HomeMy WebLinkAboutMiscellaneous - 290 BARKER STREET 4/30/2018 (2)I
D a t e .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
/A�
/1 1 le,
Thiscertifies that ............................................................................................................................
has pennission to perf onn C,
............................................... ..............................................
wiring in the building of .... / / +1 &-
....... f�� ..... . ...............................................................................
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at ...... ... 2 ................................... x
.......................................................... . North Andover, Mass.
Fee .......... 0� ...................................................................................
. ............ Lic. No.ft)
ELECTRICAL INSPECTOR
Check #
t Z
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. I )Q� , 1
Occupancy and Fee Checked
Lev. 1/07] (1,up bla'lr)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforrued in accordance with the Massachusetts Electrical Code Q%MC), 527 CMR 12
(PL E, 4 SE PR TNT IN NK 0. R TYP E, 4 L L I NFORMA TIOA 9 Date:- 7–Of
City or Town of: NORTH ANDOVER To the Inspec . tor of Wires:
By this application the -undersigned g 'es notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 2 J c)
OwnerorTenant
Owner's Address �-,Alvve_ +7
Is this permit in conjunction with a building permit? Yes
Purpose of Building__kA6 M.,
Existing Service — Amps volts Overl e,
New Service Amps Yolts Overl
�& 9, v
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
M
U/1 Completi
Vires.
INo. of Recessed Luminaires
No. 6f Cefl.-Susp. (Paddh
No. of Hot Tubs
Swimming Pool Above
Lyrnd.
No. of Oil Burners
FMMjE ALARMS No. of Zones
N
No. of Luminaire Outlets
0' of L'
N 0. of L Im
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Gas Burners
No. of Det7ection and
Initiatin Devices
n
[
No. of Ranges
Total
No. of Air Cond. Tons
-Pu
0 le
. rtinj
No. of Alerting Devices
No. of Waste Disposers
ffeat iu�
p
s�Totals:
T R�
-No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Municipal F1 other
Connection
No. of Dryers
No. &f_ —Water
Heaters KW
Heating Appliances KW
No. o No. of
signs Ballasts
Security Systerus:%,
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage)3athtubs
No. of Motors Total _1P
Teiecoiiii�u�ications Wiring:
No. of Devices or Equivalent
R:
Aaaen aaamonai aetau Y desired, or as required by the Inspector of 97res.
Estimated Value of Electrical ork 26(f-"? — (When required by municipal policy.)
Work to start:- 1 ctions to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE aRAG : 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 operatiolf' coverage or its substantial equivalent. The
undersigned certifies that such Tve
�age is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE b- BOND 0 OTBERE] (Specify:)
I certify, under thepains andpenalties 0 erjury, t7; t the information on this application is true and complete.
FIRM NAME: LIC. NO.:
Licensee: 4 Signature LIC. NO.: &C
(If applicabl r -xempt" in the license number h e) 7
re k> S.Tel.No.aw��
Add r 21 P,4 (S 43 7�� u
fflf'ir t7�"f/ IJW9�Alt. Tel. No.:
*Per IV. c. 147, s. 57-61, seicu��itywork requires Department of Public 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 (che one) 0 owner El owner's agent.
Owner/Agent
Signature Telephone No. WE: $
0 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.
Permits 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.
R The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 20 10 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 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass M V/
Failed
Re- Inspection Required 0
Inspectors Comments:
e:1 42
Inspectors Signature:
A(_
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimae.com
a
8
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS
I[Rev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code WQ, 527 CMR 12 0
(PLEME PNNT IN IYK OR TYPE,4LL NFORAM TION) Date:— I _-I - 7 of �
City or Town of.- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intentionA-Perforin the electrical work described below.
Location (Street& Number) re;�- S (
Owner or Tenant Telephone No.
Owner's Address
Is this permit in'conjunction with a building permit? Yes El No [:A""- (Check Appropriate Box)
Purpose of Building kA6 K Utility Authorization No.
Existing Service Amps — volts Overhead [-] UndgrdF] No. of Meters
New Service Amps Volts Overhead D Undgrd n No. of Meters
Number of Feeders and Ampacity
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ei In—
grnd. grnd�
N—o.of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. 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
Heat Pump
Totals: �
Number
* * ** "]
I Tons
................
I KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Mun1c'Pfil El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Wa—ter
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Eu uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of M. res.
Estimated Value of Electrical rk: (When required by municipal policy.)
Work to Start: --7-2zir kp.,—i!on�sto be requested in accordance with WC Rule 10, and upon completion.
INSURANCE OVERAGE: 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 operatioif 'coverage or its substantial equivalent. The
undersigned certifies that such cfv�pge is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE ffT BOND [I OTEEREI (Specify:)
I certify, under thepains andpenalties erjury, t7i ithe information on this application is true and com
Of plete.
FIRM NAME: P I 1 11 LIC. NO.:
Licensee: Ttw 1� P/4 W 17V Sjgnature!Q�� LIC. NO , : &Q Uri
(If apphcabl� xempt" in the license number us. Tel. No.-LK.��5� . es 7 Po
,,,e7r
6c j,9,2 r i P4
Ad 9 1��
dress: R ffwr dmvA Alt. Tel. No.:
*Per M.G1 c. -141, s. 5�-61, s�curity work r6qiiires Departm6nt of Public 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) D owner El owner's agent.
Owner/Agent
Signature Telephone No._ PtkWTFEE.- $
2012 Massacbusetts 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.
Permits 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.
F1 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.
• Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass [N
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL VqSPECTION:
Pass [N V/
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Z3
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
P
J,
0
-Jhe Commonwealth of Massachusetts
Department of IndustrialAccidefits
I Congress Street, Suite 100
Boston, HA 02114-2017
www.mass-gov1dia
ictors[Fleqtr1cians/PkPbers-
vit: Builders/contr�
Worke&, Compensation insurance Affida
I TO BE FILED WITH TEE pERMUTING AUTHORM
AD
(f EJ5 F_�
Name (BusinesslOigaAzat'onffnd'v'd"al)'Zl-'I,
Address: le, r)
h
(j�4p c1le
City/State/Zip:
Are you an P�Gye C4 4 tte app6priate box:
Type of project (Tequired):
7. El N6Vdonst4diOn
1. 1 am a employer'With �mployces (full ancVor part-tirne).-*
Orp erbip and have no employees working for me in
8- El kemodelitg
2.[J 1 am a sole propu....
any capacity. (No workers' cOmP. insurance required-]
9. Demolition
3Q 1 am a homeowner doing all -�Vork myself [No workers' comp. insurance required.]
10 Building addition
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property- I will
insurance Or arc sole
11. CgElec4ical repairs or additiPAS
-
ensure that all contractors qither have workers' compensation
12. EJ.PrTlMbing repairs or addition$
p,op,i,t,,, with no eQpldy66s-
5. 1 am a general contF4ct , piand I have hired the Ilb-COntractors listed on the attached sheet.
OOMR msur"`�
13% Ro6f re�airs
These sub-contrac,tor� ci4ioyees and have workers'
14. Other------
6.FJ We are a corporatigg and its officers have exercised their right of -exemption per MGL c.
ur
hate [No workers' comP. ins Me reTriled
152, § 1(4), anq We n� �'m pidydes.,
so on below showing their workers' compensation
applicant that chd,,Ic§ bb -k 411 nl�� �11 ' I fill out the secti
outside contractor,
Policy informatiolL
must submit anew affidavit indicating such.
'I Homeowners who su�ij,tbi� aMhavlt indic�atingtheY are doing 11 workandthenhire
bi ta the q p th QP es� v
1;�':i must d �n additional sheet showing the name of the- sub-cOntractOrs and s tPwhq r r Ot os utig ha e
tCont,a,tor, that che,ktbis attache ovide their workers' comp_ policy number -
-
employees. If the sub -contractors have employees, they must Pr
Below is thepolicy and)0b slt�
that is providing workers) compensation insurancefor MY emP lbyees.
I am an employer
information.
S_ 0 t,+
Insurance Company Name:_
Cs c.-) c 4:) (!�) 7, —Expiration Date
Policy # or Self -ins. ic. 4*____�
fob Site Address: -zc( b P -A V, K(-- �, (�2> � City/State/Zip: Xpixation date).
Attach a copy of the workers, co-mpeTsation policy c[eclaration page (showing the policy number and e
a criminal violation punishable by a fifib up to $1,500-00
Failure to secure coverage as required under MGL C. 152, §25A is an
enalties in the form of a STOP WORK ORDER dafincofupto$250.00a
and/or one-year imprisonment, as well as civil p a ns th DIA insuran
day against the violator. A copy of this statement may be forwarded to the office of frivestig tio Of 0 for - ce
coverage verification. e informationprovided above is trve and correct
I do hereby cer der tf epain ndpenalties ofpe1jUrY that th
or town official.
official use only. Do not write in this area, to be completed bY MY
permit/License #,
City or Town:
issuing Authority (circle On"'-). I
1. Board of Health 2. Building Department 3. City/ToWn Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Phone
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to providc workers' compensation for their enlpk6y�es.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofw�,
express or implied, oral or written.,,
An employer is'dbfined as "an individual', Partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enf6rpri8e, and including the legal representatives of a deceased employer, or the
receivbt'o'r, trustdd 6 fan individual, partnership, association or other legal entity, employing emploype�. - However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupani 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 b6 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 opdrate a business or to construct buildings in the commonwealth for any
applicant who has Aot proiduced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(�) states "Neither the commonwealth nor any of its political subdivisions shall
enter intp any contract for the performance of'public work until accep'table evidence of compliance with the insurance
requirements of thi I s chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
nece�sary, supply sub'contractor(s) name(s), address(es) and phone number(s) along with their cerflflcate�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 orLLP d6e's have
employees, a policy is required. 1�e 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 Dep'artment of
Industrial -Accident's. �hould you have an y* questions regarding the law or if you are required .. to obtain a �v6rkers'
compensatiad policy, please call the Department at the number listed below. Self-insured companies shoWd enter their
self-insuranc'e 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 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.
Please be sure to fill in the Permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple permit/license applications in any given yearneed 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 is o f a for Riture, pe ts or lice ses. A new
11 d m2i n 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 Department's address, telephone*and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite loo
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAYE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
y
Date ...... IdI2�1
.............. . ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ("e) �e_ ao e/rz, -,,,
............................................................................................................................
has permission to perform.. 13 i;4�
.U. Z1_d'*
wiring -in the building of ................... �A'.5 /
.....................................................................
......................................
............................................ . North Andover, Mass.
................... Lic. No . ................. . %
Checkit 'g6Z-15 E CT ��ALt��i
i 1950
J
M
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
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 performed in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00
(PLEA SE PRIWT IN NK OR TYPE,4 LL I NFOR MA YYOA9 Date:
City or Town of.- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) i� (�V A a -,v, Ltz c<:�je
Owne rorTenant Telephone No. M1 -,3eLJ!V-
Owner's Address
Is this permit in conjunction with a building permit? Yes No f4 (Check Appropriate Box)
Purpose of Building — Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd
New Servic Amps Volts Overhead Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completion ofthefollowin table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In-
Rrnd. grnd.
No of'Emergency Lighting
Bat'tery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. 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
Heat Pump
Totals:
J.N!!Mler
I ..........
I Tons
I ............. . ......... I
1KW
............ ',
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [j Municipal [-] Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Ea uivalent
OTHER:
Op" 4dach additional detail ifdesired, or as required by the Inspector of 97res.
Estimated Value of Electrical Work: . Z c -o d , o -D (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with h4EC 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 permit issuing office.
cBEcK ONE: iNsu-R-A-NcE F1 BoNDE] OTBEREI (Specify:) I
I certify, under thepains and enalties ofperjury, that the information mithis application is true and com
P plete.
FIRMNAME:. &-/-t Ele,,de-,c LIC.NO.:-
Licensee: -'RoAdjue) Signature LTC. NO.:624/
(Ifapplicable, nter "exempt" in the licensewimberl' Bus. Tel. No. -
Address: -209 -�N-4 'A" Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security wo-rkrequfiresbepartment of Publfc S�fjty "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredbylaw. By my signature below, I hereby waive this requirement. I amthe (check one)EI owner El owner's agent.
Owner/Agent — �7T
Signature Telephone No._ Fpk� 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
fallation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
7, A t'- T , 166 8 32 an
permit application form to provide no Lice o ns WIL LU I I
on the pre -scribed form. After a permit application has been accepted by an Inspector of Wires appointed pursu ible for the
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be respons
notification of completion of the work as required in M.G.L. c. 143, § 3L. I may be deemed by the Inspector of Wires abandoned and invalid if he
Permits shall be limited as to the time of ongoing construction activity, = th written
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -mon period. Upon
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. d extended by Sections 74 and 75 of Chapter 238 of
ated by Section 173 of Cha)ter 240 of the Acts of 2010 an
El The Permit Extension Act was cre pinl� and the Permit Extension Act furthers this
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovel Y
ic four-year extension to certain permits and licenses concerning the use or development of real property. With
purpose by establishing an automat e, any permit or approval that was
limited exceptions, the Act automatically extends5 for four years beyond its otherwise applicable expiration dat
"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 0
0 Permit Extension Act – Permit/Date Closed:
L rencii in jeutlun Failed Re- Inspection Required ($.) 0
Pass M
Inspectors Comments*
Date:
InSnprtnrs Signature:
ERVICE INSPECTION: El
Failed Re- inspection Required
Pass M
nspectors Comments:
Date:
Inspectors Signature:
ARTiALROUGH Failed IN Re- inspection Required
Pass N
nsoectors comments:
Date:
Inspectors Signature:
.OUGH INSPECTION: Failed Re- inspection Required ($.) El
Pass M
n,,npctors comments:
Insr)ectors
INAL INSPECTIO.N:
Pass M V Failed Ifl
V
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
Date:
Re- Insl
Date:
X
U
4
The Commonwealth ofMassachusetis
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
k1li www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectriciansfPlumbers
Applicant Information Please Print Le2ib
NaMe (Business/Organization/Individual):
Address: 0
City/State/Zip: Pa44&'Iml Phone#:
Are ou an employer? Ch.eek the appropriate box:
Type of project (required):
1. 73 am a employer with 1"9
4. 0 1 am a general contractor and 1
6. F1 New construction
employees (full and/or part-time).*
have hired the sub -contractors
7. [] Remodeling
2.11 1 am a sole proprietor or partner-
listed on the attached sheet. 1
ship and'have no employees
These sub -contractors have
8. EJ Demolition
working for me in any capacity.
workers' comp. insurance.
5. El We are a corporation and its
9. F1 Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10.El Electrical repairs or additions
3. 1 am a homeowner doing all work
right of exemption per MGL
11. [] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.n Roof repairs
insurance required.] t
employees. [No workers'
13.Fj Other
comp. insurance required.]
*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 aire doing all work and 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 em m
ployer that isproviding workers' compensation insurancefor yemployees. Below is thepollcy andjob site
information.
Insurance Company Name:.
Policy # or Self -ins. Lie. #:.
Expiration Date:
Job Site Address: , City/State/Zip:
Attach a copy of the workers' compensation 13olicy declaration page (showing the policy number and expiration date).
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 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 certtfy under thepains andpenalties ofperjury that the information provided above is true and correct.
Simature: Date:
Official use only. Do not write in this area, to he 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
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 employerlis 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 commonwealth nor any of its political subdivisions 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 ffie 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 line.
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, need 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 fille.d out each
year. Where a home owner or citizen is obtaining a license or . permitnot related to any business or comm ial venture
(i.e. a dog license or p* ermit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would Eke 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:
The Commonwealth, of Massachusetts
Department of Mustrial Accidents
Office of Invesfigationa
600 Washington Street
Boston, MA 021 It
TQL # 617-727-4900 ext 406 or 1-877-MASSAFF,
Revised 5-26-05 Fay, # 617-727-7749
_Www-mass.govaa
t
i
GENERATOR APPLICATION
DATE: /0 - .2,3 -
LOCATION:
OWNERSNAME:
GENERATOR kw -
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR: &�e-
PHONE NUMBER: 6 0�� -11 1
LECTRICAL GAS
RESIDENTIAL COMMERCIAL
LOCATION OF GENERATOR:
*ZONING DISTRICT. R2 -
a� q - �� 7�),
*PLANNING APPROVAL (IF IN WATERSHED)
*CONSERVATION APPROVAL
TEMPORARY
4::,..COMMONWt��k OF M
HUSETTS
S5
North Andover MIMAP
rM
061.0-0026
254 BARKER ST
BARKER ST
061.0-0083
269 ARKER ST
061.0-0040
061.0-0005
061.0-0029
290 BARKER ST
061.0-0028
0611.0-0027 2,78 BARKE�R ST
100 A�
�266 BARKER ST
I
— Rai Line
–, Wetlands
Interslailes
U Exempt Lands
Interstate
0 Bu inw
Major Roads
Roads
s 3 District
t7i Easements
Bu�ine:
C3 MVPC Boundary
ORT
C3 Municipal Boundary
Business District
Zoning Overlay
110 Planne,
E3 Adult Entertainment
1,10
-6
[3 Downtown Overlay District
Development Dist
I Div
[3 Historic District
o mdo
13 Water Protection
0 Parcels
�o
Deve opment Dis
1-1 Hydrographic Features
ndu
� 1 Di Irict
1 145 ft
-- Streams
n d us�r
BARKER ST
061.0-0030
Zoning
. . Bu:ine!
1 Di:�nc
0 Bu inw
: 2 Di rict
Ill Bu,,ine!
s 3 District
Bu�ine:
s 4 District
ORT
Genere
Business District
110 Planne,
I Commemial D. -v
1,10
-6
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061.0-0073
October 23, 2013 11
95�
I BARKER S1 I
\ 061.0-0082
-16,19
�, a
HICKORY HILL
061.0-0009
061.0-0077
Date.f.o. I. ;� ..................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... �0 .. o ... et -..J. -e . .................................................
has permission for gas installation ...........................
inthe buildings of ...... . . ....................................................................
at .......... .................... North Andover, Mass.
1,7
Fee... A-0 ... Lic. No. J�il.-td ....... M.I.Y ......................................................
GASINSPECTOR
Check # 44W
G � 4 9
Rje_� CAI ee_*0_V-4LA- 4L
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY INV1 MA DATEI IQ -.a -1 JIPERMIT#
JOBSITE ADDRESS iOWNER'SNAME
GOWNER
ADDRESS TELF—_JFAX
TYPE OR
PRINT
N,
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIACU
CLEARLY
NEW.U. RENOVATION:E] REPLACEMENT: El PLANS SUBMITTED: YESF-] NO DJ
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 j J
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE L�j L
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
4ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHERI .... .. ..... I ... . ..............
........ ..... . ...... .. ... ........ .... .... . ....
I___J
INSURANCE COVERAGE
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES
4 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
cf
LIABILITY INSURANCE POLiC� OTHER TYPE INDEMNITY B 0 N D f_j
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 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
and that all plumbing work and installations performed under the permit issued for this applicaflon will be in cgripliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE # SIGNATURE
M*P S MGF 0 JP D JGF E] LPGIE1 CORPORATION Ej# = PARTNERSHIP ED# LLC [J#=
COMPANY NAME:La� ADDRESS
CITY ZIP
STATE TELER
FAX CELL :EMAIL
Rje_� CAI ee_*0_V-4LA- 4L
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OR
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The Commonwealth ofMassachusetts
Department ofindustriqlAceldints
Office of Investigations
600 Washington Street
Boston., MA 02111
www.mass.govIdia
Workers' Compensation Insurance Affidavit: BuUders/ContractorsfElectricians/Plumbers
A nformation Please Print Ledb
pplicant I
NaMO (Business/Organizationffndvidual): 1�e_
Address: 4V)
City/Statp_/Zip: Phone
Are you an employer? Check the appro�rlate box:
El I am a employer with
4. Ell am a g an cral c ont ra ctor an d I
employees (fall and/or part-time),�`
have hired the sub -con -tractors
2-9 1 am a sole proprietor or partner-
listed on the attached shoot.
ship and'have no employees
These sub -contractors have
working forma in any capaGity.
workers' comp, insurance.
[No workers' comp. Insurance
5. El We are a corporation and its
required.1
officers have exercised their
3.E1 I am a homeownerdoing all work
x1ght of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we, have no
insurance requiredJ
employees. [No warke&
comp. insurance requir6dj
Type of project (required):
6. n Now construction
7 . [] Remodeling
8. Demolition
9. Building addition
10.[] Electrical repairs or additions
11.[] Plumbing repairs or additions
12.E] Roofrepairs
iffl other
*Any applicant that checT3 box#1 must also fill out the section belbw showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they 6re doing allworle and then hire outside contractors must submit anew 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 infonnation.
lam an em
,ployer that isproviding workeirs'compensation insurancefor my emp7oyees. Below is thepolley andjoh site
inforination.
Iu=ance Company Name:.
Policy or S elf -ins. Lie. 4: ExWration Date:
lob Site Address-, Citv/State/Zh):
Attach a. copy of the workers' compensation -policy declaration 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
fino up to $1,500.00 and/or on& -year imprisonment, as well as civil penalties M the form of a STOP -WORK ORDER and a fine,
ofup to V50.00 a day against the violator. Be, advised that a copy of flits statement may be forwarded to the Office -of
Investigations of ffie DIA for insurance, coverage verification.
I do h ereby!�erfl
fy under th epains an dpelartles ofterjury M at th e inforination provided ah ove is true and correct,
Phone 4:
Official use only. Do not -write in this area, to he completed by City Or tOWN OfflClal.
City or Town: Permit/LicenseN
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
-4. " ------ 'OT, - - ".
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. ofhiro,.
express or implied, oral or written."
An em
w1oYeAs defined as "an individual, partnership, association, corporation or other legal enft, or any two or more
of the foregoing engaged in a i oint enterprise, and including the legal repres; ontatives of a doccas ad employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling househaving notmore 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 licensm*g 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 requ * !red!'
Additionally, MGL chapter 15 2*, §25C(7) states "Neither the commonwealth nor any of its p olitical sub ivisions shall
enter into any contract for the, performance ofpablic work until acceptable evidence of compliance with the, insurance.
requirements of this chapter have been presented to the cQntracting authority."
Applicants
Please fill out the, workers' compensation affidavit completely, by cheoldng the boxes that apply to your situation and, if
necessary, supply sub-cortractor(s) name(s), address(es) andphone number(s) along withtheir cortificate(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 carry workers' compensation insurance. If an LLC or LLP doe's have
employees, apolicyisreqaired. Be advised &at this affidavit maybe submitted to the Department of Industrial
Accidents for confirm�ationofinsuranco 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 ifyou are required to obtain a workers' .
compensation -policy, please call the Department at the, number listed below. Solf-insured companies should eater their
self-insurance license number on the appropriate lino.
City or Town Officials
-Rleasobo, sure that-tho affidavit -is -complete -and -printed -legibly. Th6Dd-fECr�CntECs�fo-vid6A�ip-ic-Ca—tff&-b-ot—to-'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 Min the permit/license number whichwill be used as a reference number. In addition, anapplicant
that �iust submit multiple permit/license applications in any giyen year, need only submit one, affidavit indicating current
policy infonnation (ifnecessary) and under "Job Site Address" the applicant should write "all locations in -(city or
town)." A copy ofthe affidavit that has boon officially stamped or marked by the city or town maybe provided to the
applicant as -proof that a valid affidavit is'on fdo for fturc permits or licenses. A new affidavit must be fiijla�d out each
Year. %ore a homeowner or citizen is obtaining a licons a or*�ermitnot related to any business or commercial -venture.
(i.e. a dog license orp* ormit to bum 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 shQuld you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number,
Tho Commo
amalth of M�
Dopafteat ofkdwWal Accidents
Ofte of kw5tig-RUOM
6 0 G WasWWon oCVo-et
Boston, MA 02111
A9
Revised Fax # 617-727-7749
�-""COMMONWEALTH 0 MAS9klCliJdjftTt
F.
PL. MBERS AND GASFITTERS
ICEN5�D AS A MAS I -ER PLUMBER
ISSUES THE ABOVE LICENSE TO:
'�S, CO T T M. TH E I DE
BIXBY HILL RD
ch
GROTON
(MA 01472-10006
15134 os/01/14
17 4 62'
�57 777
Location 7-q03-krc&11
No. S- Date
TOWN OF NORTH ANDOVEFF
.2%
Certificate of Occupancy $
Building/Frame Permit Fee $
CH Foundation Permit Fee $
Other Permit Feeqb) $
Sewer Connection Fee $
Water Connection Fee $ cc
-1
TOTAL $ 15-8
Building Inspector
�,To Div. Public Works
8263
PER311T NO. lis:C APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1
I
MAP +40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
ZON E
SUB DIV. LOT NO.
LOCATION
IDS 32 1
PURPOSE OF BUILDING 1�
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS M!? All
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND
3RD
BUILDER'S NAME //, Cleo c, si,
%,,a
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES
REAR
GIRDERS
AREA OF LOT
FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS 13UILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS I - 3
PAGE 2 FILL OUT SECTIONS I - 12 uvoe(�
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
IIATE FILED
SIGNATURE OF OWN EJ(/loP"%%UTHO-RlZED AGENT
F E E
PERMIT GRANTED
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST -z -goa It!
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BUILDING INSPECTOR
OWNERTELJ
CONTR. TEL. #
CONTR. LIC. #
e) z
H -i -c- # -
IDS 32 1
� kUk�, 0 M,
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY I
S;ORIES I—
MULTI. FAMILY
APARTMENTS . I
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
-- 3 1 2 13
E
CONCRETE
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
RY WALL
UNFIN
3 BASEMENT
AREA FULL
FIN. B M*T AREA
1/1 1/2 14
FIN. ATTIC AREA
NO BMT
HEAD ROOM
FIRE PLACES
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
1
2 3
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING_
ASBESTOS SIDING
HARDVJ D
COMtACN
VERT. SIDING
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON.FRAME
BRICK ON MASONRY
ATTIC STRS. &
BRICK ON FRAME
CONC.OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR POOR I
_�DEQUATE I NONE
5 ROOF
10 PLUMBING
GABLE
GAMBREL
I
I
-dip
MANSARD
BATH Q FIX.)
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COILS.
STEAM
STEEL BMS. & COLS.
HOT W T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd
1�t I 3rd I
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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PEWItIT
two
0,37 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE I
MAP +40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK 'PAGE
ZON E
SUB DIV. COT NO.
LOCATION GArLll-w,
PURPOSE OF BUILDING
OWNER'S NAME j2V tj 0 eAaal GS
jee)
.0. OF STORIES SIZE
OWNER'S ADDRESS C99n iSiqvuY-Ln-
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME ra
I�L
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES — SIDES
REAR
GIRDERS
AREA OF LOT
FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
r. IS BUILDING ALTERATION
S 1-o d 4
1 S BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREME&TS OF co6E
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
2.J DATE FILVb
I`
F E E -3 5, cto
PERMIT GRANTED
Z
IZED AGENT
OWNER TEL.
CONTR. TEL.
CONTR. LIC.
I
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST VC700 23�5
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
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(Please print)
DATE ca
JOB LOCATION
Number
'HOMEOWNER"
Name
PRESENT MAILING ADDRESS
Town of North Andover
BUILDING DEPARTMENT
Homeowner License Exemption
D P9 Q_ K-1 A- 'S T,
Street Address
IA5t3a),) (029
Home Phone
Section of town
Work Phone
f,
Ci ty/Town State Zip code
The current exemption for "homeowners" was extended to include owner
-occupied dwellings of six units or less and to allow such home'owners to
engage an individual for hire who does not possess a license, provided
,that the owner acts as supervisor. (State Building Code, Section 109.1.1)
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 to six family dwell
ing, attached or detached structures accessory 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. Such "homeowner" shall submit
to the Building Official, on a form acceptable to the Bulding Official,
that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the
State Building Code and other applicable codes, by-laws, rules and
regulations.
The undersigned "homeowner" certifies that he/she understatids the TOWLI Of
North Andover Building DeparLment minimum inspection procedures and
requirements and that he/she will com with saidpx-",edures and
requirements.
Z p ),/,-I
HOMEOWNER'S SIGNATURE
kPPROVAL OF BUILDING YFFICIAL I
Note: Three family dwellings 35,000 cubic feet, or larger, will be
required to comply with State Building Code Section 127.0, Construction
Control.
_ _
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Location
No. ;2 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$ :t� 7-1V
-0.
Building/Frame Permit Fee $ X Z J, S 0
4tgo
U
u
Foundation Permit Fe e
$ X17 --19
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$ U
'Inspector
Building
'5/J�94
737
09:13 1,00.50
Div. Public Works
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate Occupancy $
m-'a%afia-aft
of
0
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
9M�06�/V%
03:53 150-00 PAID
7321
Div. Public Works
PERMIT N6.
3 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
;k AGE I
MAP 4-40.
LOT NO.
12 RECORD OF OWNERSHIP IDATE
BOOK :PAGE
ZONE
SUB DIV. LOT NO.
LOCATION ago
PUIRPOSE OF BUILDING
� ' a AS%
n
OWNER'S NAME
NO. OF STORIES SIZE
-'�'
OWNER'S ADDRESS
S ME
BASEMENT OR SLAB
'T 0
0 forc. OF ffisN�
ARCHITECT'S NAME ()6A A/?
SIZE OF FLOOR TIMBERS IST9 2ND
3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET -�) �5
.. POSTS
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
HEIGHT OF FOUNDATION THICKNESS '/6",
AREA OF LOT 14L4 FRONTAGE 0<-0
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION Vis
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER .
po.
IS BUILDING CONNECTED TO NATURAL GAS LINE
'A -s
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS I - 3
M=7 Paw
PAGE 2 FILL OUT SECTIONS I - 12
ELECTRIC METEPS MUST 13E ON OUTSIDE OF 13UILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGNATUR OF 0 RIZED AGENT
F E E
PERMIT GRANTM OWNERTEL.# Q;L-4�1;L,�-
CONTR. TEL.#
19 CONTR. LIC. # gq
I yj -ftq
f,2
3 PROPERTY INFORMATION
LAND COST
EST. SLOG. C .970
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY I
I
S�ORIES
MULTI. FAMIL�L�_j
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
3 1 2 13
PINE
HARDW D
PLASTER
CONCRETE
CONCRETE BL K.
BRICK OR STONE—
PIERS
-�RY WALL
JNFIN
3 BASEMENT
AREA FULL I_
FIN. B M T AREA
V, 1/2 1/1
FIN. ATTIC AREA
�10 8 M T
FIRE PLACES
HEAD ROOM
KITCHEN
_MODERN
—
4 WALLS 9 FLOORS
CLAPBOARDS
8
—
1
2
3
DROP SIDING
_�ONCRETE
WOOD SHINGLES
TARTH
ASPHALT SIDING
HARDNIJ D
ASBESTOS SIDING
VERT. SIDING
COM/AC;N
-ASPH —,ILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR
CONC.OR CINDER BLK-
WIRIN
STONE ON MASONRY
STONE ON FRAME
SUPERIOR OR
!022..
NONE
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
I
I HIP
BATH 13 FIX.)
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
FLOOR
_jILE
TILE DADO
6 FRAMING
HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W*T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T G
UNIT HEATERS
7 NO. OF ROOMS
AS
OIL
B'M'T 2�d
lo I 3rd
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LO, LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
/APPLICANT: L2 t 16 50 /-) Phone
LOCATION:
�S I bdivision
street
Assessor's Map Number Parcel
12 _11_6r
),10 'S1,
Lot (s)
St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Date Approved
Date Rejected
Date Approved
Town Planner Date Rejected
Comments
F od Inspector -Health
V/10
Septic inspector-Heaith
Comments
Public Works wer/water connec�ions
,*driveway permit
/Fire Department
0 --
Date Approved
Date Rejected
Date Approved WX
Dite Rejected
Received by Building Inspector Date
KEEN COMSTRUCTION CO. June 3,1994
Amendment A to contract # 1039- r Kolbensonl page one of two
Build addition to existing dwelling, as per blueprint dated April 20, 1994.
to include the followin-q:
Windowso Harvey Majesty; [30] double -hung, [1] 8'X 445 deg. bay unit,
[6] 32" X 60" dead lights for sunroom.p] Roto skylights [@ 30" X 39"].
Doors: [9] hollow -core birch units, [2] solid -core birch, Dutch -type,
[2] 6'wood-clad sliding patio units, [11 5'entry unit [allowance- $ 1500.001,
[5] 5' hollow -core birch bypass units, [2] steel insulated garage doors,
[2] elevator -spec units, [2) fire-resistant steel units.
Elevator, [1] Elevette hydraulically -operated, installed by CMC Elevator.
Flooring: @ 27 yards sheet vinyl [allowance- $ 21.00/yd], @ 343 yards
carpeting [ allowance- $ 16.00/yd].
Mastic vinyl siding and vented soffit and complete aluminum coverage on
trim boards, Bird 20 -year roofing, full ridge vent.
Paint all patchwork and new interior work;
Ceiling- 2 coats, walls- 1 coat primer, I coat finish, woodwork,
trim and doors, I coat stain, 2 coats finish.
Plurntio_cL-First floor bathroom; new fixtures to include handicapped
shower, ceramic tile floor and shower area, toilet, vanity, sink and
faucet. Second floor bathroom; new fixtures to include double vanity and
sinks, toilet, Wfiberglass shower stall, fiberglass whirlpool tub, and faucets.
Heating sy§tem* sealed combustion, gas-fired, FHW, baseboard heat on
first and second floors [two zones], commercial -rated boilermate domestic
hot water tank, natural gas to be supplied to new kitchen range and clothes
dryer.
Septic system: complete upgrade as per engineering prints dated May 20,
1994, from Merrimack Engineering Services, Inc., to include, if needed, @
12" in height, added to existing stone wall,[ allowance- $ 1,000.00].
Interior: ceilings and walls, sheet -rocked, taped, and seamed, windowidoor
trim, base molding, [colonial -type].
Electrical: new service entrance and panel, upgrade existing service panel,
outlets and switches to meet code, first and second floor baths- wall
heaters, cable TV/telephone [ installed at location specified by customer],
lighting fixtures to be construction -grade.
Perimeter drain: to be installed around new foundation.
Drivq,�Lay: hot top to area of new garage door, front stairs and patch
where shed has been removed. [to match existing]
Insulation: ceiling above new garage and second floor ceiling is R-30
rating, all new walls are R-1 3 rating.
Cut I?assageway in concrete wall between old garage and new garage, @
36" wide.
Remove all debris from premises. All disturbed grounds to be covered
with top soil and raked out, but not seeded, planted, or landscaped.
Amendment A to Contract # 1039 rKolbensonl- page two of two
Price does not include:
Problems found when excavating for new foundations or septic system, e.g
large boulders, shale, or ledge, etc.
Third coat of paint required on walls or trim.
Pgyment Schedule:
$ 10,000.00 due when contract signed
$ 15,000.00 due first workday on site
$ 40,000.00 due when lumber arrives on site
$ 35,000.00 due when framed and weather -tight [roofing, windows instj
$ 30,000.00 due when rough elec, plumbg, and insulation is complete
$ 20,000.00 due when vinyl siding and coverage is complete
$ 15,000.00 due upon completion of sheetrock
$ 11,970.00 due upon completion of work
Any additional work requested by customer will be paid when item installed.
Home Owner Signature Date -b�6ntra�tor' Signature
MA HIC reg. 108383
Date
a
5A Z2,r e6
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OFFICES OF:
APPEALS
BUILDING
CONSERVATION
HEALTH
PL,-\NNING
uNORTH ANDOVER
ir4 DIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
North Andover.
Massachusetts 0 1845
(617) 6854 -ti 5
-'r? I.
In accordance with the' provisions of MGL c 40, S 54, a condition of Building Permit
Number is that the dcbris resulting from this work shall be
disposed of in a prcpe'riv liccrucd solid waste disposal facility as dcfincd by MGL c 111, S
156A.
Tle debris will be disposed of in:
t
(Loca/ion of Facility)
1114 7-
'� � �' Z' rg, A Z -D
Sicmiture of it Acpiic-,ni
I
Date
N077: Demolition permit from the ToTwn of North �ndover must be obtaine,_� for
d4ng Inspector.
this Droject through the ofz4ce of the 3UJI
CERTIFICATEOF USE & OCCUPANCY
TomIn of North Andever
Building Permit Number 216 (1994) Date JANUARY 19, 1995
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 290 BARKER S=
MAY BE OCCUPIED AS 2nd STORY ADDITION - IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO Ruth & Charles Kolbenson
Barker St.
ADI�RESS NO th Andover. MA--�
Buildinimspector
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
1V AAIP, A 9V bo ioal
Mass. Date 19 — Permit #
Building Location Owner's Name Iq (j )-ly II(LI LBCAI 50d
Type of Occupancy
New 0 Renovation F( Replacement 0
FIXTURES
Plans Submitted: Yes El No El
1jr
Installing Company Name , Mtq Al Check one: Certificate
Address C U Y) ry� 7;T El Corporation
El Partnership
Business Telephone 600�- 0 Firm/Co..
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a cur iability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes U/ No 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Eii� Other type of indemnity 0 Bond El
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 walves this requirement. Check one:
Owner El Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in the above 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 in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofthe General Laws.
Lic nse:
By I �Iuom be r /t—�
'ter Signature of LicVed Plumber or Gas Fitter
Title 4V.,fte, �? � C.;� 6
City/town 0 journeyman License Number
APPROVED (OFFICE USE ONLY)
0
or. n". IT M,
1110y
or M-11rers
or M. rNers
EVIT
1jr
Installing Company Name , Mtq Al Check one: Certificate
Address C U Y) ry� 7;T El Corporation
El Partnership
Business Telephone 600�- 0 Firm/Co..
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a cur iability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes U/ No 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Eii� Other type of indemnity 0 Bond El
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 walves this requirement. Check one:
Owner El Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in the above 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 in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofthe General Laws.
Lic nse:
By I �Iuom be r /t—�
'ter Signature of LicVed Plumber or Gas Fitter
Title 4V.,fte, �? � C.;� 6
City/town 0 journeyman License Number
APPROVED (OFFICE USE ONLY)
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Date.....................
,40RTN TOWN OF NORTH ANDOVER t --
PERMIT FOR GAS INSTALLATION,
This certifies that ...........................................
has permission for gas installation ..............................
in the buildings of ........................................
at .................................... North Andover, Mass.
Fee......... Lic. No ........... ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
',fA%,(1Ubh I I S UNIFORM APPLICATION
(Nnt of Type) FOR PERMIT TO Do GASFITTING
NORLH ANDOVER,-_. Mass. Dale /0 - 'al 19
Building Q0
Location 96 3A4.i--4t -),7— Permit #
Owner's
Name 0 Z-OQ/ -6 6AI
Renovation C1 Replacement C]
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7TH FLOOR
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Plans submitted:. Yes D No
Sir
0
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Installing, Company Name //4p- -'s A�r .3 /AeF4 Check one: Certificate
P Corp.
Address a- IGA4,441AI eq� El Partnership
0 Firm/Co.
Business Telephone 2.56 - F -ie 0 7
Name. of Ucensed Plumber or Gas Filter Qwdu�
In--31UHANUft COVERAGE: : Check (me
I have a current liability Insurance policy or its substantial equivalent. I Yes Ef" No 0
If YOU have checked yes. Please Indicate the type coverage by checking the appropriate box
A liability Insurance policy Er"< Other type Of Indemnity 0
Bond 0
OWNER'S INSURANCE WAIVER: I am aware !hat the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that Ipy s_!gWUre on this permft application waives JW, -requirement.
Check one:
&gnature of Owner or Owner's Agent owner 11 AgentO
I he'reby certify that all of the details and Information I have submftted (or entered) in above application are true and accurate to the best of my
knowiedge and that fill Plumbing work and Installa rformed under the Pe
PefUnent. provisions of the Massachusetts State GatIcgr tmn Issued f thisappl
s Tof I appi A con�
m Hance with all
and Chapter 142 of the Germw Laws.
T I 1.1cense:
ff-Houlmber r of 3 er
Gasfitter Signature a nse urn r Of s er
C . tty/Town H Master Ucense Number
[E�Joumayman
APff)CIVED (OFFICE USE ONLY)
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0
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Plans submitted:. Yes D No
Sir
0
0
&
Installing, Company Name //4p- -'s A�r .3 /AeF4 Check one: Certificate
P Corp.
Address a- IGA4,441AI eq� El Partnership
0 Firm/Co.
Business Telephone 2.56 - F -ie 0 7
Name. of Ucensed Plumber or Gas Filter Qwdu�
In--31UHANUft COVERAGE: : Check (me
I have a current liability Insurance policy or its substantial equivalent. I Yes Ef" No 0
If YOU have checked yes. Please Indicate the type coverage by checking the appropriate box
A liability Insurance policy Er"< Other type Of Indemnity 0
Bond 0
OWNER'S INSURANCE WAIVER: I am aware !hat the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that Ipy s_!gWUre on this permft application waives JW, -requirement.
Check one:
&gnature of Owner or Owner's Agent owner 11 AgentO
I he'reby certify that all of the details and Information I have submftted (or entered) in above application are true and accurate to the best of my
knowiedge and that fill Plumbing work and Installa rformed under the Pe
PefUnent. provisions of the Massachusetts State GatIcgr tmn Issued f thisappl
s Tof I appi A con�
m Hance with all
and Chapter 142 of the Germw Laws.
T I 1.1cense:
ff-Houlmber r of 3 er
Gasfitter Signature a nse urn r Of s er
C . tty/Town H Master Ucense Number
[E�Joumayman
APff)CIVED (OFFICE USE ONLY)
tT2 2342
6
0
Date...
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ......
fo i k1i o
has permission for gas inqa4ation
in the buildings 0 ..... .
OA ...... . ............
at North Andover, Mass.
Fjj50
--hi .-No.4ji?.5-3. ..........................
r/96' Si 0"
20-00 PAID GASINSPECTOR
WHITE: Applica ARY: Building Dept. PINK: Treasurer GOLD: File
jj�-, . .%
4\ office Use Only
hu -11 a ��3 1
01 he Tommaniuralth of fflusar4artts Permit No.
Occupancy & Fee Checked
Bepartment of Publir %fitV I
3/90 (leave blank)
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 1
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 C—MR1, 12:90
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical
Location (Street & Number)
Owner or Tenant
Owner's Address
described below.
Is this permit in coniunction with a building permit: Ye s F-7 No EC (Check Appropriate Box)
Puroose of Building Utility Authorization No
Existing Service Amos Volts Overhead Undgrnd
New Service Amps 'Volts Overhead Undgrnd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Meters
No. of Meters
Total
No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA
No. of Lighting Fixtures
Swimming Pcoi Above
grna.
In-
grn
Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets
No. of Oil Sur ers
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
iotai
No. of Ranges
No. of Air Cond. tons
Initiating Devices
Devices
No. DisDosais No.of Heat –iota! Total
of
Purrics Tons
KW
No, of Sounding
No. of Self Contained
No. of Dishwashers
Soace/Area Heating
KW
Detec-don/Sounding Devices
municipal f—I Other
Local I I Co rinection
No. of Dryers Heating Devices KW
No. of No. of
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. Hydro Massage –tubs
No. of Motors Total HP
i
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of MassacnusenS general Laws I ent. YES e NO
I have a current Liability Insurance Policy including Corricieted Operations Coverage or its substantial equivai
have suomittea valid proof of same to the Office. �;E--S V NO Z If you have checked YES. please indicate the type of coverage by
checking the aqp�opriate box,
INSURANCE BOND OTHER :: (Please Scec:t./) (Expiration Datei
Estimated� �alu. of Electrical Work S
Rou'�7 6/9�� Final
Work to Stan lnsoec,:on Date Recuestea: 9
Signed uncer the Penaities of perjury:
1 4–
FIRM NAME LIC. NO. 10—
Signature LIC. NO. —
Licensee
Bus Tel. No.
0&!��Ait: Tel. No.
Address IF
OWNER*S INSURANCE WAIVER: I am aware that the Licensee does notgave the insurance coverage or its substantial equivalent as re-
cuirea by Massachusetts General Laws. ana that my signature on this permit application waives this requirement. Own Agent
(Please cheCK one) X1, —
S �5 1 —do
eieonone No. _ PERMIT FEE
S 'gna!ure of Owner or Agent$
X-6565
4 7 3 Date .............. / ........ ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... .......... ...... . n .......................................
7 F
has permission to perform ................... I ................. / ........................................
, n'l
wiring in the building of .... ........ / ........
.............................
r
............... ............................ . North Andover, Mass.
at .... :�t.yd ........
Lic. No. ...........................................................
ELECTRICAL INSPECTOR
08/09/95 09:50 15,% PAID PINK: Treasurer GOLD: File
3
WHITE: Applicant CANARY: Building ept.