HomeMy WebLinkAboutMiscellaneous - 29 ELMWOOD STREET 4/30/2018ka�
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"-�A
-T This certifies that .... . :TA� (�' 4.
has permission for gas installation ... ................
in the buildings of .....
-i .......................
at ... J ............ North Andover, Mass.
Fee. Lic. No. .
. ............... ...
Check # 4C�4 0 GASINSPECTOR
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
MA DATE M
[j�j— ? PER IT#
CITY
9 NER'S NAME
JOBSITE ADDRESS OW
GOWNER
I--—
ADDRESS _,�r ._=TE����AXE.==—
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
I NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESF-11 NO F—j
9 13 14
APPLIANCES -1 FLOOkS--- BSM 1 2 3 4 5 -6 7 8 10 11 12
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER ---'I '1—j
FIREPLACE i J
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
. .....
LABORATORY COCKS L --J
MAKEUP AIR UNIT
OVEN
POOL HEATER L�J
. . . . . ...
ROOM / SPACE HEATER —jI ... ...
ROOF TOP UNIT
TEST - - - - -
- - -
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
. .. . . ......
INSURANCE COVERAGE YES
I Aave a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITYINSURANCE POLICY OTHER TYPE INDEMNITY BOND FL]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does _not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0-1 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
ith 11 Pertin"ovision of the
under the issued for this application will be in complianceyvi a
and that all plumbing work and installations performed permit
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME LICENSE# '-'-S-rGNATURE
IMP ED MGF JP LPGI CORPORATION [J# PARTNERSHIP[ LLC D -#[j -j&
COMPANY NAME: ADDRESS J1
CITY ...... STATE ZIP ���TEL
FAX LL lb aj EMAIL
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The Commonwealth ofMassachusetts
Department oflndustriqlAceid&ts
Office of Investigations
600 Washington Street
Boston, MA 02111
-wmmass.govIdia
Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
Applicant Information Please Print Legib
NaMC (Business/Organizationqndividual): a 0) 1,4
Address: Me
CitY/State/Zip: 6� ILK 0, 1 R'v//'Phonc#: 9�o&
Are you an employer? Checkthe appropriate box:
Type of project (required):
LEI I am a employer with
4. El I am a general contractor and 1
6. . El Now coAstraction
employees (fall and/or part-time),*
have Fired the, sub -contractors
7 . E] Remodeling
2.44'K;�a sole proprietor or partner-
listed on the attached sheet. I
.
ship and'have no employees
These sub -contractors have
8. El Demolition
working for me in any capacity.
[No workers' comp. Wurance
workers' comp. insurance.
5. El We are a corporation and its
9. F1 Building addition
required.)
officers have exercised their
10.El Electrical repairs or additions
.
3. El 1 am a homeowner doing 0 work
right of exemption per MGL
I LE] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1 (4), and we have -no
12.E] Roo,frepairs
insurance required.] t
employees. [No worke&
Mr! Other
comp. insurance.Tequired.]
'Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information.
I Homeowners who submitthis affidavit indicating they tire doing all work end then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insuranceformy employees. Below is thepolicy imdjob site
infonnallon.
Insurance Company Name-.
Policy or Self -ins. Lic. Expiration Date:
Yob Site Address: City/StatelZip:
Attach a. copy of the workers' compensation -policy cleclaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one�yoar imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
ofup 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 cert�o unriepains an:;dp�en7es Pfperjury that flie informationprovided above is true and correct.
sign Date:
Phone 4:
Official use only. Do not.wrile in this area, to he completed by cl(v or town official
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
- -0
Informaflon and bstrueflons
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. ofhi-ro,.
express or implied, oral or written."
Am emploYdis 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
ow-ner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwellinghouse, of another who employs persons to do maintenance, construction orrepair work on such dweiling ho�iiso
or on the grounds or building appurtenant thereto shall not because, of such employment be deemed to be. an employer."
MGL chapter 152, §25�(Q 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 hasnot produced acceptable evidence of compliance with the insurance coverage requ.1red."
Additionally, MGL chapter 15 -2, §25C(7) states "Neither the commonwealth nor any ofits political subivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to. the contracting authority."
Applicants
Please fill out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone numbar(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 carty workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confimi];ationofinsurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that thic application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or ifyou 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 he.
City or Town Officials
-Please be sure -that-the affidavit is -complete and-printehegibly. TheDelfaffifibntlffs�f6vid6dh-sp—a-c--ea—t-tEe--b-'o--tt-o--m--
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number whichwill be used as a reference number. In addition, an applicant
that i�ust submit multiple permit/licause applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Job Site Addre&; the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has bean 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. Anew affidavit must be fille�d out each
year. More, a homeowner or citizen is obtaining a license or*�Ormitiiot related to any business or commercial venture
(i.e. a dog license orpiermit to burn leaves etc) said person is NOT required to complete this affidavit.
The Office of Investigations'would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number. -
Tho Commonmalth of M-asutchwe
Dapartment of ladustdal Accidents
office of bVesfigailas
600 WasWVou Street
Boston, MA, 02111
Teel, # 617-727-4900 at 406 or 1-877�WSAF
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Bay State Gas
A NiSource Company
May 22, 2006
Silva Frank Account Number: 8753520061
29 Elmwood St
North Andover, MA 0 1845
Dear Silva Frank:
This follow-up letter is to inform you that your gas Boiler located at 29 Elmwood St has been tagged
due to a violation of state safety regulations. It is unsafe to use until the following condition has been
corrected.
water flooding
The Masachusetts code pertaining to the installation of gas appliances and gas pipmig, established
under Chapter 737 Acts of 1960, requires that the condition be remedied.
If you have questions or would like to discuss this issue, please call 978-687-1105 and ask for the
Service supervisor.
Please disregard this notice if the condition has been corrected.
Sincerely,
Service or Meter Department
Bay State Gas Company
CRR:CRR#
C:\dsupdatedle�PdV16
"ston Street P.O. Box 869 Lawrence, MA 0 1841-2312 978-687-1105 Fax: 978-688-18
A- 2012 Mqssachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
U -`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.
Permits shall -be limited as to the time of ongoing construction activity� and may be.deemed.by the Jnspector-of-W-ires abandoned-andinx-alid-ifte—
or she has determined that the auffloriz6d 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 shaH be terminated upon the written
request of either the owner or he intalling entity tat I o t1 permit application.
P
.The Permit Extension Act was createdbySection 173 of Chapter 240 of the Acts of`2010 and extended by Sections 74 and 75 ofChapter 238 of
theActs of 2012. The, purpose of this act is to promotejob growth and long-term economic recovery and the PermitExtension Act furthers this
p�ipose byestablishing an automatic four-year extensionto certainpermits and licenses concemingtheuse or development of real property. With
limited exceptions, theAct automatically extends, forfouryears beyond its otherwise applicable expiration date, anypermitor approvalthat was
"in effect orexistence'� duringthe qualifying period beginning on August 15,2008 and extendingthrough August 15,2012.
&(Rule 8 — Permit[Date Closed:
/ �1' Note: pply for new permit
L
kermit Extension Act — Permit/Date Closed: 5'-
0 0
49
Ar
Date .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform_:l.___-l-e._..'.,. ...... ..........
.. ..........................................................
wiring -in the bw' Ing of.... .....
C2
....................
at ........ 9 .............................................. ... ..,North Andover, Mass.
Lic. Nw�—i�AAZ .... . ..... .. ..
-fee .......................
ELECTRICAL IMP EcTOR
Check #
6649
VV
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 64,17
Occupancy and Fee Checked
[Rev. 9/05] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 2 CM 12.00
(PLEASE PRINT IN INK OR TYPE ALL 1 49
0. TION) Date: �7 � 06
City or Town of- 01 To the Inspector of Wires:
By this application the undersigned gives notice o1bis or her inte t i t f the electrical work described below.
y ior oF orm
Location (Street & Number) Is
Owner or Tenant
Owner's Address
C
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service /00 Amps Volts
New Service Amps I Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
Yes 0 NqM (Check Appropriate Box)
Utility Authorization No.
OverheadZo Undgrd 11 No. of Meters
Overhead F1 Undgrd F1 No. of Meters
No. of Recessed Luminaires
No. of Ceill.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In
Swimming Pool grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JNo. 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
No. of Waste Disposers
HeaMu—m—p7—Number
Totals:
I
I Tons
KW "No.
of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local Ej Municipa 1 [1 Other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No 6r—
Signs Bailasts
—
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
elecommunications Wirin :
. No. of Devices or Equivalent
OTHER: I
Attach additional detail if desired, or as required by the Inspector of 14"ires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the pennit issuing office.
CHECK ONE: INSURANCE4�1� BOND F] OTHER E] (Specify:)
I certify, under the .
.!j!fains andpen tes qf perjury, tha, the information on this application is true and complete.
71d
I t4FIRM NA U, C - , - C, "; C, "I LIC. NO.:
Licensee --1%0141 as 8d ldvc- Signature LIC. NO.: 3 3.6,;2 0
(If applicable, ter "exe t inVicense unibfr lin�r) Bus. Tel. No.: 653 - 41-3 7
Address: �J &1 atoq 0--�p -3ai-
7 0
Alt. Tel. No.: 92f R4-5 - 620
*Security System Contractor License required for this work; if applicable, enter -the license number here:
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) F] owner 0 owner's agent.
Owner/Agent
Signature --- Telephone No. FPERMIT FEE. $
Date ... �. ......
t&ORTH
LT?WN16F NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . .11.-7" /!,-: —.,. . �. , .��
has permission for gas installation ............................
in the buildings of ..........................................
at ... North Andover, Mass.
Fee. .
Lic. No ........... .... ..........
Lk-�:I t4 �SPECTCW
Check #
5616
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date
Building Location Permi7#
Owner Amount
New Renovation Replacement Plans Submitted Yes No
FIXTURES
P
1P
01 P,
(Print or type) Check one: Certificate
Installing Company Name Corp. 75;
Address ::z Partner.
Business 1flephone Firm/Co.
Name of Licensed Plumber: -5-53--e-
Insurance Coveray
,,e: Indicate 2tfij5,,Pyqe of insurance coverage by checking the appropriate box:
Liability insurance policy M/ Other type of indemnity 1-1 Bond
Insurance Waiver: 1, the Adersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
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 ins"on ' s perform54nder Permit Isslied for this application will be in
compliance with all pertinent provisions of the Massac s e ode and General Laws.
r
By: Signalm u Zm';e;
Title Type of Plul["g License
City/Town
APPROVED (OFFICE USE ONLY ricense NUMDer Master P`�' Journeyman
Date
7 ... A
TOWN OF NORTH ANDOVER
49
S CHOS
This certifies that ... 1,�71. AJ,`
has permission to perform ......
PERMIT FOR PLUMBING
.... .............
plumbing in the buildings of .-. - ( ...............................
at. . ). 5. . 4� tk�. Jo� �1.1� ......... North Andover, Mass,
Fee. . Lic. No .......... ....... .............
IPLU-M�ING*�INSPECTOR
Check #
MASSACHUSErIN UNIMRMAPPUCATON FOR PERMrr TD DO GAS Ffr]nNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
S,7 -
Date :Z:�/ C,
New 11 Renovation 1:1 Replacement gy Plans Submitted 1:1
Permit #
Amount $
(Print or type/* 2� -cr2 Check one: Certificate Installi Cempany
Narne— M Corp. . 1:;�;VW-� -
ElPartner.
ElFirm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Chec On i
I have a current liability Insurance policy or it's substantial equivalent. Yes W No
If you have checked yes, ple!LAdicate the type coverage by checking the appropriate box.
Liability insurance policy /EJ -11 Other type of indemnity 13 Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
I Check one:
Signature of Owner or Owner's Agent Owner E-1 Agent F-1
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 installatigiaS performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massacl ��S�ds Code a%d-C
,7),apter 142 of the Qeneral Laws.
ICity/Town
I APPROVED (OFFICE USE ONLY)
_,_,,�ignature of Licen�ed Plumber Or Gas FiVer
LJ'Plumber
0 Gas Fitter License Nu=er
rZn�Naster
Journeyman
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SUB -B A SEM ENT
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2ND. F L 0 0 R
3RD. F L 0 0 R
4TH. F L 0 0 R
5 T H F L 0 0 R
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6 T H F L 0 0 R
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7 T H F L 0 0 R
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8TH. FLOOR
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-
(Print or type/* 2� -cr2 Check one: Certificate Installi Cempany
Narne— M Corp. . 1:;�;VW-� -
ElPartner.
ElFirm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Chec On i
I have a current liability Insurance policy or it's substantial equivalent. Yes W No
If you have checked yes, ple!LAdicate the type coverage by checking the appropriate box.
Liability insurance policy /EJ -11 Other type of indemnity 13 Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
I Check one:
Signature of Owner or Owner's Agent Owner E-1 Agent F-1
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 installatigiaS performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massacl ��S�ds Code a%d-C
,7),apter 142 of the Qeneral Laws.
ICity/Town
I APPROVED (OFFICE USE ONLY)
_,_,,�ignature of Licen�ed Plumber Or Gas FiVer
LJ'Plumber
0 Gas Fitter License Nu=er
rZn�Naster
Journeyman
Location W 00d
No. C-�;> Date
400VTPI
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
CHU
Building/Frame Permit Fee
$
Foundation Permit Fee
$
j>00 /
Other Permit Fee #ic,
$
TOTAL
$ C>2 J-(
Check # 0 g #—
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVAT5 OR DEMOLISH -A ONE OR TWO FAMILY DWELLING
R� %' 11, �, � , I — v � � I - a
nl��, f�
BUELDING PERMff ER: DATE ISSUED:
SIGNATURE.
Buildng Commissioner/InWector of Buildings Date
I SECTION I- SITE INFORMATION I
1. 1 Property Address:
9 f
1.2 Assessors Map and Parcel
mNum be,
Number:
Parcel Number
Alcavi Quvcvi�rc, ex��,,5. oiFY5
1.3 Zoning Information:
Zoning District Proposed Use
2.2 Owner of Record:
Name Print
1.4 Property Dimensions:
Lot Area (sf)
Frontage (ft)
1.6 BUILDING SETBACKS (ft)
SECTION 3 - CONSTRUCTION SERVICES
Front Yard .
Side Yard
3.1 Licensed Construction Supervisor:
Licensed Conttruction Supervisor:
Address
Signature Telephone
Rear Yard
Required Provide Required
Provided
Required
Provided
3.2 Registered Home Improvement Contractor
Not Applicable 0
1.7 Water Supply M.G.L.C.40. 54) 1.5.
Public 0 Private 0 zone
Flood Zone Information:
Outside Flood Zone 0
1.8
Municipal
Sewerage Disposal System:
0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSMP/AUTHORIZED AGENT
2.1 Owner of Record
Name'(Print)
V2
z T Ve t? �17/yllz
Address for Service
aa
Signature Teleph6ine
2.2 Owner of Record:
Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Conttruction Supervisor:
Address
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (MG.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 ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check appUcable)
New Construction 11 Existing Building 11 Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work: 1
I ISRCTION 6 - FSTIMATRD CONSTRUCTION rOqT.S I
Item
Estimated Cost (Dollar) to be
19.1"', .---
�4-4 "�� ,
r1p
Completed by applicant
permi
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Aut horized Agent of subject property
Hereby authorize to act on
Y behalf, in all matters relative to work authorized by this building permit application.
.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED 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
Simature of Owner ent Date
=OMM
NO. OF STORIES SIZE
BASENIENT OR SLAB
SIZE OF FLOOR T&MERS iST 2 ND 3RD
SPAN
DEMENSIONS OF SILLS
DINIENSIONS OF POSTS
DaIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVNEY
IS BUILDING ON SOLD) OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
D. Robert Nicetta
Building Commissioner
(978) 688-9545
.,..�(978�688-9542 Fax
Please print
DATE—
JOB LOCATION
Number
Town of North Andover
Building Department
27 Charles -Street
North Andover, MA. 01845
HOMEOWNER LICENSE EXEMPTION
Street Address
"HOMEOWNER SIL
Name
Home Phone
PRESENT MAILING ADDRESS ��9TZ-A�,W&6)
City Town
State
,:;� ('// C/,)
Map lot
W0_1:� P —ho n
zip Code
The current exemption for "homeowners" was extended to include owner-<=upied dwellings
of two units or less and to allow such homeowners to engage an individual The hire who does
not possess a license, provided, that the owner acts as supervisor. (State Building Code Section 108.3.5. 1 y
DEFINITION OF HOMEWOWNER:,
Person(s) who owns a parcel of land on which he/she resides or intends to reside, . on which
there is, or it intended to be, a . one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one . home in a
two-year period shall not be 'considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by4aws, rules and regulations,
The undersigned "homeowner" certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply wit:h said procedures and requirements.
HOMEOWNER's SIGNA
APPROVAL OF BUILDING OFFICIAL
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Location,-�(?
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
4CH
E
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIJ RENOVATE, OR DEM SH A ONE OR TWO FAMILY DWELLING
BUELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building C gE2!qw-tor of Buildings Date
SECTION I- SITE INFORMATION I ---- . - .
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
:29 E�I-Mwoote S-MEET7
A6jtrW
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
�red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public 0 Private D Zone Outside Flood Zone 0
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHW/AUTHORMD AGENT
historic Di'strict: Yes RO
2.1 Owner of Record
A./ S'a V/9
4NpyooV SMFE7'
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:
Not Applicable
CLI � (--z-vu Is
Licensed Construction Supervisor:
License Number
�ew
4-ddress
Expiration Date
Agnatur Telephore
. p 0
6,p
:I*AOL� , Dq
3.2 R&stered Home Improvement Contractor
7—
Not Applicable 0
Company Name
Registration Number
,Address
Expiration Date
Signab/e Telephone
1
610W/J�
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I SECTION 4 - WORXERS COMPENSATION (MG.L C 152 4 2506) 1
Workers Compensation Insurance affidavit must be completed and submitted Arith this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes ....... El No ....... 0
SECTION 5 Description o Proposed Work (check
appHcablo
New Construction 0
Existing Building 11
Repair(s) [I
ons(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 11 Specify
Brief Description of Proposed Work:
h(Al-V
i2glep C
M A4 14;&
*F-4 J.',. a 6 If w, �V CI-6WAV Fil-L., on&
CV0VCeCT-E W6'&&S 7-001f; J'4:1g, age,
-SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit licant
1. Building
(a) Building Permit Fee
Multipi er
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
-5 Fire Protection
-6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZ 4 ION TO RE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-------------- - Cas:OEe:r)/uthorized Agent"of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
-Signature of Owner Date
_SECTION7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorize�Agent of subject
property
Hereby dl�ec�larat the statements and information on the foregoing application are true and acc-pte', to the best of my knowledge
_f
and belief
Print Name
Signature of Owner/Agent Date
-NO. OF STORIES SIZE
-BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 2 ND 3 PD
SPAN
-DIMENSIONS OF SILLS
-DRvENSIONS OF POSIL
-DEAENSIONS OF 2MERS
HEIGHT OF FOUf4l)ATION THICKNRSS
-SIZE OF FOOTING X
-MATERIAL OF CHIMNEY
-IS BUILDWG ON SOLID OR FILLED LAND
-IS BUILDING CONNECTED TONIATURAL GAS LINE
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07/25/2005 16:05 FAX 6033821652 INSMANCEEXPRESS
10001
DATE (IMMM"
__r; LIABILITY INSURANCE 07/25/2005
-A' OF INFORMAIM
MATTM
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Frank Silva
L? E i ood Street
4 "1
twthlndovesr', MA 01845
ACORD 25 (2001108)
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Vic CERIFICAM
0E.-SHOTAMENMEMMOR
Ms URE'RS AFFORDING COVERAG #
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Plaistow, NH 03865
------------
_j1 ISI -11 FC04 THC POL!"Iff NQIYVIT " MDNG
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L? E i ood Street
4 "1
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IMPORTANT
It the cartificate NAd,,6*,r is an ADDITIONAL IN5UR.Ff-), *w oicy(ies) must be andompri. A ztatment
nm emfor rinhi.v. On thp hN.(ipr in lia! I of such endorsempnt(sy.
If SUSIROGATION IS WAIVED, subject to the terms and conditions of the policy, certa. In pollrAss may
require an endorsement. A blatement on this certif"te dr.%gs not confer rights to tie carlafficate
T"w 01 inwirancR on the reverse tilde of this fban dom tjol consfitulie a wltrwl betw#Ow
th—p i.elstOno imurpresi, authorized reDwenlative, or nmclitcar. and ft certificate holder, nor does it
ACORD 25 (70011108)
JUL 2b,2UUb 16:33 60338216b2 Page 2
DePartment of IndumW Accidents
Office of Invesdgadons
600 Washington S&ed
Bostoj; AM 02111
klip WWW.MaS&goV1dff8
Workers' Compensadon Insurance Affidavit: Builders/Contractors/Electiidans/Plumbers
ApipUcant Information Please Print Leribly
Name (Busims/organization%dividual): 2jQ_Mj7g,_
Address:
City/State/Zip: (�4 � '& —A - Phone JV: 6 0
Are you in employer? Check the, appropriate box:
1. 0 1 am a enloyer with
4. C] I am a general Contractor and I
rb_ (full and/or part-tinz).*
have hired the sub-contracbm
a e
2. Sol proprietor or partner-
fisted on the attached sbeet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
(No workers' conip. insurance
workers' comp. insurance.
5. 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,
OUP. insurance required.]
Type of ProJect (required):
6. New construction
7. Remodeling
S. Demolition
9. Building addition
10 -El Electrical repairs oT additions
I 1 .0 Phunbing repairs cir additions
12.[] RA
,9f TepsjM
.Y FF. zu� Mou lug UM u3c accuon Mlow mowing Um worken' coulmiabon pobcy infannatiom-
t Honnownm who subinit Ons effidevit indWaling dity on doing an work end Own hire ouWde contd. = submft a new affi&vit jnd�g inkh.
kC.onvocam tot check ft box me avahed = eddifional abeet dwwirg %e nnine offt suhvonawtm and thek wo*em, OMM. poNcy infomintion.
I am an employer" Isprovidlas workers, conymnsadon
Information; . . Insurancefir Xly emplaym Below Is Me polky mdjpb.*e
Insurance Company Name:
Policy # or Self -ins. Lic. M Expiration Date:
Job Site Address: 2 9 Ft M im retl V —j. Aj6d MORrAe 1?4UV.A.X
hize city/StaZzip: 42d&�-r- at'?9C
Attach a copy of the workers' compensation policy declars"on page (showing the policy number and expiration date).
Failure to secure coverage as requiref under Section 25A of MGL c. 152 can lead to the fiWsition of criminal penalties of a
fine up to $1,500.00 andi/or one-yearImprisonmen% 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 fbr hwance coverage verification.
I do hereby cerdft under the pains andpenakies ofperjury that Me InfwmMUnprovided above Is true and correcL
Silmature:
Phone #:
Offlchd use only. Do not write In this area, to be compkted by eby or town ojki&L
City or Town:
Issuing Authority (circle one):
1 -Board of Health 2. Building Deport at
6. Other
Contact Person:
Permlt/Llcense #
3- Cky/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
Phone 0:
iLmormation allU JL115LI U%AJIV113
Massachusetts General Laws chapter 152 requires all employers to provide workers' compew2tiOU for their enip'Oyees-
pursuant to this statute, an employee is defined as ,...every person in the service of another under any contract of hire,
express or implied, Oral OT written."
An employer is defined as -an individual, partnership, association, corporation 6T other legal entity, Or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
a,n individual, partnership, association or other legal entity, employing ernplOY00. However the
receiver or trustee Of cupan
owner of a dwelling house having not more than three apartments and who resides therein, or the oc t Of the
dwelling house Of another who employs persons to do maintenance, coustruction or repair work on such dwelling house
or on the giounds or building appurtenant thereto shall not because of such employment be deemed to be an eniploYcr."
MGL chapter 152, §25C(6) also states that " every state or local licensing agency shall withhold the Issuance or
renewal of & license or permit to operate a business or to construct buildings in the commonwealth for NUY
applicant who has out produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of con4)liance with the fimZraucc
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fin out at workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractOT(s) name(s), address(es) and phone number(s) along with their certificate(s) of
msurance. Limited Liability COMPRIUCS (LLQ Or Lunited Liability Partnerships (LLP) Ynth no employees other than the
members Or partners, are not required to carry workers' conqxwation 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 hidusprial
Accidents for c4=fh=ti0n of fimrance coverage. Also be surt to sign and date the affidavit. 7he 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 qtLestions regaTding the law or if You are required to obtain a workers'
convensatiou policy, please call the Department at the nunber listed below. Self-inmrod. cOnVanies should enter their
self-insurance license.munber on the !2222��Hne. �-.
City or Town Off1dals
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fbr you to fill out in die event the Office of Investigations has to contact you regarding the applicant
Please be sure to fin in the permitnicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit1license applications in any given year, need only submit one affidavit indicating current
policy inforuption (if uppessary) and under "Job Site Address!'Ihe applidant'ibouid write "all locations in -(city or
town).99 A copy of the affidavit dW has been officially stunped or Marked by the city or town may be provided to the
applicant as proof that a valid affiJXvit is on file for future permits or licenses. A new affidavit must be filled Out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to 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 liesitate to give us a call.
The DepartmeOt's address, telephone and fax number:
Ile Commonwealth of Massachusetts
11 Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 wwwmm.gov/dia
vtORTil TOWN OF NORTH ANDOVER
.,,So ". 6 -
OFFICE OF
BUILDING DEPARTMENT
400 Osgood Street
North Andover, Massachusetts 0 1845
D. Robert Nicetta,
Building Commissioner
HOMEOWNER LICENSE EXEMTTION
Please mint
DATE:— 7 C--�6— —
JOB LOCATION: d 9
HOMEOWNER
Number Street Address
Telephone (978) 688-95454
Fax (978) 688-9542
Map/Lot
Nam6 Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town
State
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5. 1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with saWorocedures and
requirements. ---) -7 -1
HOMEOWNERS SIGNA
APPROVAL OF BUILDING OFFICIAL
BOARD OF MPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PI.,AN-NfNG 688-9535
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In. accordance. with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
C 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
kj'&
(Location of F,
Fire Departinent Sign off-.
Dumpster Petmit
Signature of Permit Applicant
Date