HomeMy WebLinkAboutMiscellaneous - 287 FOREST STREET 4/30/2018 (3)i
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that I.J L) �� 6- '1
.............................................................................
has pern-fission for gp ps alla ion UNA
t t . . ...................................
inthe buildings of .... ... . .........................................................................
North Andover, Mass.
at .................... .............. .
Fee.30 ... . ...... Lic. No ..... .....................................................................
GASINSPECTOR
Check #
1 a 1 E, 0
P Rla - c,:) C-,�tt 60`0
A�4' W
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I NORTH ANDOVER MA DATE I SEPT. 24, 2015 PERMIT#
JOBSITE ADDRESS 1287 FOREST ST. OWNER'S NAME PAUL MARNOTO
GOWNER
ADDRESS .0 TE 175 IFAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALE]
PRINT
CLEARLY
NEW:0 RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES[] NOE]
APPLIANCES I FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATERT`IEATER
OTHER I INSTALL AN UNDERGROUND
GAS Ll 'E AND CONNECT TO A
PLO-MB-ERS-IN-SP-EQIED--GA-S-UN,E
INSURANCE COVERAGE
I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [Z] NO [j
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a] OTHER TYPE INDEMNITY [j BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNERE] AGENT [I
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are trueand accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i c pi newithallP the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Vilk =
—
PLUMBER-GASFITTER NAME I JOHN MARSHALL LICENSE # SIGNATURE
MP Ej MGF El JP [j JGF [—] LPGI Ej CORPORATION [J# PARTNERSHIPEI# LLC [I#
COMPANY NAME] EASTERN PROPANE GAS ADDRESS 131 WATER ST.
CITY I DANVERS j STATE�ZIP101923 :::]TEL 11-800-322-6628
FAXI —J CELLI 1EMAIL1
A�4' W
The Comm'onwealth of Massachusetts
Department of IndustrialA ccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PEILMrrMG AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):
Address: 13 L LA-> c�, i e.� S �� .
t-ity/mate/LIP: 0('13J Phone#: 'I 1 *5
Are you an employer? Check the appropriate box:
LE] I am aemployer with employees (full and/or part-time).
2Q I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.E] I am a homeowner doing all work myself [No workcrs'comp. insurance required.] t
4.E] I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.E] 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance. t
6.E] 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.]
"7 -3 � - 6, �'c� -;,
Type of project (required):
7. New construction
8. Remodeling
9. El Demolition
10 E] Building addition
I I. E] Electrical repairs or additions
12. [] Plumbing repairs or additions
13.E]Roof repairs
l4.ff0therCs
cr; - �') - �!, �- -5 t-O'c"^
c%,"A �'_Zk S�091,1 I -
;Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outsside contractors must submit a new affidavit indicatm- such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: Wv)�Z-
Policy # or Self -ins. Lic. #: !E� W 6 C -Q� 6 C,, o 0 .3- D &, 1 j5 Expiration Date: 3 / �ij' j I U
Job Site Address: oj e 5+ S4
Attach a con City/State/Zip:_ V17 4; r (5
� y of the workers' Compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a c riminal violation punishable by a fine up to $1,500.00
0
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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u!j�e_pains andpenalties ofp
_,Nury that the information provided above is true and co?rect
Official use only. Do not write in this area, to be completed by city or tow—n
City or Town:
Permit/License #,
3 /1 L-, / / �
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#:
a &
ACC)RD CERTIFICATE OF LIABILITY INSURANCE
16._�
DATE (MMIDDIYYYY)
3/3/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
G & A INSURANCE, INC
CT Maryann Plass
_CA0MTe FAX (603)742-2406
PHc%.E,t): (603)742-2644 (Aic No):
(A/
E A
A bMD RLE S S:
34 Dover Point Road
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A:HDI-GERLING AMERICA INS
Dover NH 03820
INSURED
INSURERS:
INSURERC:
Eastern Propane Gas Inc.
INSURER D:
P.O. Box 1800
INSURER E:
28 Industrial Way
INSURER F:
Rochester NK 03866-1800
f�^%1COAf=Q CERTIFICATE NUMBER:CL153301715 REVISION NUMInam:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR I
LTR
TYPE OF INSURANCE -
ADDL
INAn
SUBRI
vlfvn
POLICY NUMBER
P
(MMOILDISM
YE
fMOILDClyf Y% I
LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 2,000,000
DAMAGETO RENTED
PREMISES (Ea occurrenceL-- $ 250,000
CLAIMS -MADE r7X OCCUR
_MED EXP (Any one person) $ 5,000
X
EGGCDOOOOB0615
3/15/2015
3/15/2016
PERSONAL & ADV INJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000,000
PRODUCTS COMPIOP AGG $ 2,000,000
RO
POLICY 7x LOC
JPECT
OTHER:
COMBINED SINGLE UMIT $ 2, 000, 000'
tEa accident)
AUTOMOBILE LIABILITY
BODILY INJURY (Per person) S
A
x ANY AUTO
ALL OWNED SCHEDULED
F7AUTOS -
X
EAGCDO00081615
3/15/2015
3/15/2016
BODILY INJURY (Per accident) S
AUTOS
NON -OWNED
PROVE-RTYE)AMAGE
(Per accident)
HIRED AUTOS AUTOS
H
UMBRELLA LIAS
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
HCLAIMS-MADE
$
DED I I RETENTION$
OTH-
WORKERS COMPENSATION
I
I STEARTUTE I ER
E.L. EACH ACCIDENT $ 1,000,000
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETORIPARTNERIEXECUTIVE
NIA
E.L. DISEASE - EA EMPLOYEE S 1,000,000
A
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
EWGCDO00080615
3/15/2015
3/15/2016
rE7LD71SEASE:�P0::LICY �LIMIT $ 1 000 000
Wescribe under
If rs
0 RIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACOR D 101, Additional Remarks Schedule, may be attached If more space Is required)
mr-0 CANCELLATION
GER I IFICA Fri HUL
cs@eastern.com,
Any City/Town in Massachusetts
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIV15RED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MA
AUTHORIZED REPRESENTATIVE
Maryann Plass/MP ..
.......
All
ACORD 25 (2014/01)
INS025(20`14011
(0 190-204 AL;UKU `LVKrUMA I P%ll llUll—W-1 V
The ACORD name and logo are registered marks of ACORD
Fold, Then Detach Along All Perforations
'COMMONWEALTH OF MASSACHUSETTS
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE."A'
LICENSED AS AN LP GAS INST LLER
jo
JOHN F MARSHALL
ui
47 HOBART STREET lu
DANVERS MA 01923-1943
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CERTTICATE OF USE & OCCUPANCY
Town of NorthAndover
Building Permit Number 2040 Date
i THIS CERTIFIES THAT
THE BUILDING LOCATED ON _a?,09
MAY BE OCCUPIED AS -SPP tl?-- _;' 24AWIX IN ACCORDANCE
WITH THE PROVISIONS'OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
v 3/
CERTIFICATE ISSUED TO ZZ - 2)., 100
ADDRESS 9�� IVA �97t-
CHU -Building Inspector
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number 91049 Date 19—/46-0/
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THIS CERTIFIES THAT
THE BUILDING LOCATED ON 47
MAY BE OCCUPIED As -SbV t1r, Z, P�IY !,�1*0*f IN ACCORDANCE
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WITH THE PROVISIONS'OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED To 7�-
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Town of North Andover ORTH
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Building Department
27 Charles Street 1 0
North Andover, Massachusetts 0 184 5
(978) 688-9545 Fax (978) 688-9542
APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION
ADDRESS 0 7 7 -
LOT
DATE REQUEST FILED
DATE READY FOR INSPECTION
Of
tl�
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME
FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE
CHARGED IF TBESWCTURE PQES,-N�OT MEET ALL APPLICABLE CODES.
SIGNATURE
ROUTING
CONSERVA
PLANNING
D.P.W. — W)
D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED
PRIOR TO THE INSPECTION REQUEST DATE.
SIGNATURE / DPW AUTHORIZATION
Location 1:1?817 1--Orp-J-
No. 3011)
� =0 :� E
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 1--2 3 &
Foundation Permit Fee
Other Permit Fee
TOTAL
Check # /9,9c)-
1#4 C -C,
I At L 6 2 Building Inspector
Be n t b Z' - V3 J!A 1-24 -a 0 13 : 26
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No 2489
This certifies that ..................
has permission to perform
Date ..... 7.I�?.2
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
......... R"e . ........................
..... I., .... - ... . ....................................
wiring in tt Uquilding of ..... .. .. . .......... ................. .............
at ........... ......................................... .. ........ ....... orth Andover, Mass.
sop—
Fee.......... --*� ..... Lic. No . ............. .. ....... ........ ..........
LECTRICAL INSPECTOR
Check# Arlo 1-1
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
N2 2791 Date./
.. .........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................. -1
...... .................................
has permission to perform ............ ..........................................
wiring in the building of ......
.................. w ........ .............................................
...... ......................... . North Andover, Mass.
..... ....... ................................................
Fee-�,5` ............... Lic. No��-01. r�'
ELECTRICAL INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
TBE 00MW0NffE4LTH0FMAMC11USE77S Office Use only
DEPARTAfflW0FPUBL1CS4FM Permit No. 1-2 7 1
BOAM 0FMEPREVEW0NREGa4T10AS527CM 12-00 Occupancy & Fees Checked
APPUCATION FOR PERW TO PEMORM FLECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover
The undersigned applies for a permit to perfbrm the electrical work described below.
Location (Street 6
Owner or Tenant
Owner's Addre§s
To the Inspector of Wires:
Is this permit in conjunction with a building permit:
Yes [0—No r7 (Check Appropriate Box)
Purpose of Building , �5?1 Utility Authorization No. Q0
Existing Service Amps Volts Overhead El Underground No. of Meters
-� 0 n Amps //Z1 Volts Overhead FM Underground No. of Meters 4
New Service (2
Number of Feeders and Ampacity
Lvation and Nature of Proposed Electrical Work (7, o —/ r- -�r 6�e-o-- —L -
No. ofLighting Outlets
No. of Hot Tubs
No. ofTransformers
Total
-75�gr
-KVA
ft. of Lighting Fixtures
—517—,N
Swimming Pool Above
1:3
Below
Generators
KVA
ground
ground
No. ofReceptacle Outlets
C�,
No. ofOil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
Q610
No. ofGas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
6�-- Tons
No. of Detection and
No. ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
1:1 Connections
Other
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
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anddutnrf *u�3emthispmniapphcabcnva'Ntsdisro*'mayot
(Please check one) Owner M Agent
Telephone No. PERMIT FEE$ C��
I & —'// - 0,-;
N2 2631 Date ..................................
w 40RTH
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that
.........................................
has permission to perform ........................ .... ...............................................
Vring in the buildipg of ....... ..... ......................................................
ai ................. North Andover, Mass.
<- � er—_
Pee, -256 ............ Lic. No . ............. .....
R*'I*C*A'*L' *1*N'*S* P**E* c*'r'O*'R'*
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Official Use Only
Permit No. c>,��3/
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Fee Checket;—;Wl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date 10 :12 — 0 Z
Townof North Andover To the Inspector of Wires:
The under signed applies for a permit to perform the electrical work described below.
Location (Street & NumberZgo 0 7 F7,s7—
Owner or Tenant -& -Ucy-1 (2--c
Owner's Address
Is this permit in conjunction with a building permit Yes No 0 (Check Appropriate Box)
Purpose of Buildin D LAJ e� /
Utility Authorization No.
Existing ServiceL_Amps —Voits Overhead 0 Undgmd 0 No. of Meters
New Service C90o ----Amps 9-�? 0 Voits Overhead, 0/11" Undgmd 0 No. of Meters
Number of Feeders and Ampaci
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot fuse
--
No. of Transformers i otai
KVA
Above 0 In 0
No. of Lighting Fixtures
Swimming Pool
grnd Cl gmd D
(D
Generators KVA
No. of Receptacles Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
#4
No. of Switch Outlets
No of Gas Burners
FIREALARMS No.ofZone
No. of Detection and
�No: of Ranges
No of Air Cond Total
Tons
Initiating Devices
No. of Diposal
0
No.
Heat Total
a
To' I
Pumps Tons
Total
KW
T 'I
No. of Sounding Devices
No. of Dishwashers
Space/Area Heating
KW
No./ of Self Contained
Detection/Sounding Devices
0 Municipal 0 Other
ocal Connection
No. of Dryers
KW
Heating evices EE!
W
No. of Water Heaters KW
0
No. of
Signs
No of
i,
Low Voltage
_ Bailases
1
V
Wirino
No. Hydro Massage Tuds
No. of Motors
Total HP
I
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
' hae- a nt,,Li bility Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
hav&-submiftS valid proof of same to the Office YES = NO = if you have checked YES please indicate the type of coverage by checking the appropriate box.
- 'mt
'INSURANCE -
i* !RuA N nCE BOND = OTHER (Please Specify) (Expiration Date)
I-
stilihated Value of Electrical Work
Work to Start Inspection Date Resquest�d_/O - JJ pough /0 Final 611�d
Signed under the Penalties of pequry:
FIRM NAME
LIC. NO.
LIC. NO.- Z-:::- /3 :?C3 1!!�
Bus. Tel No
Address SDI seco 4/F,) S, —/ .— . &(� -:? - 2-:1.1 --1-1 -3
Aff Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
(Signature of Owner or Agent)
011
Telephone No. PERMIT f EE
357
Date... ............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .......................... ; ....................
has permission for gas installation ... �4. Z ......................
in the buildings of ....... : —.,' . . ...............................
at .... .-Z .................... North Andover, Mass.
Fee.-,(; ...... Lic. No ........... ............................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
vMASSACHUSETTS UINUORM APPLICATON FOR PERMff TO DO GAS G
�Type or print) D
j� i �,
. NORTH ANPOVER, MASSACHUSETTS
Building Locations 2 8 7 zZei,ne-s
SOL j-6 VC Owner's Name
New JZ Renovation F� Replacement 11
I Plans Submitted F-1
Permit 9 2sv/
Amount S gy d,
\iame of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
F� Corp.
MPartner.
11117irm/Co.
NSURA\i�CE COVERAGE Check one:
have a current liability Insurance policy or it's substantial equivalpnt. Yes (D No
f you have checked ves, please indicate the type coverage by checking the appropriate box.
Jability inskirance policy Other ty
pe of indemnity Bond El
Dwrier's Insurance Waiver- I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
vlass. General Laws, and that my signature on this permit application waives this requirement.
3i2nature of Owner or Owner's
hereby certify that all of the details and Informafion I
)est of my knowledge and that all plumbing work and
:omplianc-, with all pertinent provisions of the,.\,Iassac
By:
Title
L icy/ Town
APPROVED wFi-ici- USE ()NI.Y)
Check one:
Oyner M A..nt
in above application are true and accurate to the
.r Permit Issued Cor this application will be In
Chapter 1421 of the General Laws.
SignatiiM-of Lic,�nsed Plumber Or Gas \ Fitter
Plumber
Gas Fitter Lictme Numoe,
Master
Joumeyman
N2 4 5 7,1
K-? 13, . e—d
Date. Z ..........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies thatz;;�
.-f.....................
has permission to perform
..............
plumbing in the buildings of
North Andover, Mass.
F e Lc' ... Lic. NoZIO.�
1?1 . . : ..........
PLUMB NPNSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date 3-00
Building Location 2 8 7 1::6 Owners Name A Permit #_-Y,)
Amount AW
TypeofOccupancy
New Renovation Replacement Plans Submitted Yes J5 No
(Print or type) Check one: Certificate
Installing Company Name � / 1�mob&-/ — 11 Corp.
I 'I 'rirF A 4z�,
-cc .10 jVc� o oc7 �� / 11 Partner.
KJ 073d 7:2
1�usiness M Fimi/Co.
Telephone S
Name of Licensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy �] Other type of indemnity El Bond F1
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
du-ee insurance
Signature Owner
I hereby certify that all of the details and infor
best of my knowledge and that all plumbing w
compliance with all pertinent provisions of the
Title
City/Town
APPROVED (OFFICE USE ONLY
F� Agent 11
h(or entered) in above application are true and accurate to the
JqW,ormed under Permit Issued for this application will be in
rlu�.bin ne'ral Laws.
License
Master Journeyman
Mile,
(Print or type) Check one: Certificate
Installing Company Name � / 1�mob&-/ — 11 Corp.
I 'I 'rirF A 4z�,
-cc .10 jVc� o oc7 �� / 11 Partner.
KJ 073d 7:2
1�usiness M Fimi/Co.
Telephone S
Name of Licensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy �] Other type of indemnity El Bond F1
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
du-ee insurance
Signature Owner
I hereby certify that all of the details and infor
best of my knowledge and that all plumbing w
compliance with all pertinent provisions of the
Title
City/Town
APPROVED (OFFICE USE ONLY
F� Agent 11
h(or entered) in above application are true and accurate to the
JqW,ormed under Permit Issued for this application will be in
rlu�.bin ne'ral Laws.
License
Master Journeyman
'*'k5' -
c -7
2il
34�-<
�70 9
I
N
focation
NQ. Date e
TOWN OF NORTH ANDOVER
0
41
4L Certificate of Occupancy $
B ilding/Frame Permit Fee s
u
Foundation Permit Fee $ '4�5
Other Permit Fee $
TOTAL $
Check
'14-30 "'--Building Inoctor
50 -
Ir
A
4"N H`41JU-,�tK i-:�ekz JERT TEL HO -508-688-9594 rOZ9 POI
fz
R'LITVIN qjjV INVIK11i ANDOVER
BUILDING DEPARTMENT
_ePLWAXION C0146MQVC? P"m OA Dr, On O_R TWO FAMILY AWEU�p 0
BUILDING PERMrr NUMBER:
ISWED:
SIGNATURE
Building Conumissione Daft
LiSWT16N— 1. gm 1KFC
I I �hWMYA4*vw 1,2 Ameam -Mq and Pared Nu
map Nundw —isftig —Nuaw
1.4 Property Da=111ces:
/7,5
MOW —Use Ld AM (d) (A)
-prow-Age
1.6 RIDWING SETBAM (ft)
FtontYard Side YRYd Rm yard
Provide 'red T
2�8! ---�re�d Provided
Z ig
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SEMON 2 - PROPF]kTY 0Wi&R-9fM%1AUTH0RUFD AGENT
2.1 Owner of Rmord
kZWZ;� 7r&)�`T >10 57—
Name 'at) Addms for Seevioe: -
el
2,2 (Wmor of Roord:
Nam Print Addrems for Sorvirm
signatum
sk-C-n-,-O-N"—),-,-C,ONSTRLTCTION SERVICE$
3.1 Liemmd ConStraction SUperViKw: >
Not Applicable 13
Ti�,
ased Canstnwfim Supworisar:
�5-6) 5 ��T :57 Cleli�' IeJ4
Lke-Ae Numba
Address
r-,— 7!
>
7-
57j&-rz,(4
.K 0 Telephona
E,,p,.tm Dat,
3.2 Regi#Uwad Home Ireprovewomt CfttmesDr
Not Applimb le 0
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Compoty Nam
Reoftbot Namber
Addrest
IEmoration
Data
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-JU LUEL" Ht4,"Ut-JhH ��!PE DEPT TEL HOZ508-689-9594
SECTION 4 - WORKERS CONWINSATION (W I
W("*Qft CAMP"n"tiOn Insure— affidavit inust be oompleted and- itted with this 4pptj
in ths denial ofthe, isawwoo of , _e dipg Poratit. prom this
No ....... 0
sectioN s nastril&ttan, at voma...
tO39 P02
result
maw canstmi rimictifts Building 0 R4W�A) a --j—Afi—aatio*s) 0
Acoemiry Bldg, C, Dmnoatjort 0 01" 11 --- spWity
Brief Nwription of r4w-
5, P77 C
SECTION 6 PSTrMATE)D CONSTRIUMON Cort�--
Ts—timated Cost (Dollar) to be
COM -Plow hL-Anl± 4 -ant
-PpLic
1. BL[ildirig
(a) B uilddij; PenWt fee $w
�O �—
2 Electrical
—Maltiollicl,
(b) Estinwed Totpii Co$t of -/400
conkruction
!;5' 0o Buil<14 Pertrit fee
5 Fire Protection
A)
6 TOtal (1+2*344+5)
SECIE20N 7* OWNER AUTHORIZATIO-%, To UR r-0MpLKTjjD %VIUN
0 Wan EN'
TOR APPL-Ms.VoR BmLDiNG PERMIL
_7, A&wtv1'-;4bPjmt property
Hereby author,
"I
,M) t�n Ten-
toker on
al4odud by this to"ilding pennit application.
Date
%ICTION ?b OWN R;AU-i H0RIjj-
ED AGENT DECLAgATI
as OwnerlAuthwized Agent of subject
Plopefty
H=bY dtftc that the Stalexaenb
ond infienw1kn on the foregoing application mv 1= and accurate, to the best ormy imowle4ge
and belief
Priat
9019t,ure Of 0440 1
—a�
NO. OF SMRW
4
c:w_--
BASEMENT OR SLAB
--
SIZE OF FLOOR MMERS
-§P—AN
2NU
3__
DMMSICIMS OF SILLS
--
DMNSIONS OF POSTS
"�I-V4Z Y
JIMENSIONS Of GIRDERS
HFJOHTOF F0
00%-
Z�
SIZE OF FOOTING
x
MATEPIAL Of CIUWPY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATUVAL GAS LIM
FORM U - LOT RELEASE FORM c2 9 7
INSTRUCTIONS, This form is used to verity that all necessary approva)s/perrnits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements,
FILLS OUT THIS SECT
-�44 '�-7?�
APPLICANT, PHONE
LOCATION. Assessors Map N u mberiq'��Z!/!—Z'w
SUBDIVISION zz LOT (S)
ST
STREET ST. NUMBER
USE
REQOMMENDATIONS OF TOWN AGENTS:
CO�ISERVATION
COMMENTS r-%
NISTRATOR
re -
DATE APPROVED
DATE REJECTED.
TOW� PLANNER DATE APPROVED 0 (D
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT --
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECT OR DATE
Revised 9�97 jm
a elpep
Is
F5
7- oD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name
Name:
Location�
CitV / yr K4A?l
rA-
I am a homeowner performing al[work myself.
I am a sole proprietor and have no one working in any capacity
Please Print
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
city: Phone
Insurance Co. Policv
Company name:
Address
Cily: Phone #-.
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or, one years' imprisonment.as well.as cMpenaltles in.the formofa STOP WORK ORDER.and a fine of ($100.00) a day against me. I
understand that a copy of_tWsls�Aement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herreby cerrt' n pains an of p 'ury that the information provided above is true and correct.
Signatu Date
Print name —Phone
Official use only do not write in this area to be completed by city or- town official'
City or Town PerniftlLicensing
Building Dept
[]Check d immediate response is required Licensing Board
E] Selectman's Office
Contact person: Phone Health Department
Other
e
TOWN OF NORTH ANDOVER, MASSACHUSETTS
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET, 01045
J.WILLIAM HMURCIAK, P.E.
DIRECTOR
0
DRIVEWAY PERMIT
DATE
-LOCATIONd,� F7
BUILDER
phone
4� -7
QWNERZT,6,-,'17C AfA671)1 phone
THE NORTH ANDOVER SUPERINTENDENT OF OPERATIONS
MUST BE NOTIFIED OF THE GRADE AND SETBACK FROM
STREET. CALL THE SUPERINTENDENTS OFFICE BEFORE
FINISH GRADING AND SURFACING FOR APPROVAL OF
SUCH ENTRY.
FAILURE TO COMPLY AND 013TAER APPROVAL VOIDS THIS PERMIT.
Telephone (978) 685-095
Fax (978) 68"573
7 � o 47
Growth Management Bylaw Exemption Statement
Town of North Andover Building Department
This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the
Town of,North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information
as requested below.
Name of Applicant an Building Permit (below) Address of Property for Permit (below)
1;7A / -V-/ Z
_/ /T _r 05�5 7-
K7_ — '>X_'F_ cxI—P 75 1q,0 3 f OF—,
Map and Parcel: Purpose Of A
P��.>ppliCation (check below)
u b r of Applicant Single Family Two Family
1 the undersigned applicant for the above property attest that the attached building permit for which this
form is completed does comply with the EXEMP-1710N section 8.7.8 of the North Andover Growth,
Management Bylaw. I also understand providing this form does not absolve me or any party to this permit
from the requirements of obtaining other permits required prior to the issuance of the Building Permit.
Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building
Department and is only offidally accepted when the Building Permit iq issued.
Based an section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the
above lot, in the building permit application and associated attachments, complies with one or more of the
following sections as indicated by a check mark.
This is an application for a building permit for the enlargement. restoration, or reconstruction of a dwelling in
existence as of the effective date of this by-law, provided that no additional residential unit is created.
The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning
Bylaw.
This application is for dwelling units for low and/or moderate income families or individuals, where all of the
conditions of 8.7.6.ciire met and/or represents Dwelling units for senior residents, where occupancy of the units is
restricted to senior persons through a properly executed and recorded deed restriction running with the land. For
purposes of this Section "senior" shall mean persons over the age of 55.
This application is a part of a development project which voluntarily agreed to a minimum 40% permanent
reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the
environmental conditions of the tract, with the surplus land equal to at least teri buildable acres and permanently
designated as open space and/or faimland. The land to be preserved shall be protected from develooment by an
Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism
approved by the Planning Board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common awnership with an
adjacent parcel an the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth
Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit an the
parcel.
—This application represents a lot which is ready for building permits,(I.e. all other permits from all other boards and
commissions have been received and the project is in compliance with those permits), and the Development Schedule
does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per
Development until such time as the Development Schedule accommodates issuing building permits. Applicant must
supply approved form U with this EXEMPTION.
Please provide any and all information that would assist the Building Department in making a determination
that your application is allowed one or more of the above EXEMPTIONS.
By signing below I attest ac cy a information provided and that the attadhed building permit is
allowed an EXEMP as t abc . F r I understand that the submittal of misleading and or
inaccurate infcrm on, or e he ng o f a above item which does not comply, whether done to my
knowledge or n , is r s r Sal the uild �9 Department to issue a Building P��iy
T�gnature Xf O)dft-er�b� Adthonzed Ag,01 w_t;d'signed the Attached Building Permit Date
This forl r�dsit be =ched to th3r'm.
9.41ding Permit upon application for such permiL
5T
MAScheck COMPLIANCE REPORT
4
Massachusetts Energy Code
MAScheck Software Version 2.01
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 6-7-2000
DATE OF PLANS: June 6,2000
TITLE: Lot A, Forest St.
PROJECT INFORMATION:
28'x4O' Colonial, 16' Family Room
COMPANY INFORMATION:
Ralph R. Joyce
COMPLIANCE: PASSES
Required UA = 624
Your Home = 541
Permit #
Checked by/Date
Area or
Cavity Cont.
Glazing/Door
Perimeter
R -Value R -Value
U -Value
UA
----------------------------------------------------------------------------
CEILINGS 1222
30.0 0.0
43
CEILINGS: Raised Truss 90
30.0 0.0
3
WALLS: Wood Frame, 16" O.C. 3272
11.0 0.0
292
GLAZING: Windows or Doors 379
0.320
121
DOORS 40
0.350
14
DOORS 38
0.490
19
FLOORS: Over Unconditioned Space 1521
30.0 0.0
49
HVAC EQUIPMENT: Furnace, 86.0 AFUE
HVAC EQUIPMENT: Air Conditioner, 10.0 SEER
-------------------------------------------------------------------------------
COMPLIANCE STATEMENT: The proposed building
design described
here is
consistent with the building plans, specifications,
and other
calculations
submitted with the permit application. The
proposed building
has been
designed to meet the requirements of the Massachusetts
Energy
Code.
The heating load for this building, and the
cooling load if appropriate,
has been determined using the applicable Standard
Design Conditions found
in the Code. The HVAC equipment selected to
heat or cool the
building
shall be no greater than 125% of the design
load as specified
in
Sections 780CMR 1310 and J4.4.
Builder/Designer
Date
F1
"0-4 , "
MAScheck INSPECTION CHECKLIST
Massachusetts Energy Code
MAScheck Software Version 2.01
Lot A, Forest St.
DATE: 6-7-2000
Bldg.1
Dept.]
Use
CEILINGS:
1. R-30
Comments/Location
1 2. Raised Truss, R-30
Comments/Location
Insulation must achieve full height over the exterior wall.
WALLS:
1. Wood Frame, 16" O.C., R-11
Comments/Location
WINDOWS AND GLASS DOORS:
1. U -value: 0.32
For windows without labeled U -values, describe features:
# Panes Frame Type Thermal Break? Yes No
Comments/Location
DOORS:
1. U -value: 0.35
Comments/Location
2. U -value: 0.49
Comments/Location
FLOORS:
1. Over Unconditioned Space, R-30
Comments/Location
I HVAC EQUIPMENT:
1. Furnace, 86.0 AFUE or higher
Make and Model Number
2. Air Conditioner, 10.0 SEER
AIR LEAKAGE:
Joints, penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. When
I installed in the building envelope, recessed lighting fixtures
shall meet one of the following requirements:
1. Type IC rated, manufactured with no penetrations between the
inside of the recessed fixture and ceiling cavity and sealed or
gasketed to prevent air leakage into the unconditioned space.
2. Type IC rated, in accordance with Standard ASTM E 283, with no
more than 2.0 cfm (0.944 L/s) air movement from the the
conditioned space to the ceiling cavity. The lighting fixture
shall have been tested at 75 PA or 1.57 lbs/ft2 pressure
difference and shall be labeled.
VAPOR RETARDER:
Required on the warm -in -winter side of all non -vented framed
ceilings, walls, and floors.
MATERIALS IDENTIFICATION:
Materials and equipment must be identified so that compliance can
be determined. Manufacturer manuals for all installed heating
and cooling equipment and service water heating equipment must be
provided. Insulation R -values, glazing U -values, and heating
equipment efficiency must be clearly marked on the building plans
or specifications.
DUCT INSULATION:
Ducts shall be insulated per Table J4.4.7.1.
DUCT CONSTRUCTION:
All accessible joints, seams, and connections of supply and return
ductwork located outside conditioned space, including stud bays or
joist cavities/spaces used to transport air, shall be sealed
using mastic and fibrous backing tape installed according to the
manufacturer's installation instructions. Mesh tape may be
omitted where gaps are less than 1/8 inch. Duct tape is not
permitted. The HVAC system must provide a means for balancing
air and water systems.
TEMPERATURE CONTROLS:
Thermostats are required for each separate HVAC system. A manual
or automatic means to partially restrict or shut off the heating
and/or cooling input to each zone or floor shall be provided.
I HVAC EQUIPMENT SIZING:
Rated output capacity of the heating/cooling system is
not greater than 125% of the design load as specified
in Sections 780CMR 1310 and J4.4.
SWIMMING POOLS:
All heated swimming pools must have an on/off heater switch and
require a cover unless over 20% of the heating energy is from
non-depletable sources. Pool pumps require a time clock.
HVAC PIPING INSULATION:
HVAC piping conveying fluids above 120 F or chilled fluids
below 55 F must be insulated to the following levels (in.):
PIPE SIZES (in.)
HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-211 2.5-4"
Low pressure/temp. 201-250 1.0 1.5 1.5 2.0
Low temperature 120-200 0.5 1.0 1.0 1.5
Steam condensate any 1.0 1.0 1.5 2.0
COOLING SYSTEMS:
Chilled water or 40-55 0.5 0.5 0.75 1.0
refrigerant below 40 1.0 1.0 1.5 1.5
CIRCULATING HOT WATER SYSTEMS:
Insulate circulating hot water pipes to the following levels (in.):
PIPE SIZES (in.
NON -CIRCULATING CIRCULATING MAINS & RUNOUTS
HEATED WATER TEMP (F): RUNOUTS 0-l" 0-1.25" 1.5-2.0" 2.0+"
170-180 0.5 1.0 1.5 2.0
140-160 0.5 0.5 1.0 1.5
100-130 0.5 0.5 0.5 1.0
NOTES TO FIELD (Building Department Use Only) -------------------------
IN
m
c
aj o
:3 —
CL
n m o
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r+ CL LA.
--% Qj :r o
0 r+ (D 0 (A 0 rrl
I G. 0 A 0 CD 0
M :3 1 M M 0 pe
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This certifies that .............
Date ..... 7... d 2 , -, r,)
... .......................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
...........................................................
has permission to perform ...... ..............................
wiring in tLbepuilding of ...... ...................................................
,I0 I — I/
'7
at ............................................................................... ; North Mdover, Mass.
Fee.,6 1� .... . . ..... Lic. No . ............. ..L� ..............................
............. . .
ELEcrRICAL 1NsPEc'r0R
Check#
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
ThFC0AM0AWE4LTH0FAfl&"0RS= Office Use only
DEPARTAIENTOFPUBLIC&4f M Permit No. Aq q
BOARD 0FFMPREYEAW0NMGM770ASR7CVR 12-00 Occupancy & Fees Checked --J
W04
APPUCATION FOR PERW TO XWORM ELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Datj-l-:��- �00�
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perfbrrn the electrical work described below.
Location (Street & Number) . i—o TER 151—/
Owner or Tenant ; 9 C-( C T
Owner's Address 57 -
Is this permit in conjunction with a building permit: - Yes rM No r7 (Check Appropriate Box)
3) L.J=
Purpose of Building P-0 (3 ) t- Utility Authorization Nop 0
Existing Service Amps Volts Overhead Underground ED No. of Meters
New Service /00 Amps olts Overhead Underground [=] No. of Meters
Number of Feeders and Ampacity VIA 5S r-�-CTR o ozI - n q-3
Location and Nature of Proposed Electrical Work - 7-0
No. ofLighting Outlets
No. ofHot Tubs
No. ofTransformers
Total
KVA
No. ofLighting Fixtures
Swimming Poo) Above
Below
Generators
KVA
ground
ground 0
No. of Receptacle Outlets
No, ofOil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas B umers
FIRE ALARMS
No. of Zones
No. of Ranges
N o. of Air Cond. Total
Tons
No. ofDetection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
htiating Devices
No. ofSounding Devices
No. o�Dishwashers
Space Area Heating KW
No. ofSelfContained
I
Detection/Sounding Devices
Local Municipal
M
Other
No, * Dryers
Heating Devices KW
0 Connections
No, of Water Heaters KW
No. of No. of
Signs
Bailasis
No. HydTo Massage Tubs
No. of Motors
Total HP
OT1-lER,;---Fe-�F> Pa
NO F1
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FIRMNAME
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Addresi-
OWNER'SR4SURANUWARIM[ammmtaftLjmmdmW
(Please check one) Owner Agent 0 Telephone No. PERMIT FEE S
E 3( R (/C- U-)tq -1 108 15- T 0? 6 3 /-CD 5,( �� YT