HomeMy WebLinkAboutMiscellaneous - 299 DALE STREET 4/30/2018 (2)LLS
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10432
Date..
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
d . . ..... ! � � Q e) VId 0/) e-, 0
This certifies that ........................................... .................................................................
has permission to perform..../�?&C-'kr ... OV71M ...... 5. 4-,1?I.D.?Sr..V ....
0 plumbing in the buildings of ................................. ...........................................
at ..... ��?.72 S.5/ye"
............. ............. I North Andover, Mass.
Fee.7 ...... Lic. No. .... .....................................
Check # 4�� ��UMB I INGINSPECTOR
ep4p 1poq-(4� vl,.,- 2
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY = MA DATE I PERMIT#— bq �
JOBSITE ADDRESS Ml -,F 5-1 =OWNER'SNAMEI' '7,e- 4 -
OWNER ADDRESS TEL FAXE
OCCUPANCY TYPE COMMERCIAL EH EDUCATIONAL E.0
NEW: 0 RENOVATION: E�r REPLACEMENT: Of
FIXTURES -1 FLOOR- BSM
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTEF
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER F
RESIDENTIAL Ea—
PLANS SUBMITTED: YESEq NOD
10 1 11 1 12 1 13 1 14
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES B'NO Ell
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V�r OTHER TYPE OF INDEMNITY pi BOND [3
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 M-1 AGENT 101
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application Will be in compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /2 - d A .4 If - / 4
d� 4MTURE
PLUMBER'S NAME
iLICENSE#
MP or JP 0-1 CORPORATI ON 0'# ��PARTN ERSH IP LLC
COMPANY NAME ADDRESS] --7
CITY STATE ZIP T E L
FAX ]I CELL EMAIL
I El
z
LU
CL
Lii
LLJ
U-
The Commonwealth ofMassachusetts
07 Department ofIndustriqlAccWks
Office of Investigations
600 Washington Street
Boston, MA 02111
�kvi www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual)
Adclress: 7_�5 -f
City/State/Zip: 4 le"19- Pho ne 4�� -7 -
.Are you an employ . er? Check the appropriate box:
Type of project (required):
LEI I am a employer with �3 d
4. El I am a general contractor and 1
6. El New construction
I employees (fall and/or part-time).*
2.0 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. I
7. R-Re-model'ing
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
workers' comp. insurance.
I
9. E] Building addition
[No workers' comp. insurance
5. We are a corporation and its
1011 Electrical repairs or additions
required.]
3.0 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
ME] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.0 Roof repairs
insurance required.] t
employees. [No workers'
11bother
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are, doing all work and then hire outside contractors must submit a new 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.
lam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjob site
information.
Insurance Company Name:.
Policy # or S elf -ins. Lie. 9: ExpirationDate:
AJ P ty zip
Job Site Address: 4:2?9 M41 --e— !!�7 i /State/ :
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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 andlor 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 h ereby certify un der th e p ains an dp en alfles ofperjury A at th e information pro vided ab ove is tru e an d correct.
Simiature: K2Z-4u & I/
00_4�_ Date: 3 A 9/,-
- A-6;AY, /_
Official use only. Do not write in this area, to he completed by city or town official
City or Town:
Permit/License 9
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 8:
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 emplueiis 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 constiruct 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 the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained 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 questioins 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 line.
City or Town Officials
Please be sure that the affidavit is complete and printedlegibly. 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 is' on file for future permits or licenses. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaftiffig a license or'pJermit not related to any business or commercial venture
(i.e. a dog license or permit 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 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 Massachuse,,tts
Department of Industrial Accidents,
Office of Investigations
600 Washington Street
Boston, MA 02111
TO. # 617-727-4900 ext 406 or 1-877,7MASSAF
Revised 5-26-05 Fax # 617-727-7749
__www-mass.gov1dia
0
I
STATE OF NEW HAMPSHIRE CTION
BUREAU OF BUILDING SAFET* & C . ONSTRU
PLUMBING SAFETY . SECTION'
NAMEi-ALFRED A SPOLIDO RO
LI& #: 1685 M
P :S. 11/30/2014
IRE
WEALTH OF MASSACHUSETTS
yXi",
ISSUES THE ABOVE LICENSE TO:
Date...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
1�
This certifies that ...... V..(9 ...
.... ...............
has permission to perform ... /V,.OVJ
..................
0'r., // eat
................................... ...... -
/? fs),-4 / 4 /,X * ,
.............. I ..................................................... .........
wiring in the building of ................... Olt' .61 tx,
Fee.:2�?. C ............. Lic. No. /Y ..................................................................
ELECTRICAL INSPECTOR
Check #
r -r) 7121111,41
llj
ET
\14
Commonwealth of Massachusetts Official Use Only
p
ermit No
Department of Fire Services P
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071
V\ U9 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRDVT INMK OR TYPEALLMFORM-4 TION) Date: -7
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or.Uer intention to perform the electrical work described below.
Location (Street & Number) 0'? 9
Owner or Tenant
Owner's Address
r
Ma
Telephone No.
.t?
Is this permit in conjunction WP a Iding permi . Yes [� No F] (Check Appropriate Box)
Purpose of Building S,�� d6lo ///.,2q Utility Authorization No.
Existing Service Amps /7-,3/ >Zovoits Ovdhead Undgrd No. of Meters _41
New Servic Amps volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion ofthe-followiniz table may be waived bv the Inspector of Wires.
No. of Recessed Luminaires 7
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires -7
Above Ei In- 1:1
swimming Pool Rrnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets 26
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:
I Nq ��r..[Tons
........................
IKW
I .......................
No. of Self -Contained
Detection/Alerting Devi es /,0
No. of Dishwashers
Space/Area Heating KW
Local E] Municippl El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalen
No. of Water KW
Heaters
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 Eauivalent
[OTHER:
,4 dach additional detail if desired, or as required by th e Inspector of 97res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: , � —;V,,—J�L 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 operatioif '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-PANcE El BoNDEJ OTBEREI (Specify:)
I certify, undef t��Ins andpe tiesof t1i tfi, ' rmation on this application is true and complete.
,per. a ze info
FIRM NAME: ao yyry, I LIC.NO.:93
V 01
0
Licensee: Signature LIC. NO.:
(If applicable, enter "ex;er lin
,rt" in the licen e,,,r,7
�. I/
Bus.Tel.No.:'?7J''1?Y
Address: Vi.Z STU!
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-6 1, security work reqi -,Daf Public Sa "S" License: 111c. Ao.
OWNER'S INSURANCE WAYUR: 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)E] owner El owner's agent.
Owner/Agent e'7-' ) 10
Signature Telephone No. PEMIHTFEE.- $
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.
F -I 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
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
PAPMAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signatu re':
Date:
ON:
ROUGH Mf f:c� �Tl I
Passo-*,
Failed IN
Re- Inspection Required El
Inspectors Comments:
4Z
Inspectors Signature: 41 d"
Z(.,r &I
Date: 7
FINAL INSYXCTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
LI -7,q (-"r
Date: al
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinh old @town ofm errimac-com
The Commonwealth of Massachusetts
Department oflndustrialAccWnits
q a UVW Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/l�lumbers
Applicant Information Please Print Le2ib
Name (Business/OrganizatiorAndividual): Anc
Address:
City/State/Zip: j0?39L0YPhone#: '21
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
(fall and/or part-time).*
have hired the sub -contractors
2. eployees
I aim a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' conip. insurance.
[No workers' comp. insurance
5. 0 We are a corporation and its
required.]
officers have exercised their
3.E1 I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. n New con.straction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12.E] Roofrepairs
13TJ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new afridavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers'compensation insuranceformy employees. Below is thepollcy andjob, site
information.
Insurance Company Name:
Policy # or Solf-ins. Lie.
Expiration Date:
Job Site Address: City/State/Zip:
r - -
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 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 certftunder thepains
th at th e information pro vided above is true and correct.
Official use only. Do not write in this area, to he completed by city or town offlicial
City or Town:
Permit/License N
—,p -7,—
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 of hire,
express or implied, oral or written."
An employer1s 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 of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is ' required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for coriffimation 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 is'on file for future permits or licenses. A new affidavit must be filje�d 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 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 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 Industrial Accidents
office of Investigations
600 Washington Street
Boston, MA 02111
TO, # 617-727-4900 ext 406 or 1-877rMASSAFE
Revised 5-26-05 Fax # 617-727-7749
__WWW.mass,9ov1dia
TH OF
Date. !:� -. /:v.-. C- J. -. . -
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . . 111� L-1- ki- 5- e -� . J . . //2� Ar -
........... .. ............
has permission for gas installation . . �� e. -. � '. � . .1 J, ... P-"-- . . .
in the buildings of . 6--.11t ...........................
at d --,A
.............. I North Andover, Mass.
Fee ... *7.P ... Lic. No.. .... ID >- �- . ......
GASINSPECTOR
Check #
5028
%4
MASSACHUSE17S UNIFORM APPLICATION
(Print or Type)
IVODate 20�
_,4njover
M
Building Location
Map:— Lot: Zone
New Ll Renovation U
PERMIT TO DO GASFITTING
—RecMpt# Pwmtt# '�;- 0 )— r
OwneesName Det C.k-,r-r;c-k
Type of Occupancy
t Q PlansSubmitted: Yes[3 No 13
Installing Company Name Townsend Propane Services, Inc.
Address 27 Cherry Street, Danvers, MA, 01923
Estimate Value of Work:
Business Telephone
978-777-0700
Name of Licensed Plumber or Gas Fitter
,4,q� 1,4�4
..Z
Chackone: Certificate
U Corporation
U Partnership
Q Firlmn
0/22c,
INSURANCE COVERAGE:
I have a curren; liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ICA No 13
If you have crecked Yes, please indicate the type coverage by checking the appropriate box.
i
A liability insurance pollcyA Other type of Indemnity U
Bond (3
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.
Chackone:
owner a Agent 0
Signature ot Owner or Owner's 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 installations performed underthe permitissued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Ty e of License:
ElPlumber lg�5aw�rof ��Iumb;ro�rGasli.�r
Tibe f1gGastitter 41D 1220
'H Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONLY)
30
Ravised C5117100
Q1,7
OL,
J_t
'P OT �l a
ID e, c �. CTT'i C V,
� 0 v <(j -)?-
Date...
..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... ......
-S- ..' ..' . . ................................
has permission to perform ..... "'c74-- . ..........................................
wiring in the building of ........ c 1�'z ............................................
Qat..e�/Zp .. k-zi--re . .............................. . North / Andover, Mass.
FeeA............... Lic. ....... ....... ......
tLicrRICAL INSP
L -I
Check # -zl"I��I'
5
TBECOAMOATWEALTHOFAL4SSACHUSE77S Office Use only
DEPARTAIEWOFPUBLICS4FM Permit No.
BOAMOFFREPREVENHOIN7N 5,rCM12.00 fi- — —1
Occupancy & Fees Checked
APPLICATIONFORPERAIRTTO ELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSAC SSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover
The undersigned applies for a permit to perform the electrical worA desiribed below.
To the Inspector of Wires:
Location (Street & Number) - ?
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes [�No (Check Appropriate Box)
Purpose of Building "&P / ;r-1 0 A? Utility Authorization No.
Existing Service Amps Volts Overhead Underground 1:3 No. of Meters
New Service Amps Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
YES Ej'� NO
IhawsthriwdvafidpfoofofsmwtodrOffi= YIES
No. of Transformers
Total
If)uihawdrdodYES,OmokdcatedrMmofcow
tp
&Bckir� dr MxTdae bboRx-
INSLRANCE
KVA
No. of Lighting Fixtures
c,2
Swimming Pool Above
- ground
Below
ground
Generators
KVA
No. of Receptacle Outlets
Sigxdunclerl:�Pff�6fmw
No. of Oil Burners
FIRMNAME n
I-imm No.
No. of Emergency Lighting Battery Units
Noq of Switch Outlets
LkffwNo
Bu4m Tel No. /�,o .3.,2 -?�RZ —
AMm__� -7
Alt Tel No. 4,' o 3) �, 7 0
OWT,,WS INSURANCEWAIVER, lam awðalthel-ketwdoesnotbaw themarmoDNuageoritssubMmtWcqnvalwas requitedbyMassachuseas Cff)ffwuws
and diatmysigiamon thispeimitapplicmOn wamsths mqm* ffrfm
No. of Gas Burners
F-1
FIRE ALARMS No. of Zone
No. of Ranges
No. of Air Cond. Total
Signature of Uwner Or Agent
Tons
No. ofDetection and
No!ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municip, at r --J
Other
No. of Dryers
Heating Devices KW
.
Connections L --J
No. of Water Heaters KW`
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Tot"P
OTHER-
kU== COWraW- PdM= ID dIC WqMWIC& Of N11%adMS0M Coled I-aAs
Ih&feaam=1iab&yhR==Pb1iqyff rhxkigCarnp1eeO
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YES Ej'� NO
IhawsthriwdvafidpfoofofsmwtodrOffi= YIES
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0 U
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L
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Sigxdunclerl:�Pff�6fmw
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I-imm No.
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and diatmysigiamon thispeimitapplicmOn wamsths mqm* ffrfm
(Please check one) Owner M Agent
F-1
Telephone No.
PERMIT FEE,�—/6,oj
Signature of Uwner Or Agent
�,�
/o � � f�.
TRE COAMONUFALMOFAIASSACHUSE77S Office Use only
DEPAATA1EW0FPUB1JCS4FM 270M12--00 Permit No. — 6—�I-a r-1—
EMONRW75 Occupancy & Fees Checked
ARDOFFMEP
Do
APPLICAHONFORPERWTTO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE I
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Town of North Andover I
IRM ELECMCU WORK
ELECTRICAL CODE, 527 CMR 12:00
Date
To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical wor des ribed below.
Location (Street & Number) 1
VS
Owner or Tenant
Owner's Address 2
Is this permit in conjunction with a building permit: Yes [ZyNo (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead E3 Underground No. of Meters
New Service Amps Volts Overhead M Underground M No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
ground 1:1
Below
ground
Generators
KVA
eceptacle Outlets
r.;2
No. of Oil Burners
No. of Emergency Lighting Battery Units
itch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
langes
No. of Air Cord. Total
Tons
jisposals
No. of Heat Total
Total
No. of Detection and
Pumps Tons
KW
Initiating Devices
shwashers
Space Area Heating
KW
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Iryers
Heating Devices
KW
Local Municip al
Other
I
El Connections
L
tater Heaters
KW
No. of No. of
--J
Massage Tubs
No. of Motors Total
bWM@�. RUR=tD&mWimiaCofNb%adimUsGuixdlaws
umLiabkhn==R&ygrhx&gCoW]eeOEr&omCowr,Werits&bg3tWmpNabt YES Ej NO
iiWdva]idpfoofofswvelotheOffia-- YES Jf)uuhawdedWYESPbMHKbC&dE�rOfODVOob
CE BOND F7 011 -HR
ft"Spfflly)
F*a6on D& ///.;I-
Estim&d Vahx offlDmical Wcdc $
kspectionDaleRequesiad Rough 1,6"1 Final
�"4 L A 6�/ Licmse No.
LicenseNio
Bu�nmTel.No.
�; 0 3) :7 7 0 —,6 4/
7 `9 57�7 A/If� A/ AiTel.No (.
. "pi-,R'SINSURANCEWAIVEPIamawmedittheLmwdoesriothawthemmreOD'WWorlsabtmba . leqnval�asmqiodbyMmdugezGffx�dLaws
and that my sgnft= an this petmit applicatim waives this m4z' emat
(Please check one) Owner M Agent r-1 Telephone No. 'PERMrF FEE $ (0i
Signature ot Uwner or Agent
910 u ;t-�/ - ok,
F�, � — or,,
,.p - I I- , O'j /11
3-3-0-C. 7-3,�
i
f,
Locationc-;;�9,9
No. 117 Date
,0, �01,,,-,,
14. TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Ar..
Building/Frame Permit Fee $
Mu
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 39 00
17571
Building 4wPector
L
k I
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIJ RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUNIBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/InEeEtor of Buildin2 Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
6V
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dia;ict Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (il)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
EE!E�red Provide Required F -Provided.
Required Provided
1.7Water SupplyM.G.L.C.40.. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 11
1.9 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHW/AUTHORIZED AGENT
F- HistoriC LAStrict: Yes N o
2.1 Owner of Record
1,�IJ116Z— Af"� Z>,l L6- 7-
rint) Address for Service
(-7 '/-7
qg-1 - -I D 0-
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature T I h c
SECTION 3 - CONSTRUCTION SERVICES
I Licensed Construction Supervisor:
-TC)
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
00
M
X
z
0
M
0
z
M
90
0
ic
M
z
G)
SECTION 4 - WORKERS COMIPENSATION (NLG.IL 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 of Proposed Work (check all appficable)
New Construction 0 1 Existing Building 0 1 Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg. 0 1 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
A -D � %f ',k Z -Y 41 AFA 7' xzo A- To 3A c k- o klok -s
'0q D D "Z�Al <7-A.IL A 4 F L26 / Y 2Z
I SECTION 6 - ESTIMATY.-n CONSTRUCTION CORTR I
( -:> R e ID V"I
CA"C_�elj,#Ck S/0)ILO'l
Item
Estimated Cost (Dollar) to be
Completed y permit applicant
OFFICL46L USE ONLY
I . Building
(a) Building Permit Fee
lier
2 Electrical
(b) Estimated Total Cost oT_
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAQ
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
bhU I lUfN /a UWNER AUI HOKIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, '�— /,.A 1 1 7 r/ as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf. in all wtters relative to work authorized by this building permit application.
Signature ofY)wner Date
-SECTION 7b OWNEIVAUTHORIZED AGENT DECLARATION
1, -,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
Signature of 0 Date
NO. OF STORIES SIZE
-BASEMENT OR SLAB
-SIZE OF FLOOR TIMBERS iST 2 ND 3 RD
SPAN
-DIMENSIONS OF SILLS
-DIMENSIONS OF POSTS
-DIMENSIONS OF GIRDERS
-HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
-MATERIAL OF CHEVINEY
IS BUUDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
600, -
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
F' -------- ******************APPLICANT FILLS OUT THIS SECTION***********************
-)98q -9 0-70
APPLICANT,,41 I z-tM 6- L- e-14 I ;r- tic-lt- PHONE� 9 -7 9
LOCATION: Assessors Map Number PARCEL_QI/4
Z-10
SUBDIVISION LOT (S)
STREET— -9,,4 1-0c -5 T /1 &C- T ST. NU I MBER
USE ONLY***************
I RECONO�NDATIONS-PFTQWN-A-GENTS: I
ERVATION
COMMENTS
DATEAPPROVED
DATE REJECTED
1. -WK-
to , ANNER DATEAPPROVED
(VOk DATE REJECTED_
FOOD INSPECTOR -HEAL
SEPTIC INSPECTOR -HEAL
COMMENTS
DAT,E APPROVED
DATE'REJECTED
DA;rE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT.
—72-&5 — 0
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
t.A 0 V�zr \,P\ -
IKI — — Ir a low d IN
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ftoewoh Is tar tno4maa
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PLAN
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work:— At>D 17-)Orj Est. Cost
Address of Work '2-'I'q P11%t4 57/1-ec-7-
OwnerName: "-14,1 7 7- /
Date of Permit Application:
I hereby certify that:
--� /7- 3 /a 41
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner -occupied
,---Owner pulling own permit
Other (specify)
Notice is hereby given that:
For office Use Only
Pemit No.
Date
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND LINER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
-7---? -T,,,- Y OL -1
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
T"\LY 0 1-f
Date
Owner Name
w
.JUL72e-2004 oe:20 FROM:MATERIALS-ENGINEERIN 1-97e-470-5219 TD:9197eGBe9542 P.2
04 J1
LAY,09--T OF /./-p 6f o4 r
(F 7Lo,,-7)
Co o4a.A 4 e
7Z.00,A- APOV6
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AP) 11'19
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ntete-<-- 7
14-1 1 Ck. #1 t4
V-qr-q —,1070
living room
fam#y room
0
kitchen
L e
0 .4-r 10,
0
4g,e,^-r
ROOAO%
(P,L,,4,4f-JZ—b
AD b III
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offning room
IJOT-e : PLA(4 'S
V 0 f-
wo Z-4- f
JUL-28-2004 oe:21 FROM:MATERIALS-ENGINEERIN 1-978-470-5219 TD:919786989542 P.3
L,AY0147- 14 0 41 S�� A Ir
front
bathroom
Leah's room Master
bedroom
Cie 3E.
Halfway
T
Julia's room
ColAeen'.s I
mom hathmmn
rz--o 0 1-7,
----------- -
.AUG -10-2004 10:57 FROM:MATERIALS-ENGINEERIN 1-978-470-5219 TO:919786889542 P.1
,r% -rL Wetlands &
1�7
Land Managenient, Inc.
August 3, 2004
JulieParrino
North Andover Planmg Departrnem
27 Charles Sbmt
North Andover, MA 01845
RE: 299 Me Street— Site inspection for wetlands with respect to the Watershed Protection Overlay
District
Den Ms Parrino-.
Be advised that on August 2, 2004, 1 visited the property at 299 Dale StrCeL The purpose of my site
inspection was 10 reconnoiter the lands within 323 fed of a proposed addition to the existing home for the
presence of any wetland resource area Wedand resource areas within 325 feet of the proposed addluon
would likely requm a Watershed Protection District Special perruit for the proposed construction -
The MWerly is within an established naghborhood with other =der" hmm to the sides, southerly to
the rear and northerly, on the opposite side of Dale Street I reconnoitered all areas witMn 325 A!et of the
proposed additiolL There were no areas that would be characterized as a welland resource as defined by the
Wetlands Protection Act Chapter 131 Section 40, he embling regulations at 3 10 CMR 10.00, or the North
Andover Wetlands By-law.
Sincerely,
Wetlands & Land Management Inc
9
Wialiam L Manuell
Wetland Scientist
CC: p&Cbwl ChittiCk
J?
500 Maple Street, Danvers. Massachusetts 01923
Tel'978-777-0004 e Fax 978-777-6363
.AUG -10-2004 10:57 FROM:MATERIALS-ENGINEERIN 1-9713-470-5219
Facsimile
Cover Sheet
Ret General Policies
And Pmcedures
Na 39 500S 110
Date: -
To: P/-1 0
From:
111lessage:
NMI
T161.
Ana NO:
TO:91978688%42 P.2
Raytheon IDS
integrated
Defense
Systems
MateriWs Engineering
350 Lowell Street
Andover, MA 018 10
Fax: 978-470-3003
FAX: 978.470.9003
�Ontenft: Total Pages Tra
Page
p L' r— ,4 r7-,.4 C- 14 eLD 4,6- J -7V ---
."q -.3- <45--
Af-,11-)' LA 01
-q -7
iO-354OPC (9199)
&P. General Pdicies and PwAdures
No. 39 -SMS -1 10
This facsintile transmission is intended only for the use of the individual
or entity to which A is aftessed and may cotain information Whch is
pwlegK confldentlal, and exempt ham disclosure WKW applicable law.
It the reader ot this message is not the intended recipient or the employee Or
agent r&V*nsible to deliver k to the intended recipient, you are hereby notilled
that reading disseminating. distribubn OF Copying this Communication is *COY
pmhbW. It you have recemd this communication M error PWOe no* us
immediately by telephone and return the original message to us at the above
address via Me U.S. Postal Service- Thank You.
r- /Z -..-O e'%n
Notes:
I , 11 messW is not received completely or W received by intended party.
pisase contad sender.
2. No classified information shag be sent by facsimle.
3. No technical dat . a related to defense articles or services shad be
imnsnidled out of the UtWd Slates.
4, No *Company Most P&aw. Raylliew ProprIalary. of CWWMon
Sensit;W material $hall be sent to an unattended machine, and
Iransmimon to an attended machine requires telephone confIrmaijon
by intended recipient Upon recs'Pt.
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'1 � -� —/�, - 5�
No � ( ,, :� L" Date .... ... ........................
0, TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... Tox� ...... ...... QC)"O(Q-
...........................................................
has permission to perform ........ 11�
wiring in the building of ........... -? ................
.............................
a, .........
..7
.. Ij ................ North A�'dovrer
............
Fee .... Lic. No..E.Jm� ......... a. e. 7.?.: 1 ...............
ELECTRWAL I SPECTOR
08/23/99 13:29 15.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
ThE COMMONHIEALTHOFAUMarusms Olffice Use only, 3
Permit No.
BOARD 0FFMPREVEW0NREGM7Y0NS527(M12.00
Occupancy & Fees Checked
,4p,PL[".HONFORPERAIRTTOPEI?FORMELE(=CAL W01?K
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 cx4R 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector ofWires:
ARD
The undersigned applies for a permit to peZEK! below. FiA—P 70 G� PARCEL ZD
Location (Street & Number) Q22�' MZ
Owner or Tenant C, 0 04 (J ,A Iv, wyt�
Owner's Address SAM, -
Is this permit in conjunction with a building permit: Yes M No r -1 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead Underground No. of Meters
New Service Amps Volts Overhead Underground No. of Meters
140amber of Feeders and Ampacity
Location and Nature of Proposed Electrical Work b-Im"g- Et-,-Ifif CT,�rw iou,&14
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swunnung Pool Above [p
Below
Generators
KVA
ground
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Bumcm
FUZE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
TOM
No. ofDetection and
No. ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Cormcctons
No. of Water Heaters KW
No. of No. of
Signs
Bailasi
Nq#Hydro Massage Tubs
No. of Motors
Total HP
OTHER-
-330
Fiial
L=MT40. pp��
Bum�sTdllb 7 - 3.2 O -e
Z 1 ei 5 i L LIL, zz—e Alt. Td No.
OVIT,�SR4SURANICEWAIVER,Iamaw&ediatdrL=mdoesnottumirmsmm=c7xwo�crits aksbntialcqr,-�asregmedbyNlgsmdmsetts GaxxalLa,�Ns
anddidnrysgrjk=cn�wpwilapphcabmviar%tsflmlegmi anat
(Please check one) Owner ED Agent El Telephone No. PERMIT FEE $
-Stigna-ture of Mwner or 7gent
m
C�
k.