HomeMy WebLinkAboutMiscellaneous - 29 BARCO LANE 4/30/2018 (2)N
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2012 Massachusetts Electrical Code Amendments 527 CMR12,00 § Rule 8: in accordance-withthtprovisions; of M.G.L. c. 143, 3L, the
permit application form to provide notice of installation of wiring sh all be uniform throughout the Commonwealth, and applications shall be filed'
on the prescribed form. After a permit application has been accepted by an Inspector of Wires '
appointed pursuant to M. GI o. 166, § 32, an
electrical permit shall he issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction. activity, and may bedeemed-bytheJnspector-of-W.ires abandoned-and.inx-alid-ifhe—
or she has determined that the authorized wor% has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the. permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of'Chapt-,r238 of
the Acts of 2012. The purpose of this act is to promotejob,growth and long-term economic recovery and the Permit Extension Act farthers this
puipose by establishing an automatic four-year extension to cortairpermits -and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically dxtends, for four years beyond its othei-wise applicable expiration date, any permit or approval that was
"in effict or existence' during the qualifying period beginning on August 15,2008.and extendiagthrough August 15,2012.
8 — Permit/Date Closed:
0 Permit Extension Act — Permit/Date Closed:
— 2-;::!�:7 _ /
*** Note:.Reapply for new permit
This certifies that ...... T
has permission to perform. . k— f,77/9/97-�.`�`/—
wiring in the building of ..... W!E� ,-./ . ....................
at . . ............ Aorth Andover, Mass.
7, 4, P..
Fee ......... Lic. No. -7
ELECTRICAL INSPE6-/FOR
Check # -S 9 -S-3
I
k 10 9 0 7
6,jWwnwaaA,,1 Vadd=luaA
BOARD OF FIRE PREVENTION REGULATIONS
official
Permit'No. zo,?,c -7
Occupancy and Fee Checked
Fu::* 1/073 (lemblanki
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All %Vmk to be perrornied in amordwce %viffi am Mmaw:husWs ElecWcal Code RAEQ,527 CMR 12.00
(PL rs A M PR W N AW OW ME, 1= B VFOMM Tj0jV Date: ) 1 �i �,
CityorTownofi DaLL4A To flie impactor -
By this application Me unde 4 & Wires:
migued gives notice of'his or bar lulmdon to pef.. the electrical wo descnibed bel9w.
Location (Street &Number) r , LC�_
Osvner or Tenant
Owner's Address
up Olue 0. -
's tilis Permit in c0nJuRcfi0n with a building permit? Yes IM No El
Purpose of Bundin (Check Appropriate BOX)
aiL Y_\—S— Utility Authorization No.
I D'xktiug Service
_ Amps -volts Overhead 0 Undgrd 0 NM ormeters
New Se e, Amps Volts Overhead 0 Undgrd 0 No. OrMeters
Number of Feeders and Ampndty
Location and Naturs of Proposed Electrical Woric..
r%
^ - "-,)N n iN
Q:
to. of Recessed Luminaires 1 jS
lo. GfLumine Outicts
'NO- Of Cell.-Susp. ftddle) Falls
of Hot Tubs
— -- -_-.r .,ow is
IWW� — u2a±�t�
TOW
Transformers ICVA
Generators _1CVA
Fo. of Luminaires
la. of Receptacle outlets
Ab a-
SwimmingP��dve 11 1
No. of OR Burners _;j!j, 0
- - -
mam units
FME ALARMS lNo. of zones
No. orDefection. ff�
Initlatin Devices
[a. of Switches
o. of Ranges
No. of Gas Burners
Total - -
Na. of Air Cond. Tons
No. ofAlerting Deviem
-
o. of Self-
o. orWnste Disposers
o. of Dishwashers
D. of Dryers
a. of ater
Heaters IC%Y
a. Hydromassage Bathtubs
umber Tons IC.W -
Tota
Space/Area Beating JCW
HentingApplinuces JCW
1140.01 No. of
Shws B
No. of Motors Total jj�_jTffS_j—omRoniFaflons
Data ned
Deferfia rtin Devices,
Muni Pal 0 OhL
Connection
Security SysteuCsjW--
. No. Devices or Equivalent
Data Wiring:
No. of Devices Gr� �,jvn�jeat
_yvi,r,
jng:
.=all y u"az% or ar rp4mea by tile Iftspgr
Estimajed Value of Electrical w0da (When required by municipal policy.) t0rjjjrrr&L
Work to Stam Inspections W 6 -requested in accordance with MEC Ride 10, and upon completion-
'NSURANCi COVFJtAGE-�zUftIMs -,VniVcd-hy4hr_ovvne,.- 06�9ffWt-fiJr-'1h6-pbrf bfiftanee ii j s
the liemsee provides pronforliabi* insurance including ucampleted operation r Hiles
.0v=ge, or
same to the permit issWng office
undersigned certifies thatsuch coverage is in fbrM and has exhibited proof of its substantial equivalenL The
CHECK ONE: INSURANCE g) BOM El OTHER[] (Specify-)
I cer40, zwder diepaffis andpanalfies ofperjury, illat tile hirfirawflon an mas appilrallon !S into old conipleje-
FIRM NALM:J?� �4, "(I'- LTC No..,3qo�.Ck,
Licensee-.
(Yapplicable, Mier %xi 'm dig LIQ NO---_D,05;,rj A
liewwnumberfinp-) r Q —1--k -
Add req r�. C, Bus. Tel. No. IS
q (-) -_&j
-61, security work requiregbeptutment ofPublic Saflij L-1cense: Lic.No.
*Per IvLGJL. c. 147, s. 57 Aft. TPJ. No
OVANIE RIS INSURANCE WAIVEJU I am aware that the Licensee dogs nat have"th-1- liability insurance coverage nmmally
required by law. By my signature below, I hereby waive this requirement I am the (cbeL::-one) El owner 0 owner's agent
Owner/Agent
Signature Telephone Nix _jPERWTFFX.-S
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, M,4 02111
www.mass.govIdia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
Applicant Information- Please Print LeLpiblv
Name (Businessiorganization/Individual): V�cwr-6,f T--\ f rr�_- k
Address: N -- &T,tY
City/State/Zip 0 � qo/p Phone #:
Are you an employer? Check the appropriate box:
I am a employer with
4. [11 am a general contractor and I
employees (full and/o
have hired the sub -contractors
2.E1 I am a sole proprietor ci,- 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.]
officers have exercised their
3. 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. El New construction
7. E] Remodeling
8. El Demolition
9. E] Building addition
I0.E1 Electrical repairs or additions
ILEI Plumbing repairs or additions
12.n Roof repairs
13.[] Other
--.Y .11P..�LURUWICu" uoxfF, music also nil out tne 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.
.:Contractors 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 'Compensadon insurancefor my employees. Below is thepo i y andjobsite
information. I c
Insurance Company Name: ComuYN'.eu e
Policy # or Self -ins. Lic. #:_WQ, (,)9 A Expiration Date: -,A,
Job Site Address:
0 City/State/Zip:.oa-:k�,\ f--NyT)Cj� )f
Attach 2 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
i�e 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 cerfify under thepains andpenallies ofperjury that the information provided above is true and correct.
Sign re- d,
�a Date: 7— 0
Phone #:
Official use only. Do not write in this area, to be completed by city orlown officiaL
City or Town: � 4-
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Date. .�hihz—
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
T h i s c e r t i fi e s t h a t .....................
has permission to perform /o '-+1A41--
plumbing in the buildings of ..... 44*�� /17
at. . Ardo.. 4e� ............... I North Andover, Mass.
Fee.,��Z-�� . Lic. No..00�55.7 .......
PLUMBING INSPECTOR
Check ?4s,9
8 4 1 2
1LIN
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT#
JOBSITE ADDRESS tq -cj OWNER'S NAME
POWNER
ADDRESS -11 TEL FAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL Ell EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
N E W: E-11 RENOVATION: REPLACEMENT: Fj PLANS SUBMITTED: YES NO F-1
FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9
10 11 12 13 14
CROSS CONNECTION DEVI E
DEDICATED SPECIAL WASTE SYSTEM .-
DEDICATED GASIOIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
i
DRINKING FOUNTAIN —A
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIORF
KITCHEN SINK
LAVATORY
ROOF DRAIN ji –J
SHOWER STALL
SERVICE / MOP SINK
TOILET i J
41
URINAL
- -L-1-1-1111 F- A -1--l-,
WASHING MACHINE CONNECTION i i
WATER HEATER ALL TYPES
WATER PIPING F-77
OTHER
'j
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [R/NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND MJ
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove . rage 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 10,
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 i mpfia ce with rtj prit pjovision of the
Massachusetts State Plumbing Code and hapter 142 of the General Laws. IHT'P
PLUMBER'S NAME LICENSE# SIGNATURE
MPO ip CORPORATION Fl! # PARTNERSHIP 0# LLC D�
COMPANY NAME [jE 4 1
ADDRESS
C I TY IISTATE[�ZIP=' TEL 7
-2
FAX CELL IL
113
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The Commonwealth ofMassachusetts
Department OP-ndustrialAccidents
Offide of 1-nvesfigadons
.600 Washington Street
Boston, AM 02111
www-mass.govldia
Workers' Compensation Insurance Affidavit: RuUders/Contra
Mfiennf Infnrm-af;,,� etors/Electricians/Plumbers
Name (Business/Organizationfindividual)
Addre'
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box.,
1. am loyer with
n? MP
4. El I am a ge eral contractor and I
Oyees fu and/or part-time).*'
have hired th6 sub -contractors
ajp
2. �Ze
In 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. insurance.
[No workers' comp. *
msurance
5. We are a coiporation and its
required.)
3-0.1 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 *orkers'
cOmP. insurance required.]
*AuY spplicaut that checks box. #! must aisc,
T al cat the nction below shewina,
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. El Building addition
10-11 Electrical repairs oradditions
.11-0 Plumbing repairs or additions
12 -El Roof repairs
13.El Other
no C
�Uon poll"I'mtorma
meowners who submit this affidavit indicating they are dqing all work and ;�; hire out'side contractors must submit a now 'affidavit indicating such.
4contractors that check this box rnu t attached an additional sheet showing the name of the sub-coutactors and their workers' cOMP. Policy information.
I am an eMPIOYer that isproviding workers'compensation
informadoyL InsUranCefor my employees. Belom, is thepolicy andjob site
Insurance Company
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 OfMGL 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 again§t the violator. Be advised that a copy of this 9tatement may be for*warded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereh un rthep in a penalties
Sienatu c eriu'31 that . -in ormation Provided above is true and correct
U LZ 1� / (�f_l
V,O - -1 1 , Date.
OffIcial use only. Do not write in this area, to be completed by
citY Or town officiaL
City or Town:
PermiffrAf-pnea
Issuing Authority (circle one): -
L Board of Health 2. Building Department 3. Cityrrown Clerk 4. Electrical Ins c
6. Other pe tor 5. Plumbing Inspector
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 6r 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 ernplqye�.-, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing e rnployees. However the
owner of a dwelling house having not more than -three apartments and who resides therein, or the occupant of the
dwollinghouse" of another -who employs persons to -do-maintenance, construction or -repair -work on -such dwelling -house
or on the grounds 6r building appurtenant thereto shall not because of such employment be deemed to be an employer!)
MGL chapter 15.2; §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 coinpliancewith 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 fo.r the perforinance.of public work urt-til acceptable M*idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.,'
Applicants
Please fill out the workers' compensation affi&vit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub1contractor(s) name(s), address(es) and phone number(s) along with their cerdficat:6(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 ca.rry workers' compensation insurance. If an LLC or LLP does have,
employees, a policy is required. Be -advised that this affidavit may be submittedto the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date -the affidairit. The affidavit should
be rob=nedto f-br, city or town thef. the application. forth-epern2it-or' license is being requested . , Put th-_ Dep.artm-"n 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 numbp--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 spaceat the bottom
of , the affidavi ' t 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 wiU 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 in -formation (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 offici�lly stamped or marked by the city or town in�y be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be fined out each
year. Where a home, owner or citizen is obtaining a license. or permit not related to any business. or comm ial venture
(i.e. a dog license or permit to burn.lea.ves etc'.) said person is NOT required to complete, this affidavit.
The Office of Investigations woulflike to thank you in advance f6r your cooperation and should you have any questions,
please do n'ot -hesitate to give us a call.
The Department'.s address, telephone and fax number.
The Cornmonwealth of Massachusetts
Department of Industrial Accidents
Of Elce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #-. 6.17-727-4900 eat 4.06 or 1-8-77M ASSAFE
Revised 5-26-05 Fax # 617-727-7749
ur
. xxnxr rn %on "-/A;
(978) 687-2783 OFFICE
(978) 687-3042 FAX
LEVIS COMPANIES, INC.
PROPERTY MANAGEMENT, MAINTENANCE & CONSTRUCTION
SPECIALIZING IN REHABILITATION OF OLDER PROPERTIES
(RESIDENTIAL & COMMERCIAL)
65 SALEM ST.
P.O. BOX 952
JOE LEVIS LAWRENCE, MA 01842
FORM - U LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval / pe
'm
Boards and Departments having jurisdiction have been obta mied. This does not relieve
applicant and or landowner from compliance with any applicable requirements.
TED
APPLICANT &,fe-r q- Carlo I U.) eqe r —PHONE (p� 4
4 . 1.0
ASSESSORS MAP NUMBER LOTNUMBER C/
SUBDIVISION LOTNUMBER
STREET 8 a rco a Y) P_ STREET NUMBER
OFFICIAL USE ONLY
lannam
RECOq;��ATIONS OF TOWN AGENTS
DATE APPROVED
CONSERVATION ADMDUTRATOR
DATE REJECTED Q I
DATE APPROVED
TOWNPLANNER
DATE REJECTED
CONEVIENTS
DATE APPROVED
FOOD INSPECTOR - HgALTH DATE REJECTED
'" laILE
SE INSPECTOR - HEALTH
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAYPERMIT
FIRE DEPARTMENT
DATE APPROVED
DATE REJECTED - ql,3 16
DATE APPROVED
DATE REJECTED
CONRVIENTS
RECEWED BY BUILDING INSPECTOR DATE
Town of North Andover
Office of the Health Department
(7-ommumi-ty Development and Services Division
William J. Scott, Division Director
27 Charles Street
North Andover, Massachusetts 01845
Sandra Stirr
Health Director
Id
North Andover, MA 0 1845
Re: Application for <k
N NO
Telephone (978) 688-9540
Fax (978) 688-9542
Dear: A," 1�1,)c-29 e -l'
' i
Your application forc4vi o�i dd'-4� at 19 )39/"� has been reviewed by the Health Department. The
application was been denied on ?131
/)/ , 2001 for the following reasons:
1. 0 Missing information
2.
Passing Title 5 inspection of septic system required 5<n n e. L,<-)
3. 0 Location of structure not acceptable
To address the problem(s):
If 91 is checked, please supply:
a. Floor plan of existing and proposed addition
b. Certified plot plan showing house, septic system and proposed project in scale
If #2 isAqcked:
a.) Have the septic system inspected by a certified Title 5 inspector to determine the size of the system
and whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
BOAIRD OFAPPEALS 688-9541 BUILDINTC, 688-95LO CONSERVATION 688-9530 NTTRSE 688-95413 PLANNING 6i,'8-9�5,35
TOWN OF NORTH ANDOVER BUELDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
Section for Official Use 0
BUELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Buildiu Colnmissi��j �or of Buildings Date
—019
1. 1 Property Addren:
1.2 Assessors h4ap and Pared Number
P -e BcLtc-o Labo
/ 6) Cf
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
V"Q/
A'?, 9 Ts� 160-
Zmm�f, District PropmW Use
Lot �;e-a'(sfi Frontage (fl)
1.6 BURDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required
Provide Required
Provi&d
ReqWmd
Provi&d
1.7 Water Supply M.G.L.C.40. 1.5. Flood Zone Information:
1.8 Sewerage Disposal Systeny.
Public 0 Private zone ---- Outside Flood Zone 0
Municipal On Site Disposal System aloo'
2.1 Owner of Record
?-e;fe r q. C'a ro I uj e, q e, r 2-9 f3a rGo L a n 0-
14ame (print) Address for Service:
/,/—) Cl 79 - 77 42
Signature/ Tdepfionj
Ate
horized Agent
Name Print Address for Service:
Signature Telephone
I MW
3.1 Licensed Construction Supervisor Not Applicable 0
Tasef � G Le
Address License Number
s,5- e. rn �Sj Pee
j
Licensed Construction Su- . sor. 0.
9-78 �R7- Palg-? Expiration Date
Siqpf�re Telephone -7—
,Z 7
3.2 Registered Home lm�rovem&t Contractor
Not Applicable 0
Tos en; Le- V t"S
CompanyName" F
Registration Number
(g.. S- S 8f r acl L a Lv yle
I /-) 7� -7 -7
Address
9 -7 9 -CR -7-
Expirfition Difie -
7— .9- oa
Signabf* Telephone
ic
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Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial ofthe
issuance of the building permit.
Signed affidavit Attached Yea ....... 0 No ....... 0
S19MON: S PIR00WONAL, MIGO"A'"
ICTION; "Ovic Ps M BV MoS-A" MWw"s sum I
M, -Mmik
CONSTIMUCTION CONTROL44 Tin IM,
5. 1 Registered Architect:
Name:
Address
Signature
Telephone
LS Go M 12,q ly L Oz 3� ric
CnName: I I
ac-e,*A G
Responsible in diarge of Construction
Not Applicable 0
Area of Responsibility
Registration Number
Expiration Date
Name:
Address:
Signature Total
Not applicable 0
Registration Number
Expiration Date
Name:
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
LS Go M 12,q ly L Oz 3� ric
CnName: I I
ac-e,*A G
Responsible in diarge of Construction
Not Applicable 0
1,11SR, M-90141�
New Construction 0
Existing Building 0
Repair(s) 0
erations(s) 0
�ddition
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
,37 X 14' akt(t ic h To rear o -C Qwedl(r,� To e-niotge- KLiclqu
d Lacldt,)! NP!A Ct YJ T!!Ccce
A-2
A-5
0 A-3
0
Structural Engineering Structural Peer Review Rmpired Ybs 0 ' No 0
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Hereby authorize
My behalfi,*4
Signature
e #I -
1 (-31.- LZ v ILL-L-elv LE (
two work authoriz&I �this b�uilding
Owner of the subject property
Date
act on
USE GROUP (Check as applicable)
CONSTRUCTION
TYPE
A Assembly
0
A-1 0
A4 0
A-2
A-5
0 A-3
0
0
]A
IB
0
0
B Business
0
2A
2B
2C
0
0
D
C Educational 0
F Factory 0 F -I 0 F-2 0
H High Hazard
0
3A
3B
0
0
1 Institutional 0 1-1 0 1-2 0 1-3 0
M Mercantile
0
4
0
R residential
0
R -I 0
R-2
0 R-3
0
5A
5B
0
0
S Storage 0 S-1 0 S-2 0
U utility 0 Specify:
M Mixed Use 0 Specify:
S Special Use 0 Specify:
COMPLETE TERS SECTION EF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE
Existing Use Group:_
Existing Hazard Index 780 CUR 34:
Proposed Use Group:
I
Proposed Hazard Index 780 CMR 34:
Structural Engineering Structural Peer Review Rmpired Ybs 0 ' No 0
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Hereby authorize
My behalfi,*4
Signature
e #I -
1 (-31.- LZ v ILL-L-elv LE (
two work authoriz&I �this b�uilding
Owner of the subject property
Date
act on
1, - L e, U LS C- o M no es -I YLc Z-Tosea� 6 Lcut-r asowner/Authorized
I
Agent I- f,
,Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties.of pe�ury
Print Name
Sign Joz�
,*fire of 04ef/A 7gentT---'o' Date
item
Estimated Cost (Dollars) to be
Completed by permit applicant
1. Building
(a) Building Permit Fee
-73
(e2d Multiplier
2 Electrical
(b) Estimated Total Cost of
4QrO 0
Construction from (6)
3 Plumbing
Building Permit fee (a) x (b)
7z 0 o o
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
.9 ing R"""r,
-- KN
NO. OF STORIES SIZE
137 X,
BASEMENT OR SLAB 13aSe
MpK4
SIZE OF FLOOR TIMBERS 161 2 ND 3 RD
.-.Z)(
SPAN .4
DEMENSIONS OF SELLS
DEMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION If THICKNESS 0/
4
SIZE OF FOOTING o x
MATERIAL OF CBMINEY
IS BUILDING ON SOLID OR FILLED LAND
S 01i a
IS BUILDING CONNECTED TO NATURAL GAS LINE
R
R4 or
rO 7We 7 -17e -e 1A1Se1,COW,4VO
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.00444-00,4AF)-
,47-1041 7XotC-V oc^-O.*f er1.f77,G1,a oeog—eaeas 00,4,(W X7,-rzFe7-
,e OV,9 I 4A1,OOY4-,f,
LEVIS COMPANIES, INC.
Property Management
Maintenance & Construction
65 Salem St. , - P.O. Box 952
Lawrence, MA 01842
.(978) 687-2783 OFFICE
(978) 687-3042 FAX
TO: Peter & Carol Weger
29 Bar-co'Lane
North Andover MA 01845
4
PHONE DATE
978-725-6542 5-17-01
JOB NAME I LOCATION
Kitchen, Laundry, Office Addition 14x3l
JO�WJMBER JOBIPHONE
Barco Lane
Supply all necessary material, labor and permits for new 14x3l addition
to rear of existing dwelling as shown on plans by Colonial Drafting of
170 Main Street Tewksbury, MA dated 3/17/01.
Price includes the following allowances :
Windows and Doors .......................... i .......... $ 5,800.00
Interior and Exterior Painting of new addition ........ $ 4,000.00
Landscaping ........................................... $ 2,800.00
Paving................................................ $ 2,000.00
Permits and Site Plans ................................ $ 1,500.00
Note not included in this proposal
Kitchen and bathroom cabinets and countertops material and labor
Appliances
Finish flooring material and labor
Excavating clause - Any ledge or other objects or material not removed
with a back hoe will be an additional cost at that time.
WE PROPOSE hereby to furnish material and labor —complete in accordance with the above specifications, for the sum of:
Eighty Five Thousand One Hundred Eighty and 00/100 Dollars dollars ($ 85,180.00
Payee2Vo 8b Taqe as follows:
f due on starting date, $ 25,000 due after all rough inspections.
$ 20,000 due after drywall, Balance due upon completion
All material is guaranteed to be as specified. All work to be completed in a professional
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tomado, and other necessary insurance. Our
workers are fully covered by Worker's Compensation insurance.
Authorized
Signature
Note:
withdrawn
ACCEPTANCE OF PROPOSAL —The above prices,
specifications and conditions are satisfactory and are hereby accepted. You are Signature
authorized to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature
PRODUCT 13128T FOLD AT (�) TO FIT COMPANION 771 DU-O-VUE ENVELOPE.
mav be
PRINTED IN U.S.A. A *
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tAORTH
Town of North Andover
16 -A
0
6
Building Department
27 Charles Street
North Andover, Massachusetts 01845
N6
(978) 6.88-9545 Fax (978) 688-9542
If-ATE0 PY
CHU
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and. a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility -as defined by MGL cl 1, s150a.
The debris will be disposed of in /at:
TZLIP �e PVJ t I
, L- I "e LQ V) 10. 01,er 'M! r, U I C - S"Im IV tj
(0 03- �?01R— L.6�ej Facility location
Sigature o!(A:p anT'
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
U A K L) Workers' Comensation and EmDloyerls Liability Poli
_11cV
INSURANCE AMGUARD Insurance Company
Policy Number LEWC104655
GROUP R . enewal of LEWC004119
NCCI No. [21873]
D#%Ii�% Information Page - Fini pe: Actual Mail)
[1] Named Insured and Mailing Address Agency
LEVIS COMPANIES INC. LANDMARK INSURANCE AGENCY
Joseph Levis 198 Massachusetts Ave.
65 Salem Street
Lawrence, MA 01843 North Andover, MA 01845
Agency Code: MALAND10
Federal Employer's ID 04-3144874 Insured is Corporation
Risk ID Number
[2] Policy Period
From February 27, 2000 to February 27, 2001, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $100,000
Bodily Injury by Disease - each employee $100,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming.
D. This Policy includes these endorsements and schedules:
WC OOOOOOA - STANDARD POLICY
WC 000001A - INFORMATION PAGE
WC 000403 - EXPERIENCE RATING MODIFICATION FACTOR
WC 200301 - MASSACHUSETTS LIMITS OF LIABILITY ENDT.
WC 200302 - MASSACH USETTS-ASSESSM ENT CHARGE
WC 200303B - MASSACHUSETTS NOTICE TO POLICYHOLDER END
WC 200401 - MASS. PENDING PREMIUM CHANGE ENDORSEMENT
WC 200601 - MASSACHUSETTS CANCELATION ENDORSEMENT
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium
Total Surcharges/Assessments
Total Estimated Cost
$ 2,750
$ 119
$ 2,869
INTERNAL USE OP
IVIGA LEWC104655 Page - 1 -
Date 03/19/2001 Endorsement
WC890600
P.O. BOX A -H, WILKES-BARRE, PENNSYLVANIA 18703
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Date .....
.... . . ... .. .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that .............................................................................................
has permission to perform ............................................... o .............................
wiring in the building of
.............................................................
....................................... . North Andover, Mass.
Fee�-Xs ............... Lic. Nd�..-� I< ...... 9 ...... .................
ELECTRICAL INSPECTOR
Check #
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
Official Use Only
Permit No.
y & Fee
Occupanc:L Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 R 12
-;2-
(Please Print in ink or type all information) Date
To the �Ipel�dr of Wires:
Tom of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number 1 C:)q
Owner or Tenant
Ownees Address 41
64 > -, I -A 3 42 -5-
is this permit in conjunction with a building permit Yes 2-",�
No 0 (Check Appropriate Box)
Purpose
E)dstinq
New Service Amps________ycits
Authorization No.
Undgmd 49-- No. of Meters
Overhead 0 Undgmd 0 No. of Meters
Number of Feeders and Ampacity ow-�,41e ez/
ae -y /is
Location and Nature of Proposed Electrical Work
OTHER:
INSURANCE COVERAGE. Pursuant to the requiLemen6ts of Massachusetts General Laws
I have a curr&nt Liability insurance Policy incl pleted Operations Coverage or its substantial equivalen YaESNO
t�iVlled va id Of same to the offi�QEWTNO = If you have checked YES please indicate the ;(ey rage by checking the appropriate box
1 0 proo� --%
B ND OTHER (Please ecify)
(Ex pilration Date)
f.a� alue of Eldrial Work$_ Foy, k1V
Work to Start Inspection Date Resqpested_______,. �Rough Final 114151�
Signed under the Penalties of pedury:
FIRM NAME LIC. NO.
Lkensee A�lcl< e!;�Vc6iz�w Signature LIC. NO. <:2
A:. Tel No.
Address/ _A�� Tel. No. 12112 e F y
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,,5ignature on this permit application waives this requirement Owner Agent JPlease Check one)
Telephone No. PERMITf EE $
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 0 In 0
No, of Lighting Fixtures
Swimming Pool
gmd 11 gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
.No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of AJr Cond
Tons
Initiating Devices
Heat Total Total
No. f Diposal
No.
Pumps Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
0 Municipal 0 Other
No. of Dryers
Heating Devices
KW
Local Connecbon
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Sailases
Win'
No., Hydro, Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiLemen6ts of Massachusetts General Laws
I have a curr&nt Liability insurance Policy incl pleted Operations Coverage or its substantial equivalen YaESNO
t�iVlled va id Of same to the offi�QEWTNO = If you have checked YES please indicate the ;(ey rage by checking the appropriate box
1 0 proo� --%
B ND OTHER (Please ecify)
(Ex pilration Date)
f.a� alue of Eldrial Work$_ Foy, k1V
Work to Start Inspection Date Resqpested_______,. �Rough Final 114151�
Signed under the Penalties of pedury:
FIRM NAME LIC. NO.
Lkensee A�lcl< e!;�Vc6iz�w Signature LIC. NO. <:2
A:. Tel No.
Address/ _A�� Tel. No. 12112 e F y
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,,5ignature on this permit application waives this requirement Owner Agent JPlease Check one)
Telephone No. PERMITf EE $
(Signature of Owner or Agent)