HomeMy WebLinkAboutMiscellaneous - 287 MASSACHUSETTS AVENUE 4/30/20189D
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Date..!6b.,b.1.6 .......................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ;TO -14) H(Aal�-b e,41 Ld)AC
........... ; ................................ / ......................................................
has permission for gas installation 3 ....... C %,
in the buildings of . .... .............. : ........................................
at ........... s2..� ...... * ........ ............. . North Andover, Mass.
Fe*ok�... Lic. No. ......... M.v ..................................... i ...............
1,11,4 . 15P GASINSPECTOR
Check#
9381
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY lAorth Andover MA DATE 30/2014 PERMIT# C
"I UIV
JOBSITE ADDRESS [2f7 Mp_ §achusefts Ave OWNER'S NAME
GOWNER ADDRESS TEd IFAX
TYPE OR OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL RESIDENTIALE]
PRINT
CLEARLY I NEW:E] RENOVATION:E] REPLACEMENT: El PLANS SUBMITTED: YES[_-] NO[j
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
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
WATER HEATER
-- ------------- - - ----
OTHE7RF - - - - -------------------- =L::i ==3L—JL:JL:J
Replace 1 as Meter
(I --A- 0 1
U
INSURANCE COVERAGE
I have a current liabili!y insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY [j BOND [j
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [] 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 e and accurate to the best of my knowledge
c 'tj
and that all plumbing work and installations performed under the permit issued for this application will be in mp ance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I
PLUMBER-GASFITTER NAME 1 4044411--�
_jose_ph Marin LICENSE # 8736
P 14F
MP El MGF [] JP [j JGF LPGI CORPORATION 0# PART SH I P [Fj # LLC []#
COMPANY NAME: truction Co ADDRESS -al St
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CITY I Auburn STATE = ZIP 101501 �TELLJ� �)832-3�295� 4 lt� I
FAX j-5-MK6--4347 JCELL EMAILI JMarino@RHWhite.com
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CERTIFICATE 01: 1 [Awl rry
1111-40V"NUt: page I DATE (MMMbNYYYI
THI� CERTIFICATE is ISSUED AS A MATTER OF INF 1 of 1 1 08/ 9/2013
ORMATION ONLY AND CONFERS No RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE WoRDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
I�EPRESENTATIVE DIR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder isan ADDITIONAL INSURED, the poljoy(ies)must be endorsed. If SU13ROGATION 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
Certift2te holder in IIOU Of such endorsement(s).
[Ahlin=0
willia of massachugotts, Inc.
c/o 26 co-Atury Blvd.
P. 0. Box n5191
N&MhvillG, TN 37230-3191
R' K' White COnfftr=tion Company, znc.
41 Cmntraj Street
P- 0. Box 2S7
AUbUrn, MA 01.901
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSIJRrDmN1A1'1!_-'
ED ABOVE FOR THE POLICY PERIOD
INQICA7ED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTH ER OOCUMENT WrfH 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,
EXCWSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS S Y HAVE BEEN REDUCED By PAID CLAIMS.
A I GENERALLIANLITY
WFROIAL GENERAL LIAI;11.17Y
CLAIMS-MADEOX OCCUR
GEN'LAGGRr=GATr. LIMITAPPUES PER;
B I AUTOMOBILE LIABILITY
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WORKIZRS COMPENSATION
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OFFICERQEM13�R EXCLUDED? Iq NfA
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VTaCAP 977K95sA_13 9/l/2013 9/1/2014
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VTRXUB 8205AI�5-13 19/j/.2013
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BODILY INJURY(Per vemon)
BODILY INJURY(Peraceld(jnt)
! 9/1/2014 X RKLI, U
!9/l/2014 E.L. EACH ACCIDENT s 1,000 ! 000
E.L.O10rzA8E-EAEmP[,9yP.rz s 1, ooc), 000
El, DISEASE- POLICY Lu'r s 00,000
!19;f 1,o 9
SHOULD ANY OF THE AeOvE DESCRIBED F30LICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DCLIVERED IN
ACCORDANCE WITH THE POLICY PROVI$IONS.
AUTHQRIZI!D REPRESUNTATWE
,CORD 25 (2oiotn) C0114429 �604 T�p3-'3-6�-940-12 �@)1988-�2010 AC�ORD CD�RPORATION. All �rights res�
The ACORD name and logo are registered marks of ACORD erved.
I
Date ..... . — .. 2 .. .. 1'�2 ....
. . ... ... . ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... M
has permission to perform .......... .... .. ...... . ... ... ......
wiring in the building of ............... 42gD ....................................................
at ... ........................ /1.. , North Andover, Mass.
Ifee ... Lic. No . .... ........
-�Check #
9267
i
I
Commonwealth of Massachusetts Official Use Only
FPermfil No.
Department of Fire Services :mi
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07]
L (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEA SE PADVT flV NK OR TYPE ALL INFOR&M T101V) Date:— 3 - -Z , / �2
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his perform the electrical work described below.
Location (Street & Number)., .2 7A 0666.
Owner or Tenant
Owner's Address j-xg kitylr" Telephone No. bq-193 (o
Is this permit in conjunction with a building permit? Yes 14 No 0 (Check Appropriate Box)
Purpose of Building
Utility Authorization No.
Eidsdng Service Amps volts
Overhead D Undgrd No. of Meters
New Service Amps volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Loca tion and Nature of Proposed Electrical Work:
No. of Recessed Luminaires 1,3
No. of Luminaire Outlets
No. of Luminaires
N 0. p
o. of Receptacle Outlets 4
No. of Switches
No. of Ranges
No. of Waste Disposers
F No. of jDishwashers
a
No. of DryersE,
No. of Water KW
Heaters
No. Hydromassage Bathtubs
OTHER:
No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Abov
d. _d
gru
No. of OU Burners
4No.of Gas Burners
01
No. of Air Cond. ota'
us
Tons
eat Pummpn um er on KW
Totals:
Space/Area Heating KW
Heating Appliances KW
11W. No. oT—
Signs Baflasts
No. of Motors Total HP
table may be waivedby the Inspector of Wires
0.0 1
ranSformers W17A
Generators KVA
0 0 mergency 9
Ba e Units
FIRE ALARMS No. of Zones
No. of Detection and
I Initiating Devices
No. of Alerting Devices C�
I etection/Alerting Devices
IVILunicipal
"c EJConnection Other
Security System :*
No. of Device- or Equivalent
Data Wiring:
No. of Devic�s or Equivalen
TeleFo—mmunications wirm,g:
No. of Devices or Equivalent
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start (When required by municipal policy.)
I Inspections to be requested in accordance with MEC Rule 10, and upon completion.
11 L —K)
INSURANCE COVER,4,GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licenseeprovides proof of Lability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited of of same to the permit issuing office.
CHECK ONE: INSURANCE QK BOND F-1 OTHER [] ( pro
Specify:)
I certify, under the pains andpenalties ofperjurY, that the information on this application is true and complete -
FIRM NAAR:
Licensee: Signature LIC. NO.:
(If applicable, enter "exempt in th license number line) PAM lt�AL"111 LIC. NO.: jUf7
Address: sr&- it Bus. Tel. No.:
*Per M.G1 c. 147, s. 57 AIL Tel. No.: ff (_.0
-61, security work requires Department of Public Safety "S" Licen—se: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage noi�Ta_l_ly
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [D owner
Owner/Agent owner's auent.
Signature Telephone No.
P��Iv� �V_
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0
I
The Commo),zweajtk of Afl=achusetts
Department of Industrial Accidents
Office of Invesdgations
600 ff,"ashingmn Street
Boston, M4 02111
www.mmsg9v1&a
iWorkers' Compelm2tion lukrance Affidavit. Bufiders/Contractors/Electriciara/Plmbers
plicant Informatian
Nairli (Business/organizafion/individual):
Adaress:
M
City/State/Zip: ro,,� Ait ---------
2,�L� 1 4, Phone#:. P (06
YOU an employer? Check the appropriate box:
11 am a employer with 4. F1 I am a geneml contractor and I Type Of PrOjed (required):
employees (full and/or �part_tjme).* have hired the sub-coTftctors 6. []New cOnstruction
I am asole proprietor. or partner. listed CM the attached sheet 7- Remodeling
ship and have no employees 7bese sub -contractors have
working for mein any capac 8. Demolition
ity. workers' comp. insurance.
[No workers' comp. insurance S. E]We am a corporation and its 9. Building addition
required-] offic=. have exercised their 10. Electrical repairs or additions
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3. 1 am a homeowner doing all work right of exemption per MOL I Plumbing repairs or additions
n7yself. [No -workers, camp. c.. 152, § 1(4)1'and wehave no
insurance required.] t k :: . , 12.[] Roof repairs
L ..employees, [No workers'
u Lj 13.n Other
*Any "licant ftt cheeks bo*j #I must glso fill out COMP. Msurance mquired_1
t Homeownm; who submit this atWdavft indi the seetiOn below shounng their workets' bompensgion pol iey iformatiotL
=itig they am doing all wo* and then him outside comnwtommust submit a new afrldavit j,,d,cHtT sucL
—thw check this box Must aftftched 11 dditi,,l sheet showittg- the nmmm of Om sub-cotms&�m 6 — - .-1— 1 ____ W Cy inibr=tion.
_qd t�
am an employer fkar isprovi&7g:workers, c&Mpensajon
information. bzSUrVnCef0 . r)"Yemployem Below 'sth"Polic7--djobsile
Insurance Company Name: CT C, Q At4_y,
POlic
Y 4 Or Self -ins. Lic.. Pro—
Expiration Date:
Job Site Address. -J, -A.0 _Hn5e,
City/statezip: -9,
)�\jo
Attach 0 cOPY of the workers' cOmPens;ation policy d' F_
Failure to s ecLuratiOD page (showing the policy number and expiration dzte�
ecure coverage as required under Section 25A of MCjL c, I S2 can lead to the imposition of crrminal 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 S250.00 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 heray cerli and, he p �penoM� ofperja�
do hereby C an 'hep ' andp I enaUiz ofperjary that 1*e'fff0rn1Wi0ff PA0Vj&d above is me and Correa
Date- 0
Phone 4: (0 ------
2t
ofrj"ar ase (Ifi1Y- Do not wrhe in &is area, m he complejed or w ff
by city to M 0 rriaz
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City or Town:
g :
ng A ffior;�(circ
in
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Issuing Authority (circle one): Permit/License 4
0 of
f
I. Board of Health 2- Building Department 3. CiWTOwn Clerk 4. Electrical inspector S. Pium
6. EO�th �er bing Inspector
Phone
Contact Person:
Location C7Y7
No. Date
R T
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
U
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
U ��
18076 ildino
Inspector
U
12
Location C71Y7
No. 15�6-16r- Date
CHU
k Check #
18076
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT I
APPLICATION TO CONSTRUCT REPAK RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERM[IT NUMBER:
DATE ISSUED:
SIGNATURE:
Building Commissionerfln!�=tor of Buildings Date
SECTION I- SITE INFORMATION I
I Property Address:
5-
1.2 Assessors Map and Parcel Number:
RIC,
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BURDING SETBACKS (ft)
Front Yard
Side Yard
Rear Yard
Required Provide
Required Prmi&d
ReqWred Pr(yvi&d
1
1.7 Water Supply M.G.L.C.40. 54)
public 0 prhve 0
1.5. Flood Zone Information:
Zone Outside Flood ZA1110 0
1.8 Sewerage Disposal System
municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT UlVnot: )/��3
2.1 Owner of Record
J04,07
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUC770M SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
V 4e III, . -,j z-- 0- , 4 C
Lici�-sed-qonstruction Supervisor: 0 )t S -V=6 7
; & License Number
Ad
Expiration Dite
Six,aiw Telephone
3.2 Rmsiered Home Improvement Contractor Not Applicable 0
Company�ame a
Registration Number
Address
>Z,/
7 -2 Expiration'Date
Sign*turi q/ Telephone
I t
I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit %rill result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Descripdon o Proposed Work (ccheeck
app6mbit.)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify m
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY
.
I . Building
Z00%
Buil ding Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) ; (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTH8E—MTION TO BE COMPLETED WIIEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERN[IT
---------
as Owner/Authorized Agent of subject property
Hereby /uthorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
&- :9--3 - a6�
Signature ofOwner Date
SECTION 7b OWNERJAUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Si "tauvre of Owner/Agent Date
NO. OF STOREES SIZE
BASEI�ENT OR SLAB
I !!NiJ
SIZE OF FLOOR TPvIBERS 2 3KD
SPAN
DIENSIONS OF SELLS
DMIENSIONS OF POSTS
D24ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TMcKNEss
SIZE OF FOOTING X
MATERIAL OF CH2vMY
I IS BUILD ON SOLID OR FlILED LAND
[_LS BUILDING CONNECTED TO NATLY11AL GAS LINE
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
dispose f in a properly licensed solid waste disposal faci I lity as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
.0 a. el V"
—5, Ive
(Location of Facility)
Signatur4e; Wermit �App�ficantr�—
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector