HomeMy WebLinkAboutMiscellaneous - 29 DELUCIA WAY 4/30/2018�3
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10352
Date .... y- .....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies thatV Al-,� CA �e � / ��
............................................
has permission to perform .... / .... dl"
...... ................. I<
.... ............... ... .............................
plumbing in the buildings of .... . "IelP /9 1A e-4'
at.C>?..7 ....... -7
.................... .............. . North Andover, Mass
Fee ��.7 ......... Lic. No. Ll .......... Y.
Ch . eckit PLUMBING INSPECTOR
6f kl9,-1A1- H on li�
\A\�)K
�\\VVA
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
POWNER
TYPE OR
PRINT
CLEARLY
CITY-.nQtTi,,. [jn&(JeJC- MA DATE PERMIT#—OW
JOBSITE ADDRESS C- A Y OWNER'S NAME!Rio:� 'R iztPu cc
ADDRESS TEL FAX
OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL El RESIDENTIAL 54,""
NEW: RENOVATION: W REPLACEMENT: PLANS SUBMITTED: YES El NO P""
FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIIJSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSORAN& C&VERAE:
I have a current liabili!y insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES B"'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 El BOND [I
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 E]
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this ap ' tio are t rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wi in co iance ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C—
PLUMBER'S NAME 1()Vtrj C-A<CCt 9� —LdJR, LICENSE # SIGNATURE
MP jP CORPORATION # PARTNERSHIP [:1 # LLC Ej #
COMPANY NAME -,A C, Q MA 1'n ADDRESS 191 V C,
CITY, STATE ZIP TEL
FAX CELL (00 :��q -(-I " EMAILMOCC-il FMOY-e—
r)
\A\�)K
�\\VVA
L.
Date
.......... . ....
TOWN OF NORTH ANOOVER
PERMIT FOR GAS INSTALLATION
'16 k rl� CA Q- (-� I \A�
Thiscertifies that ....................................................................................................................
has permission for gas
. . ...............................................
inthe buildings of ............. ......................................................................................
at ...... North Andover, Mass.
................................ ... ..
Fee ... !PP= ... Lic. No.157-4-S I ...................................................
..........................
Check#, 6� 6� GASINSPECMR
90.68
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
GOWNER
TYPE OR
PRINT
CLEARLY
CITY nit 1c, MA DATE k— 00— PERMIT # 0 bl5
JOBSITE ADDRESS A OWNER'S NAME
ADDRESS TEL FAX
OCCUPANCYTYPE COMMERCIALE] EDUCATIONAL RESIDENTIAL
NEW: F] RENOVATION: El REPLACEMENT: UK-" PLANS SUBMITTED: YESEJ NO Erl*,
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
OTHER
IN URAN�E COVERAGE
I have a current liabili!y nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 9KINO [:1
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CO Y CHECKING THE APPROPPJATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY n BONDE]
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 applicat n re e — a e to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will in plia vAth all ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S;:��
PLUM;B7ER-GFSFITTER NAME ZO(nq Cpj-cC_(tc�T0V-e LICENSE # 2iSIGNATURE
MPE MGF [:] JP Ej JGF 0 LPGIE:1 CORPORATION [:1 # PARTNERSHIP [] # LLC [:] #
M
COMPANYNAME UM 0�( 06j ADDRESS �5 ?.. fi<� A M.6 RVL..)
CITY \3R(,4 STATEMft ZIP 0 TEL
FAX CELL b-1-7 EMAIL AQQ
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The Commonwealth ofMassachusefts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, AM 02114-2017
I. - - Pri Ft EWE]
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1-1 Please Print Le2ib
Name (Business/Organization/Individual):
Address: !S_F5: lftaLaw S A 061
itv/State/Zi
Phone#: ( n F1
Are "Yo -ml-employer? Check the appropriate box:
1. [B I am a employer with 4. [] I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2.0 lam a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. 1 am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
5. 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.]
Type of project (required):
6. F1 New construction
7. E] Remodeling
8. E] Demolition
9. F1 Building addition
10.0-Ele fical repairs or additions
1 . luml
I �Vlumbing repairs or additions
12.F] Roof repairs
13.R Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors 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 polky andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
provided above is true and correct.
Phone #: (0 1 --� -5��q — CI Ab (�--
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
it
D a t e .. ///. �//v
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... j .......... Im 4z '0 A e,
.......................................... ............
has permission to perform *00t::z 4 . ....... ...... ..................
..... . . ............. .... ...
wiring in the building of ............ /�"
it/ .... ... !.X ......... a ....................................................
-th Andover, Mass.
at .......... 7 ....... �0
4 Noii
Fee./10.7 ................ Lic. No��b 7 �qL
....... ..... .......... ..... ........... e .. .. . .... .. .....
&*J �:;�Cz INSPEcr
Check #
1-2098 �)P4- L53c4�>—t4 vv\. 'I 1-�'! 14
Commonwealth of Massachusetts Offici I Use ORIV
Permit No.
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
I[Rev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforined in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00
(PLEASE PPMT IN)YK OR TYPE ALL MFORW TIOA9 Date'—
T
City or Town of. NORTH ANDOVER 0 the lns�ect�orf W�ires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 0e Lk rl-
Owner or Tenant TelepiioneNo.
/f,14;24 2 6/ /-- zw 6
Owner's Address
Is this permit in'conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of . Building .-� 1 A-1 � Z �� �Utility Authorization No.
Existing Service Amps Volts Overhead
New Service — Amps
Number of Feeders and Ampacity
Volts. Overhead 11
Location and Nature of Proposed Electrical Work:
UndgrdE] No. of Meters
Undgrd n No. of Meters
ej
Completion of thefb�lowlng 6ble may be waived by the Inspector of Wires.
No. of Recessed Luminaires 6
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above
Swimming pool grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
—0f
Heat Pump
NM�tr]Xon.s
I
KW
No. Self-contained
No. of Waste Disposers
Totals:
I
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municippl n Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent_
OTHER:
Attach additional detail i(desired, or as required by the Inspector of 97res.
Estimated Value of Eleqtrical Work: 2 50e) . 6�; (When required by municipal policy.)
Work to Start: �& ZY Inspections to be requested in accordance with MEC Rule 10, and upon completion.
JNSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation7' coverage or its substantial equivalent. The
undersigned certffies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
,,CBECK ONE: INSURANCE 1A BOND El OTBER El (Specify:)
I certify, under thepains and,#?e'61ties ofperjury, thatthe information on thi§ application is true and co 1plete. Y
FIRM NAME:. LIC. NO.: 41-,2�--2
Licensee: -T/) Signature LTC. NO.:
(Ifopplicable, enter "eiempt" in'the license number h e) Bus. Tel. No. -
Address: x-,. 0- A/jv 5 4d L,- 0 A 121J Alt. Tel. No.:
*Per M.G.1, c. IiP—, -S. 0-611, sedirity'w-ork reqjuires Depaftmep of Publi Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) Q owner El owner's agent.
Owner/Agent
Signature Telephone No. AMT FEE: $
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall 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. G.L c. 166, § 32, an
electrical permit shall be 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.
Pennits shall -be limited as to the time of ongoing construction activity, and may be -deemed -by the Inspector -of Wires abandoned -and invalid if.he —
or she has determined that the authorized work 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 Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit El
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass N
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTLAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
R UGIJ MPECTION:
Pass X!
Failed
Re- Inspection Required 0
Inspectors CoTffreknts:
Inspectors Signature:
Date:
FINAL INSPECTIOV
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments: /,-%
14.
A
4
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetis
Department oflndustrial,AccW�ls
Office of Investigations
600 Washington Street
Boston., MA 02111
quo www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ib
Name (Businoss/Orgadzation/Individual): 'T_-rr eze�M�Cl � I
City/State/Zip: 44 A 4W6 Phone #:- il 7
Are you an employer? Check the appropriate box:
Type of project (required):
1. 1 am a employer with
N
4. El I am a general contractor and 1
6. E] New con.struction
employees (fall and/or part-time).*
2.11 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. $
7. F1 Remodeling
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
workers' comp. insurance.
5. We are a corporation and its
9. E] Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10.glElectrical repairs or addit . ions
3. 1 am a homeowner doing all work
right of exemption per MGL
1 M Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roof repairs
insurance required.]
employees. [No workers'
13.Fi Other
comp. insurance required.]
!Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�bontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy inforniation.
Iam an employer that isproviding workers'compensadon insuranceformy employees. Below is thepolley andjoh site
Information.
Insurance Company Name;
Policy # or Self -ins. Lic. 9:
Expiration Date;
Job Site Address: c2 120 L w rzzQ city/Statelzip:_041A gL4U12 1-14
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration da�ie)�'/*Y�_
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one�year imprisonment, as well as civil penalties in the fonn of a STORWORK 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.
Ido hereby certify u der thepains andpenalties ofperjury that the information provided above is true and correct.
./T S,— — I I / , , / , " -
Official use only. Do not write in this area, to he completed by city or town offlicial.
City or Town:
Permit[License 0
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 N:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhire,
express or implied, oral or written."
An employer - is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a -deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealthrior any of its political subdivLons shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the' application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Eric.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas ' e be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, reed only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address"' the applicant should write "all locations in _(City or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ii on file for future permits or licenses. A new affidavit must be ffflQd out each
year. Where a home owner or citizen is obtaining a license or"permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone -aiad fax number:
The Commonwalth of Massachusetts
Depaftent of Industrial Accidents
Office of Investigations
600 Wasbington Street
Boston, MA 02111
Tel, # 617-7274900 oxt 406 or 1-877,MASSAFE
Revised 5-26-05 Fax # 617-727-7749
-www.mass.gov/dia
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Location �o4 V #o2 U1,4
No. 6 S,� Date
TOWN OF NORTH ANDOVER
Check # 13 / �-
15826
60ding Inspector
Certificate of Occupancy
$
CHUS
Building/Frame Permit Fee
$ 00
Fouodation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # 13 / �-
15826
60ding Inspector
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Town of North Andover
,Building Department
27 Charles Street -
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax (978) 688-9542
C"
49
APPLICATION FOR CERTIEFICATE OF OCUMANCY I INSPECTION
ADDRESS IVr r -A W,
LOT NUMBER
DATE REQUEST FILED
DATE READY FOR INSPECTION
VIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REOVIRED
ALL WORK AND SIGN-OFF'S MUST BE COM[PLETED WITHIN THIS TIME
FRAME. A RE-INSPJ�CTION FEE OF TWENTY
. �RUC 1. �FIVE ($25.) DOLLARS WILL BE
CHARGED IF THO ,7 -URE PPES*TfiEET ALL APPLICABLE CODES -
SIGNATURE
ROUTING
CONSERVATION,n, DATE
i
//VO
PLANNING
D.P.W. — WATA04TER
�ATE
D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED
0 THE INSPECTION DV QUEST DATE.
;;10-0�
ATURE / DPW AUTHORIZATION
0
4
14/
Location oil, L�vt 1-7
No. 0�- Date S-5 -49).
Check # by Y- 0
15759 crt, e -
Building Inspector
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy
$
CHUS
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # by Y- 0
15759 crt, e -
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BMDING PERM[IT NUMBER: DATE ISSUED:
SIGNATURE: .1�.
Building Commissioner/12a)ector of Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address: �0 7�—
1
41-7 (T
'T
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information: 4vpsf�;
V - 4es
Zoning Disi�ct &posed Use
1.4 Propetty Dimensions:
137
Lot Area (sf) Frontage (ft)
1.6 BUIULDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide. Required Provided
Requir=ed Provided
I o I r.
)r 0 1
1.7 Water ;71ylivE..G., �4) 1-5. Flood Zone Information:
public P, 0, Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 1i OnSiteDisposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIIZED AGENT
2.1 Ownerof Record
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
tep -z//
Licensed Construction Supervisor:
.-16 �Z
Address
7LT el,
Telephone
Not Applicable 0
C5 05-1 /-76
License Number
.2 -- /5—, 0-3
-Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
gnature Telephone
Si
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I SECTION 4 - WORXERS COMPENSATION (KG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... D�" No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction P-'-
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 �pecify
Brief Description of Proposed Work:
.141'k-e4l sfl-1 I Ile
L
-SECTION 6 - ESTE14ATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
0 ONLY,
I . Building
tf
W
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
goo 0
Building Permit fee (a) x (b)
-4 Mechanical (HVAC)
060
5 Fire Protection
-6 Total (1+2+3+4+5)
16-6, coo
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 1 as Owner/Authorized Agent of subject property
Herebymuthorize —to act on
My,�,b�alf., in, 11 matt Is elativeWwork �':tjhfized by this building permit applicat7',
S i-griaWpad Chvner Date
-SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Sir of Owner/A 0 ent Date
,zature
F6_ W, 711 MMEXIM-0—
NO. OF STORIES ;2 SIZE J 4 -
-BASEWNT OR SLAB
SIZE OF FLOOR TINMERS IIT A _te 2 ND 3 RD
i�&L4-2
SPAN
DEAENSIONS OF SMLS
-DINIENSIONS OF POSTS
-DIA4ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TIECKNESS /0//
-SIZE OF FOOTING 2= L4 X
-MATERIAL OF CfMVINEY
IS BUI1,DING ON SOLD) OR FILLED LAND
IS BUILDING CONNECTED TO NATIJRAL GAS LINE
CHU
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 6
Date 6?-Q4-c?663
THIS CERTIFIES THAT
THE BUILDING LOCATED ON
e- /// A,
MAY BE OCCUPIED AS
IN ACCORDANCE WITH THE PROVISIONS OF mAssmm qFTlrsSTATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 8 Pow "b t @L'/�, Z 4+4.5, f0i-411
CERTMCATE ISSUED TO IS I-CPA40A) SN8)
DA I
Building Inspector
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits 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.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT Stvez4o 5�� /4 P H 0 N E 4r
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION /-(,/c LOT (S)
STREET k"- ct D L 0 c- 'a Y' z z-/ 9 S4 IR 'T BER--,7J-
D �sra-H
PUBLIC WORK! - -
DRIVEW
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9\97 jm
TE
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COMMENTS--
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SEPTIC INSPEC
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COMMENTS -
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PUBLIC WORK! - -
DRIVEW
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9\97 jm
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.- 4 Aeal korwo
FORM U - LOT RELEASE FORM Z -
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits 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.
*****************************APPLICANT FILLS OUT THIS SECTION*********************** I
APPLICANT 5" /,, 4 PHONE- '� 7 7 &, F 5_ 1-11Y1
LOCATION: Assessor's Map Number .2 �_/=, PARCEL__���
SUBDIVISION S�;� 1cle t, r 64 4t, -,C LOT (S) (-/
STREET ST. NUMBER__Z_�
I USE I
I RECOMMENDATIONS OF T -OWN AGENTS: I
fig A —f-- go,
CONSERVATION ADMINIST
COMMENTS
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
RECEIVED BY BUILDING INSPECTOR / DATE
Revised 9\97 jm
FOOD INSPECTOR -HEALTH
DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH
DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
;71fll
RECEIVED BY BUILDING INSPECTOR / DATE
Revised 9\97 jm
ftASdheck-CODiPLIANCE REPORT
Massachusetts Energy Code
MAScheck Software Version 2.0
CITY: Haverhill
STATE: Massachusetts
HDD: 6027
CONSTRUCTION TYPE: 1
HEATING SYSTEM TYPE:
DATE: 5-18-2002
or 2 family, detached
Other (Non -Electric Resistance)
DATE OF PLANS: 5/15/02
TITLE: NEW SINGLE FAMILY DWELLING
COMPANY INFORMATION:
STEVEN SMOLAK
COMPLIANCE: PASSES
Required UA = 394
Your Home = 387
Permit #
Checked by/Date
COMPLIANCE STATEMENT: The proposed building design represented in these
documents 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
Area or
Insul
Sheath
Glazing/Door
-------------------------------------------------------------------------------
Perimeter
R -Value
R -Value
U -Value
UA
CEILINGS
1404
30.0
0.0
49
WALLS: Wood Frame, 16" O.C.
1870
15.0
3.0
125
WALLS: Wood Frame, 16" O.C.
160
19.0
3.0
9
GLAZING: Windows or Doors
264
0.350
92
DOORS
56
0.350
20
FLOORS: Over Unconditioned Space
896
19.0
43
FLOORS: Over Outside Air
304
19.0
14
BSMT: 8.0' ht/7.0' bg/0.01 insul.
-------------------------------------------------------------------------------
160
0.0
35
COMPLIANCE STATEMENT: The proposed building design represented in these
documents 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
MAScheck INSPECTION CHECKLIST
1�ass'ac�usetts Energy Code
'MAScheck Software Version 2.0
NEW SINGLE FAMILY DWELLING
DATE: 5-18-2002
Bldg.
Dept.
Use I
CEILINGS:
1. R-30
Comments/Location
WALLS:
1. Wood Frame, 16" O.C., R-15 + R-3
Comments/Location
2. Wood Frame, 16" O.C., R-19 + R-3
Comments/Location
WINDOWS AND GLASS DOORS:
1. U -value: 0.35
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
FLOORS:
1. Over Unconditioned Space, R-19
Comments/Location
2. Over Outside Air, R-19
Comments/Location
BASEMENT WALLS:
1. 8.0' ht/7.0' bg/0.0' insul., R-0
Comments/Location
AIR LEAKAGE:
Joints, penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. Recessed
lights must be type IC rated and installed with no penetrations
or installed inside an appropriate air -tight assembly with a 0.511
clearance from combustible materials and 3" clearance from insulation.
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 and glazing U -values must be clearly
marked on the building plans or specifications.
DUCT INSULATION:
Ducts in unconditioned spaces must be insulated to R-5.
Ducts outside the building must be insulated to R-8.0.
DUCT CONSTRUCTION:
I,
I system must provide a means tor nalancing 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.
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.
MISC REQUIREMENTS:
Refer to 780 CMR, Appendix J for requirements relating to swimming
pools, HVAC piping conveying fluids above 120 F or chilled fluids
below 55 F, and circulating hot water systems.
---- NOTES TO FIELD (Building Department Use Only) -------------------------
-1-A-wad-M&
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 053176
Birthdate: 02/15/1958
Expires: 02J15/2003 Tr.no: 6696
-r_ nA
Mcbmumu :
STEPHEN M SMOLAK
762 DALE ST
NOANDOVER, MA Ola45
Administrator
GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT
TOWN OF NORTH ANDOVERBUILDING DEPARTMENT
This form shall be used to assist the Building Department in their determination of exemption under section
8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the
necessary information as re uested below.
= L07�
13-e�rmit Applicant Property address Map/ Parcel
-q�7
V -
Applicant's Phone Single Family Two Family
I the undersigned applicant for the above property attest that the attached building permit for which this form is completed
does comply with the EXEMPTION section 8.7.6 of the 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
officially accepted when the building permit is issued.
Based on 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 bylaw, provided that no additional residential unit is created.
The lot(s) was / were created prior to May 6, 1996 and are exempt from the provisions of 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 are met and or represents dwelling units for senior residents, where occupancy of the units is restricted to senior citizens
through a property 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 part of a development project which voluntarily agreed to a minimum 40 % permanent reduction in
density (buildable lots) below the density permitted under zoning and feasible given the environmental conditions of the tract, with the
surplus land equal to at least ten buildable acres and permanently designated as open space or farmland. The land to be preserved shall
be protected from development by an Agricultural Preservation Restriction, Conservation Restriction. dedication to the Town, or other
similar mechanism approved bythe planning board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent
parcel on the effective date of this Section 8.7 and shall receive a onetime exemption from the Planned Growth Rate and
Development Scheduling provisions for thepurpose of constructing one single family dwelling unit on the parcel.
This application represents a lot which is ready for a building permit ( 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 submit an approved FORM U with this
EXEMPTION.
PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A
DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS.
BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED
BUILDING PERMIT IS ALLOWED AN EXEMPTION AS CITED ABOVE.
FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE
CHECKING OFF OF A ABOVE EXEMPTION WHICH DOES NOT COMPLY, WHETHER DONE TO MY KNOWLEDGE OR
NAOTIROUNDSF RREF ALB THE L G DEPARTMENT TO ISSUE A BUILDING PERMIT.
LIC
S
-X'Alffft S SIGN DATE
TI -11S FORM TO BE ATTACBED TO THE BUILDING PERMIT APPLICATION
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4133 Date
,0-"OKF" -N 0
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
z'
This certifies that ............. e7— ..........
.................
.......... 7 ............................................
has permission to perform .... .......................
....................................................
wiring in the building of ......
....................................................
at ......... North Andover, Mass.
e ............
F ... ... . .... Lic. No . .....
LEcrRicAL INSPECMR
Check #
TBECOAMONWEALTHOFMASSACHUSEM
DEPAJUMMT0FPUBUCS4FE7Y
BOARO 0FFJREPREVEVH0NREGULA7Y0NS527 CAIR-12-00
vOffice Use only
Permit No. Lk? 3
1z
cc
upancy &Fees Checked I
APPUCATIONFOR PERAlff TO PERFORMELECMCAL 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—/O —9
Town of North Andover
The undersigned applies for a permit to perfonn
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a
Purpose of Building , 3-,(\A I
To the Inspector of Wires:
e electrical work described below.
t) e— L L, c— v
M90117waz
Existing Service I — 'Amps V'Olts
New Service QJQ 0— Amps 1(514,-30 volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
—;' No (Check Appropriate Box)
Yes L[A.,
Utility Authorization No.
Overhead L_J Underground [M No. of Meters
Overhead r--1 Under&ound CE] No. of Meters
No. of Lighting Outlets No. of Hot Tubs N mers
ransfor EEE
'g f TE
No. of Transformers
No. of Lighting EFixtures Swimm 00
Swimming Pool Above M 6Below GeEnerators
round round
I tj 0. of Oi in --A round 0 of KVA
No. of Receptacle outlets No. of Oil Burners 4No. of Emergency Lighting Battery lu--t—s---
No. of Switch Outlets
C/Sc f --
I �?m 5' Ir 4 -h
nS==UDMXa9t POOMttDftmqmniff&dWb%wtxmasC=edj_am —
bawacumtLdXldYk=M=PbkYMCkAgGOffpl&-OpWdb=COWWorgSaftndaMVa]ffI
bawstjbtp&dVAdpFO0f0fSa[W1D1hCOffiM YES Yes NO
i Ifymha,&drckAYESPkmnbc&&�Fofcc)wrwby
ha�gft bg& El
14SURANCE BOND ftazSpoffy) V,(1
7TMD&RWskd Rgh E0matcdVakieofEbcfixalWcjk $
gned underTr Pamkies of pffmls* rMal
RMNANM cc Llfrestw— 7-- DwEeNT0.
misee
sma Ue licumNo
BukmTdNb.
AleJpi VW 0 3 5;J->
Al Tel No 6n-;�
ATU�'SMLRAMMWAMEKlamav�wd9theLxffwdoesnotbavedrff=MCCODWr,igCCr&,wbstarMegLivalalasm#edbyMa%admmclffrdLal�NS
Jfllatrrry*whmonftpmnkappkationwaimNftm#Ml&t
lease check one) Owner Agent M Telephone No. PERMIT FEE $
signature of Owner or AgellL -----------
No. of Gas Burners
No. of Ranges
No. of Air Cond.
Tot
FIRE ALARMS
Tons
No. of Zones ---------
No. of Disposals
No. of Heat
J�
Total
Total
No. Of Detection and
No. of Dishwashers
Pumps
Space Area Heating
Tons
KW
Initiating Devices
KW
No. of Sounding Devices
flined
No. of Self Contai
No. of Dryers
Heating Devices
KW
Detection/Sounding Devices
Local Municipal Other
No. of Water Heaters KW
=J
0 of
No. of
No. of
Connections ID
i ns
S S!
�
Bailasis
No. Hydro Massage Tubs
0.
No. of Motors
of
Total HP
--------------
C/Sc f --
I �?m 5' Ir 4 -h
nS==UDMXa9t POOMttDftmqmniff&dWb%wtxmasC=edj_am —
bawacumtLdXldYk=M=PbkYMCkAgGOffpl&-OpWdb=COWWorgSaftndaMVa]ffI
bawstjbtp&dVAdpFO0f0fSa[W1D1hCOffiM YES Yes NO
i Ifymha,&drckAYESPkmnbc&&�Fofcc)wrwby
ha�gft bg& El
14SURANCE BOND ftazSpoffy) V,(1
7TMD&RWskd Rgh E0matcdVakieofEbcfixalWcjk $
gned underTr Pamkies of pffmls* rMal
RMNANM cc Llfrestw— 7-- DwEeNT0.
misee
sma Ue licumNo
BukmTdNb.
AleJpi VW 0 3 5;J->
Al Tel No 6n-;�
ATU�'SMLRAMMWAMEKlamav�wd9theLxffwdoesnotbavedrff=MCCODWr,igCCr&,wbstarMegLivalalasm#edbyMa%admmclffrdLal�NS
Jfllatrrry*whmonftpmnkappkationwaimNftm#Ml&t
lease check one) Owner Agent M Telephone No. PERMIT FEE $
signature of Owner or AgellL -----------
3�--d
61
4 0 7 2 Date ... Zz---..n/
O'� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
(-3
This certifies that ......................... I, ...................
..............................
has permission to perform . c ---
wiring in the building of ........ .......... ......................................
rth dover, Mass.
at..Z/� ...
Fee<.'-�) ...... —.. Lic. Nor2bA .. ................... . .........
Li'MUCAL INSPECrOR
Check #
official Use Only
io�r /(03 Permi N
VO4VI-W 4 ;pd& 5410 occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Ail work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
Date q- — to --
(Please Print in ink or type all information) To the IA�or of'Wires:
Tom of North And
The undersigned applies for a
Location (Street &
f,*..-- �
omees Address --
to perform the electrical work described below.
�- I " nzcz wco'-J tc4
Is this permit in conjunction with a building permit Yes NK No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No
E)dsting Service___________._Amps�Voits
New 3 vvice —Amps------Ydft
Number of Feeders and Ampacity_
Location and Nature of Proposed Electrical
Overhead 0 Undgmd 0
Overhead 0 Undgmd D
e, /co 1/)
No. of Lighting Outlets
No. of Hot fuse
14U.
Above 0 In 0
No. of Lighting Fixtures
Swimming Pool gmd 0 gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
'No. Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
of
Total
No. of Detection and
No ofAir Cond Tons
Initiating Devices
No. of Meters
No. of Meters
I No. Pumr)s Tons KW No. of Sounding Devices
No. of Diposal No./ of Self Contained
Spec a Healing KW Detection/Sounding Devices
No. of Dishwashers 0 Municipal 0 Other
No. of Dryers "Pating Devices KW Local Connection
No. of No. of Low Voltage
No. of
HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a curr6nt Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have cherq�o YES please indicate the tn� cove7!� b�y checking the appropriate box
17ave submitted valid proof of same to the Office YES = NO = If
INSURANCE = BOND = OTHER (Please Specify) eui 'Rk; 6LT
JExpiration Date)
Estimated Value of Electrical Work$
Work to Ste Inspection Date Resqm,mted Rough__---L-----------Final
Signed under the =0 LIC. NO.— dR611
FIRM NAM
LIC. NO
Bus. Tel No.
J0 C,.b &L /�11 til Aft Tel. No'
Address� I equivalent as required by Massachusetts
OWNER'S INSURANCE WAIVg I h the Licenses does not haye,the insurance coverage or Its substantia
JR: am aware t
General Laws. And that my #i9nature on this permit application waives this rpgu'lrement Owner Agent . (Please Check one)
Telephone No PERMITV�EE S
(Signature of Owner or Agent)
Date.. /e.- ?. 6 -:9.z --
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that X/6', ./� . ...........
has permission for gas installation . . . . . /--**—*****—'*
in the buildings of /,0. .........
at ...... North Andover, Mass.
169 . C/ ' 2"( ..........
Fee��'... Lic. No ......
Check #
4161
MASSACHUSETTS UNIFORM APPUCATON FOR PERNUr TO DO GAS FITTING
A0 — "9
(Type or print) ,,�D<ate
f%UrFW AAT1%f%XrV I" A 00 A qrvro
Building Locations c>2 7 —Y (f c— i k4 Lk-/ A-51 Perini#
Amount $
—Owner's Name v_
New Renovation Replacement Plans Submitted
(Print or
.. — I
one� Certificate Installing Company
Corp -
Partner.
Firm/Co.
Name ofiLicensed Plumber or Gas Fitter r, F<_ je— c-, � .-e--
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent Yes � No[3
If you have checked yes please indicate the type coverage by checking the appropriate box.
Liability insurance policy [0--' Other type of indemnity [:] Bond 0
Owner's Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. C36neral Laws, and that my signature on this permit application waives this requirement
Check one.
Signature of Owner or Owner's Agent , Owner
FE -1
I hereby certily that all ofthe details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and pi5qllations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massafifp6its State Gas C9* and C�pter JA2 of the Qpneral Laws.
(OFFICE USE ONLY)
r,,Signature of Licensed Plumber Or Gas Fitter
.n
Plumber
[:] Gas Fitter License Number
[�aster
E] Journeyman
17TH. FLOOR
(Print or
.. — I
one� Certificate Installing Company
Corp -
Partner.
Firm/Co.
Name ofiLicensed Plumber or Gas Fitter r, F<_ je— c-, � .-e--
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent Yes � No[3
If you have checked yes please indicate the type coverage by checking the appropriate box.
Liability insurance policy [0--' Other type of indemnity [:] Bond 0
Owner's Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. C36neral Laws, and that my signature on this permit application waives this requirement
Check one.
Signature of Owner or Owner's Agent , Owner
FE -1
I hereby certily that all ofthe details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and pi5qllations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massafifp6its State Gas C9* and C�pter JA2 of the Qpneral Laws.
(OFFICE USE ONLY)
r,,Signature of Licensed Plumber Or Gas Fitter
.n
Plumber
[:] Gas Fitter License Number
[�aster
E] Journeyman
Date/q 2—.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .... 1, ........
has permission to perform,-,-,-,-
.... .........
plumbing in the b�uildings of . 4.
at. . . . .......... North%ndover, Mass.
Fee.
.16h. ic. No. .4/0 .
,��PLUMBINIS 7[NS� AT`®R
Check #
5400
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TOD6 -PLUMBING
(Type or print)
Date
Building Location 02 2 -pc L (/ cl,(, 604P6wners Name 5 4- S Penn
Amount
"c;r
Type of Occupancy
New Er"', Renovation ri Replacement 0 Plans Submitted Yes No
FIXTURES
(Print or type) Check one: Certificate
Installing Company Name _& P ( f (� 'g- Corp.
Address 10L �_ 11�j C_ . .0 6�_j Ae8 4, - El Partner.
UJ-T-0';tj '_T7 1 11
SsTelephone 66�� 2VOL-7?,29 1:1 Firm/Co.
Name of Licensed Plumber: efI6 re'v
A -
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Er Other type of indemnity Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature I Owner El Agent 11
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and i stallati ns perform nd r Permit Issued for this application will be in
'o e
setts te Plu 0 of
compliance with all pertinent provisions of the Sta de- h 142 e General Laws.
By: 3igLmture or Eicensea Flumbor-
Type of P bing License
Title
City/Town
APPROVED(OFFICE USE ONLY ri—cense TNumDer Master Erjoumeyman
11