................................................ O%A) at X ................. :�4.; /6--a.-4147 ...... ..... . North Andover, Mass. Fee...I,'.'K� ... Lic. No . ............. ................ L C -4 Check # 58,17 11M wimmun VVEALdn Ur DEPAiU3fiM0FPE7A BawOFFREPREVEMN Permit No. Occupancy & Fees heck OR IZVO I C ed APPLICATIONFORPERMUTOPE,RFORMELE wo D Y/ IXJ7, / ALL WORK TO BE PERFORMED IN ACCORDANCE wrrH THE MAW'ACHUSSTS ELIXTRICAL CODE, M57 C�MMRM2:00 i (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover To the Inspector of Wires: Tic undersig I ned applies for a permit to perform the electrical wo , /described below. Location (Street & Number) a Owner or Tenant Owner's Address A -M Is this pernlit in conjunction with a building permit: UYes M No (Check Appropriate Box) Purpose of Building ne s c, Utility Authorization No. Existing Service Amps Volts Overhead Underground IM No. of Meters New _Service Amps_..L.Volts Overhead Underground Im No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No- of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIREALARms No. of Zones No. of Ranges No. of Air Cond. Total �3 Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating XW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER. IPD�,-Y%�hL ( - 0 &J,��< AC bstwxecovmw PowtiDdiem4naTuacfh4onwhaaCandLms rMENE1 1hne&ftrmWdvaidpwdofsMzloftOffi= YM drckk - - . , bmL INSUFCA� rM BOND" I WodcloStmt 1qxcdmDaleReqxWd Sgnedt��4�ftakksofpmiuv. FERMNANE Lic� 4ou -77�-,Om Vakjeofl3mWcalWcik $ F#W Li==Nd LAD TeL Na 11\% I.- I -.e --., V__- -V- . AILTeLNa OWMVSMRANCEWAM3k-Iammmdndrljomdpesmt xddaffq*0=cnftpantffkadmW;liwsftm#=ft (Please check one) Owner Agent M Telephone No. ,,,,,.PERMIT FEE Signature of Owner Or Agent 15��,Od o -e-, *v-// ,40R,r" SA US This certifies that Date. �7/-. . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING /17 . . . . . . . . . . . . . . . . . has permission to perform ........ ....... plumbing in the buildings of ................................ at. North Andover, Mass. Fee, Lic. No// -?,y Check # �!? — 8560 ........... P kW/ LUNtBI , �'SPECTOR V MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT' TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building L Date Permit # Amount Owner ra [-"-b cp'� C' New Renovation Replacement Plans Submitted Yes No (Print or type) Installing Company Name -h 'e &PC)- 4 (-,Z- 4- Check- one: \'ri c.. Partner. �5 �Firm/Co Name of Licensed Plumber: MA? -V--. Insurance Coverage: Indicate the V box: px of insurance coverage by checlang the appropriate Liability insurance policy Other type of inde mmty E no Certificate InsuranceWai : L the undersigned, have been made aware that t1ae licensee of this application does not have anyone of the above three insurance Signature � I Owner 11 I hereby certify that all of the details and information I have submitted (or entered) n ed best of my knowledge and that all plumbing work and iinstallatio is %5 compliance with all pertinent provisions of the Massachusetts State d By: b1g]OFITure of Mcenseclrlumbar� Title Type of Plumbing License Cityaown 9--k � 3 00 '1�1 - APPROVED (omcF usE oNLY mse Num Master Agent F1 oif application are true and accurate to the zt Issued for this application will be in Chapter 142 of the General Laws, Ei�- Journeyman [] The Commonwealth of Massachusetts Department of 1ndustrial Accidents Office of Investigations 1600 Washington Street Boston, AL4 02111 WWW-mass.gov1dia Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers Appficant Information Please Print Legibi Name (Business/C)rganization/Individual): Address: City/State/Zip:__ il ci-2z T). ICA Phone #:- Are you an employer? Check the appropriate box: 1. El I am a employer with 4-7 1 am a general contractor and I ;Mployees (full and/or art -time). have hired the sub -contractors 2. YI am a sole proprietor or partner- listed on the attached sheet. T ship and have no employees These sub -contractors have working for me in any capacity. workers' cOMP. msurance. [NO workers' Comp. insurance 5. 0 We are a corporation and its required.] 3. 1 am a homeowner doing all work Officers have exercised their right Of exemption per MGL myself [No workers' comp. c. 152, § 1 (4), and we have no insurance required.] t employees. [No workers, I- cOmP. insurance required.] -7bao Type of project (required): 6. El New construction 7. Remodeling 8. Demolition 9. Building addition 10. O'Electrical repairs or additions 11. [] Plumbing rep -airs or additions 12.0 Roof repairs 13. [1 Other MLLNL X!SV lul OUR Lne se -CUM beiaw m + 1 - w workers com a polic, , sormation. pens tier , " m Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurancefor MY employees. Below is the policy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 M'GL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify uj�$�he p�qis and th mation provided above is true and correct S!taldes ofperjury that c infor ,3 2 6 d_o Officiat 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other el Contact Person: Phone V 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, 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 apartinerits 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 work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The.affidavit should be returned to the cit ty or town the, the application for the permit or license ;is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition� an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city 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 Industrial Accidents OfBee of Investigations 600 Washington Street Boston, 1AA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.mass-gov/dia Date ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Z - This certifies that .... 2�4 57 has permission for gas installation .... .... in the buildings of ... ................... at ....... .. J"'North Andover, Mass. Z/ Fee. -�" -' i ........ Lic. No. /GAS IN c��' Check# --2;24 9 Ti 72 MASSACHUSETTS UNNORMAPPUCAIDNFORPERWrTODO GAS FTMNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date 14- 1 o -v- i o Buildin-, Locations e__ (R -D —(A0 C4,r4L�--�-rjcj Permit # Owner's Name Amount $ "('�]-L AN-P-6�0 t--3 New Renovation 0 Replacement Elrll� Plans Submitted ri (Print or type) Check one: Certificate Installing Company Name_M ro (—,i — ?a, + L+�, . — Corp. Address Ny� 0 IR fn S— Partner. rus"Iness I Telephone____ q -7j? fo�, ?ra C) d'CCO. Name of Licensed Plumber or Gas Fitter CCJL�, INSURANCE COVERAGE CheckLone. I have a current liability Insurance policy or it's substantial equivalent. Yes Lff No If you have checked yes, please in��the type coverage by checking the appropriate box. Liability insuran ce policy EST 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one, Signature of Owner or Owner's Agent Owner 0 Agent I ],�A— —+;r— +1—+ �11 A--:1- --A . 1 0 I — — -- — — � —, Duun"LLcu kur best of my knowledge and that all plumbing work and installations p5l�h compliance with all pertinent provisions of the Massachusetts StatwGaer, By: Title City/Town APPROVED (OFFICE USE ONLY) ,Sigriature of. Plumber Gas Fitter ffKasster Joumeyman a above application are true and accurate to the Permit Issued for this application will be in 1 11 aRLeL142 of the General Laws. sed Plumber Or Gas Fitter I I 7-U �, License Number WD Go COD U rn z P C, z a, W G Cn U P f- 0 > > Z z S U B - B A S E M E N T U > BASEMENT. IST. F L 0 0 R 2ND. F L 0 0 R 3 R D F L 0 0 R 4 T H F L 0 0 R 5TH. F L 0 0 R 6TH. F L 0 0 R 7 T H . F L 0 0 R 18-T H. f L 0 0 R (Print or type) Check one: Certificate Installing Company Name_M ro (—,i — ?a, + L+�, . — Corp. Address Ny� 0 IR fn S— Partner. rus"Iness I Telephone____ q -7j? fo�, ?ra C) d'CCO. Name of Licensed Plumber or Gas Fitter CCJL�, INSURANCE COVERAGE CheckLone. I have a current liability Insurance policy or it's substantial equivalent. Yes Lff No If you have checked yes, please in��the type coverage by checking the appropriate box. Liability insuran ce policy EST 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one, Signature of Owner or Owner's Agent Owner 0 Agent I ],�A— —+;r— +1—+ �11 A--:1- --A . 1 0 I — — -- — — � —, Duun"LLcu kur best of my knowledge and that all plumbing work and installations p5l�h compliance with all pertinent provisions of the Massachusetts StatwGaer, By: Title City/Town APPROVED (OFFICE USE ONLY) ,Sigriature of. Plumber Gas Fitter ffKasster Joumeyman a above application are true and accurate to the Permit Issued for this application will be in 1 11 aRLeL142 of the General Laws. sed Plumber Or Gas Fitter I I 7-U �, License Number V_ 4 The Commonwealth of Massachusetts Department qf L"dustrial Accidents Office of Investigations 600 Washington Street Boston, AL4 02111 www-mas&9ov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El I ectricians/Plumbers [mlienrit Infn"",. Name (Business/Organizafion/Individual): Address: IS -o K City/State/Zip: &Luv)_� C--� , VA 0 �3G Y Phone # :. q?866370ac� Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9- Building addition 10.0 Electrical repairs or additi ons I I - F�l �Piumbing repairs or additions 12.7 Roof repairs 13.7 Other -oxneownerswhos mitthisaffidav el� compm—on Poilcy xniurmaticm it indicating they are doing all work and then hire outside contmetors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workas, cOMP. Policy information. Iam an employer that isproviding workers, compensation InSuranceformy employee& Below is the policy andiob site information. Insurance Company Name: -Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaratioll page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of M'GL 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 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 co�e verification. I do hereb -�i& un e aides o at the information provided above is true and correct y cer�ft ry. and alties Si ature: Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: PermitfLicense # Issuing Authority (circle one): 1- Board of Health 2. Building, Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone ff: Are you an employer? Check the appropriate boxi 1 - El I am a'employer with - -T 4. El I am a general contractor and I Md 6 or part-time).* have hired the sub -contractors 2. E2/I amp ayseceles p(firofflpraintdo/r or partner- listed on the attached sheet t ship and have no employees These sub-COntractors have working for me in any capacity. workers' comp. insurance - [NO workers' COMP. insurance 5. El We are a corporation and its required.] 3T1 I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1 (4), and we have no insurance required-] t employees. [No workers' A -Y aPPPli cant ffiat checks boxil! must also fffl cOmP. insurance required.] out the section bu"DW Sh'",viag their w—, T Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9- Building addition 10.0 Electrical repairs or additi ons I I - F�l �Piumbing repairs or additions 12.7 Roof repairs 13.7 Other -oxneownerswhos mitthisaffidav el� compm—on Poilcy xniurmaticm it indicating they are doing all work and then hire outside contmetors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workas, cOMP. Policy information. Iam an employer that isproviding workers, compensation InSuranceformy employee& Below is the policy andiob site information. Insurance Company Name: -Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaratioll page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of M'GL 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 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 co�e verification. I do hereb -�i& un e aides o at the information provided above is true and correct y cer�ft ry. and alties Si ature: Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: PermitfLicense # Issuing Authority (circle one): 1- Board of Health 2. Building, Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone ff: Information anL d 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 pe--rson in the service of another under any contact of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, associELtion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including t1he legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees, However the owner of a dwelling house having not more than three aparttments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maint--mance, construction or repair work onsuch dwelling house or on the grounds or building appurtenant thereto shall not be:c--ause of such employment be deemed to be an employer." MGL chapter 152, �25C(6) also fttes 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 coxnpliance with the insurance coverage required." Additionally, MGL chapter 152, §25CM states "Neither the c--ommonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cont-.-xcting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) n-arne(s), address(es) and phone number(s) along with their certificate(g) of insurance. Limited Liability Companies OaC) or Limited Liability Partnerships (LIT) with no employees other than the metabers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pperrxiiit or license ;is being - , eque-sted, not the Deartment. 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 numbf--r listed below. Self-insured companies should enter their self-insurance license number on. the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future perinits or license&. 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 affida-vit. . The Office of Investigations would like to ffiank 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 ext 406 or 1-8 77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass..gov/dia Location 5 7 t No. C Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ w— 4R $ Other Permit Fee oft" onnection Fee, $ IVOV ,Water �Aection Fee $ 4r OTAL $ Met - ' - I.- I ' . ' Co//ftjof Building Inspector Div. Public Works it 4D, 14 Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ /C0.00 Other Permit Fee Sewer Connection Fee $ Yvater, Connection Fee $ U ik TOTAL $ /00,00 -V Buildin, lnsqedtm,,' 'I colietto Div. Public Works Location No. Date ViORTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ 5-0,00 Building/Frame Permit Fee $ -5 -00 Mu Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ 'T OTAL Building Inspector Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS./� ,4_ y A 1 % PAGE I A P 44-b. LOT 110. 2 RECORD OF OWNERSHIP IDATE BOOK PAGE tONE SUB DIV. LOT NO. i�OCA�!N PURPOSE OF BUILDING,,,�,/��jjV�10/ 4; OWNbA.S NAME: NO. OF STORIES if SIZE I? 36-Y26 IZ)< 17�6 _/7jiz`An_ OWNER'S ADDRESS 4VII P _�L le,10 BASEMENT OR SLAB ARCHITECT'S NAME BUILDER'S NAME SIZE OF FLOOR TIMBERS IST2 (3 2ND 3RD SPAN DIMENSIONS OF SILLS DISTANCE TO NEAREST BUK-DING DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES SIDES REAR GIRDERS AREA OF LOT. . �� FRONTAGEV-/ / IIW,, _)p HEIGHT OF FOUNDATION —71,6 THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDITIdf. MATER:AL OF CHIMNEY gx /4 IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND J-0 &, V WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Y&Y IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLk,NS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED OF OfIVNERoOR AUTHORIZED AGENT CONTR. TEL. 6&7'6 FEE 0 ww"11%. LIU. P MIT GRA ER4 _=Zo 19 SLOG. PERMi-j- j[_r 0,00 LESSFDAFEE air FMUE FWX PERMIT FOR FRAME/BUILOING A DATE: FEE PAID- 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SCf. FT`0'5_C EST. BLDG. COST PER ROOM I — SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN Pic 0N)IV3H.Or4 Oldl:)313 P -Z IMA SWOON dO svo SS3lV3H llNfl O.i.H INVIGVb DNINOIIIGNOD SIV sd3ljvd COOM SOdVA NO d.I.N\ IOH 'SIOD 'R 'SWI3 1331S MRS -SIOD -9 -SWS NTMI 'NdnA wy IOH (1� SO L_4 3�"Nin, �S3,3d" Islor 000M ONILYM L I ONIWVVA 9 OCIVG 3111 NOMA 3111 SRnmA NUGOW ONIJ00b 1106 -63MOHS IlViS 13AVdO 'R 8VI E)Niewnld ON 3ivl§ ANIS NgH:)11)1 S30NIHS GOOM QOIVAVI S310NIHS IIVHdSV 13SO1:) N31VM C13HS IVIA I'M z I ws 131101 6VSNVW ��3 b BW 'VV r-XIJ C) HIV9 C6 3 il 319vo ONiewnld OL dooll 9 �NON "1 31vno3<iv Sood 12 NOld3dns 3WVdA NO 3NOiS ONIalM ANNOSVW NO 3NOIS >119 NRINID NO ':)NO:), IWVdJ NO NDIH NOMA V 'SdIS DIIIV ANNOSVVV NO )4DIdg 3WV?H NO 0:)Dnis kdNOSVW NO oxmis 3 111'HdSV ONIGIS 'A3A INJOVIIIVIVOD INIIII 10111111 G MCIdVH ONIGIS IIVHdSV HldV3 S,-IONIHS G007A iDLNLIIIS dOdG 313dDNOD S"VOladVID slooll 6 SlIvm 7Z N3HDil>l Nd3GOW WOOd GVIH Sg:)Vld 3d,IJ IM 9 ON V3NV DIliV NIA 1A V98V lm�q Nil X iinj V3dV 11 IN3W3SV2 NI�Nn llvtA Ad(] Sd3ld �31SVld -N\(JdVH 3NOIS NO >0169 z i �? 3NId A.19 3138DNO:) 31gd:)rqo5 HSINId 110IMNI 8 NOILVONnoi z NOuonmisNOD -NV-ld 10-ld S3:),YW3UAN+&M3SOdWiU3cins.*3i3�. S30VU -VV 'S3H:)bl0d HIIAA 'SE)NIC3-line =10 SN0ISN3M1is,4.m:xvx3�WV IS3NI-1 10-1 SIN3WIMV kiiwvj aim WONA 3:)NVJLSIU aNV 1.0-IdOSNOI&N s -LsnW N01103S SIHI x Allwvj 31 AONVdn 000 I (310331 ONia i in a FOM U TOWN OF NORTH ANDOVER LOT RELEASE FOM SUBDIVISION J C: ASSESSORS MAP SUBDIVISION LOT(S) JERMA��NT ADPRES '3SIZE, BY D.P.W.) STREET 2c APPLICANT -7 2,4 P�L PHONE DATE OF APPLICATION -PLANNING BOARD TOWN PLANNER L/CONSERVATION C CONSER N A.DMIY-. S ION TOWN USE BELOW THIS LINE ATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DEPARTMENT OF PUBLIC WORKS cr, Z-C'DRIVEWAY PERMIT __&E1ttt04ATER CONNECTIONS FIRE DEPT. L(C e^S 4- V,.0 -(Wt 7-P t -VI 7-2 P, JT'_T'� Out n W>v�- RECEIVED BY BUILDING INSPECTION DAT . E SEP 2 M+� - This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. I _,_J