HomeMy WebLinkAboutMiscellaneous - 3 CIDERPRESS WAY 4/30/2018IZS
e. / /w.,
Date. . .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .... .......................
A 0 rA ...............
has permission to perform .... 1. .-. � : .... I .... . .
plumbing in the,buildings of .... ......... 5
at ... ?,. .............. /North Andover, Mass.
Fee. ... Lic. 'No.. 5 � ......... .... .............
LUMBING INSPECTOR
Check ff
G -J, -'. i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location 14 & Owners Name r -t k-6 Permit
Type of Occupancy )a Amount
New Ef Renovation El Replacement 0 Plans Submitted Yes No
(Print: or type)
Installing Company
Check one: Certificate
Corp.
Partner.
F1 Firm/Co.
Name ofLicensed Plumber: EK ol-KAgA "4 Ax -L
Insurance Coverage: Indicate th� tp"f insurance coverage by checking the appropriate bo)c
Liability insurance policy Er Other type of indemnity Bond 0
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
7. Owner Agent E]
Signature
I hereby certify that all of the details and information I have submitted (or ent'e-red) in above application are.true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plu. * Cod d Cha t P142 of the General Laws.
Zng I e an
By: 7gn=a otyicensea Flumoer
Type of Plumbing License
Title /5' /S.
City/Town License NumBer Master a Journeyman
APPROVED pm.a USE ONLY
...........
NOW
No
0
NMI
0
NMI
OWN
N'
IIIIIIIIIIIIIINEWIN
NOON
No
M
wool
m
=NMI
mom
mom
0
mom
MIM
No
MOMOMM
No
MONO
Wei 11, 11 re—_$ am
ON
(Print: or type)
Installing Company
Check one: Certificate
Corp.
Partner.
F1 Firm/Co.
Name ofLicensed Plumber: EK ol-KAgA "4 Ax -L
Insurance Coverage: Indicate th� tp"f insurance coverage by checking the appropriate bo)c
Liability insurance policy Er Other type of indemnity Bond 0
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
7. Owner Agent E]
Signature
I hereby certify that all of the details and information I have submitted (or ent'e-red) in above application are.true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plu. * Cod d Cha t P142 of the General Laws.
Zng I e an
By: 7gn=a otyicensea Flumoer
Type of Plumbing License
Title /5' /S.
City/Town License NumBer Master a Journeyman
APPROVED pm.a USE ONLY
...........
The COmMOKWeetzIth of Massachusetts
DePartment qf rndusfrial Accidents
Ofji-ce Of I'livestigations
.600 Washin,.,ton Street
Bostorz, 3L4 0211,
WWW-MzzSS-,-ov1dia
Workers' Compensation Insurance Affi-davit: BuRders/Contractors/Electri
cians/Plumbers
Name (Business/C)rganization/Indi--�idual):
Address:
city/state/zip-
Phone #:
------------
,Are you an employer? Check the appropriate box,
1. M I am a employ-, with -
4. El I am a -eheral contractor
employees (fat and/or part-time).*
2. [D'I am a sole
and I
have hired the sub -contractors
proprietor or partner-
listed on t1le att�ched sheet I
ship and have no ' employees
These sub— contractors have
working, for me in any capacity.
workers I COMP. insurance,
[No workers' comp. insurance
5. 0 We are a corporation and its
re quired.]
3. 1 am a homeowner doing work
of
fcers have exercised their
all
Myself [No workers' comp,
right Of exegiiiption Per MGL
c. 152, § 1 (4), and we
, have no
insurance required.] t
employees. LNo *ork-ers,
r .6111p. .
Insuzancf, required-]
Y EPPECaMt that ch—k- boxt#j M* --i alxo 0 out fL= SCOdOM be:oW 7--
Homeow- 9 .1 �
Type of project (required):
6. El New construction
7. E] Rernodeling
8. E] Demolition
9. 0 Building addition
10.[] Electrical repairs or additions
11. [1 Plumbing repairs or ad'ditions
12.E] Roof repairs
13.E] Other
—Mit uns amdavit indicatin UM—, --E aepu:10Y =cz--aftam-
9 they am doing all' Wolk and then hireoutsid, colra-
b,, ctors 41iSt Submit a new 9:ffidavit idicating such.
*Contractors &atchtolcth attached - additional ShCd showing the,
rInTne Of the sub-contmeto, and their work=, comp. poHcy informal�=.
an 6mPloyer durt 'sProv'ding workers' cOmp6nSadon if=ztrance
informagalL for my emPloYeMT Below is thepolicy andjob site
Insurance Company Name . :
.Policy # or Self-iiis. Lic.
Ex-piration.Date:
Job Sit-- Address:
City/State/Zip:
Attach a copy- of the workers' compensation policy declaratiUR Page (showing the policy number,and expiration date)*.
Failure to secure coverage as required under Section 25A of M'C--L c. 152 can lead to the imposition
fine up to $1,500.00 and/or one-year imprisonnient� as well as i pemLal es Of crimina.1 penalties of a
Of up to S250-.00 a day agai� the violator. Be advised that a c c vil ti in the form of a STOP WORK ORDER and a fine
Investigations of the. DIA for insurance coverage verification. cpy of this st . attment May be forwarded to the� Office of
I do h,�reby cerVjy . updcr the pains andpc�alides pf*riury thz-r the informadon provided
above'is true and correct
Official use only. Do not write'in this area, to be completed hj, city or go"In officiaL
City or Tovm:
-Issuiag Authority (circle one):
1'ernlitUcense #
I.- Board of Health 2. Building, DePartment 3. City/Tqwn Clerk�
6. Other 4. Electrical Inspector S. Plumbing Inspector
Contact Persoxz:
Phone'#-
Information an- d Instructions
Massachusetts General Laws chapter 152 requires all cirrployc--rs to priovide workers' compensation. for their cinpioYms.
Pursuant to this statute, an employee is cb-,fined as "...evzTypc---rson in the Service ofanother under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individuaL partnetship,,associzaLtion, corporation: or other'legal entity, o . r any two or Mort
of the foregoiag engaged in a joint criterprise, and including tilae legal representatives of a deceased employer, or tha
a - b -
receiver or trustee of an individual, partnership, association Dx- other legal entity, employing employees. However the
owner of a dwelling house havinz not mom fhan ' -three aPartnL ents and who resides therrin, or ffie,- occupant. of the
dwrllip.- houst-- of another who employs persons to do maintf-'mance, construction or repiir work on such dwelling house
or on the grounds or building appurtenant thereto shall not be:c--ause of such, employment be de-emed to be- an employer."
MGL chapter 152, §25C(6) also states that "every state or I * o.�cal licensing'agency shall withhold -the issuance or
renewal of a license or permit to operate a'business or to c—� anstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cupignpliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the c--ommonwealth nor any of its political subdivisions shall
entzr into any contract for the.performance of public worku'm-til acceptable evidrmce of compliance with the fiisuranre
requirements of this chapter hay.t b=n presented to the contraLcting authority.
Applicants
'Please fill- out the workers' compensation affidavit comPletel:y, by checking the b'ox.-s that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) !long with their certificate(s) of
insurance. Limited Liability Companics ' (LLC) or Limited U. -ability, Partnerships (LLP) 1�rith.no employees other than ffie
members or partaers,. are not required to carry workrrs' comp, g=ation 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 confirinaiion of insurance coverage. -Also be svire to sign and date the affidavit. The affidavit should
be ratarne-d. to the city or town that, the application 'r the p5riaaft. se is being requested . -not tht! D, -T Purt—ment of
or licens
Industrial Acri&nts. Should you have any..L.luestiOns regardii-�Z the law or if you art required to obtain a workers'
compensation policy, ple;ase call the Department at the numbe:x 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 provideda space at the bottom
of the affidavitfor you to fdl out in tha.ev.ei * it the, Office of Irrvesfigations has to contact you regarding -the applicant
Please be sure to fill in thi,- permit/licemse number which Will be -used as a mference number. In addifion� an applicant
tJaat must submit multiple permit/license applications in any 9xven year, need only submit one affida:vit indicatincr 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 stampr--d or marked by the city or tovm may be providtd to the.
applicant as proof that a valid affidavit is on ffle for filtue Peramits or license&. k new affidavit must be filled out each
year. Whcm a home owner or citizen is obtaining a license or _pm -mit not related to any business. or commercial V'entar
(i.e. a dog licmse or permit to bum leaves etc.) said person is NOT required to complete this affidivit.
The Office, ofInvestigations would like to than you in advance f6r
your cooperation and should you have. any quesdons,
please do not hesitate to give us a call.
The Depqrrmen-'s address, ie1ephonczncLEax-uumber
The Commonwmlh of Ma&&a�usett&
Department of Endustrial Accidents
.01-fice of Inrestigations
600 Wash* ---tan Street
Boston, M -A 02111
T( -,I. # 617-727-4900 cxt 406 or 1-8 —/7-Kks-.sA-FE
R-m,rised 5-26-05 Fay.#6.17-727-7749
vrv7v1.maM-gov/dia
Date. . ........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...... J.*'A ...... 1A /-/ ........
has permission for gas installation ..............
in the buildings of .... I. ....... ......
at .... ...... Noxth Andover, Mass.
7
Fee. Lic. No ...... ................
SPECTOR
Check #
7 2J
-A
e -
MASSACHUSETIS L?�BORMAPPLICATONFORPERNUrT)C)DO GAS FTFnNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building, Locations
C,
��-5
Owner's Name
New Renovation Replacement
sr 1:1 1:1
Date
Permit #
Amount $
Plans Submitted
(Print or typ&) Check one: Certificate Installing Company
Name f Z� I /V �� � //9/1 // F1 Corp.
Address 0 .4n&Y4 cv�- El Partner.
7 L
Business'l elephone — 1, 0 1-74 7 FimiJCo.
Name of Licensed Plumber or Gas Fitter *1
INSURANCE COVERAGE Check one -
I have a current liability Insurance policy or it's substantial equivalent. Yes ffl-- No13
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 0 Bond
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.
Check one:
Signature of Owner or Owner's Agent Owner El Agent 13
— j � 11.y — — vi ui� u�Lanz, cuiu wjuimauun 1 nave sumninea kor enterea) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the MassachusVp StateJas jode a
A %,�hapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or �s Fitter
Plumber /5—/J-
�es Fitter License lNumber
Master
Joumeyman
U
6�
Z
z
i -
z
z
g
W)
z
6.
z
>
z
0
z
C
rA
z
U
SUB -BA SEM ENT
B A S E M E N T
f
IST. F L 0 0 R
2 N D F L 0 0 R
3 R D F L 0 0 R
4TH. F L 0 0 R
5TH. F L 0 0 R
6 T H F L 0 0 R
7 T H F L 0 0 R
8 T H F L 0 0 R
(Print or typ&) Check one: Certificate Installing Company
Name f Z� I /V �� � //9/1 // F1 Corp.
Address 0 .4n&Y4 cv�- El Partner.
7 L
Business'l elephone — 1, 0 1-74 7 FimiJCo.
Name of Licensed Plumber or Gas Fitter *1
INSURANCE COVERAGE Check one -
I have a current liability Insurance policy or it's substantial equivalent. Yes ffl-- No13
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 0 Bond
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.
Check one:
Signature of Owner or Owner's Agent Owner El Agent 13
— j � 11.y — — vi ui� u�Lanz, cuiu wjuimauun 1 nave sumninea kor enterea) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the MassachusVp StateJas jode a
A %,�hapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or �s Fitter
Plumber /5—/J-
�es Fitter License lNumber
Master
Joumeyman
The Commonwealth of Massachusetts
Department qf Lndustrial Accidents
Office of Lnvestigations
600 Washington Street
Boston, M4 o2111
www-mas&gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/C)rganization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
LEI I am a employer with -
4. 1 am a general contractor and I
employees (full and/or part-time).*
2.7 1 am a sole or
have hired the sub -contractors
listed
proprietor partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. 0 We are a corporation and its
required.)
3. 1 am a homeowner doing all work
officers have exercised their
right Of exemption per MGL
myself [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required-] f
employees. [No workers'
*A__ !
. _;_
cOMP. insurance required.]
Type of project (required):
6. [] New construction
7. 7 Remodeling
8. 7 Demolition
9. [] Building addition
10. 0 Electrical repairs or additions
I L 7 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
Vul LLIC NCUUM ne.-DIR, snMAllug th-;� Worj;:=! comp=is =-= Policy information.
Home�owners who submit this affidavit indicating they are doing all work and then hire outside co'ntractors must submit a new affidavit indicating such.
�Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' cOmP. Policy information.
W
I am an employer thatisproviding workers' compensation w*surancefor my employees. Below is thepolicy andiob 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 policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D1A for insurance coverage verification.
I do hereby certify under the pains andpenalties ofperiurY thIt the information provided above is true and correct
Signature: Date:
Phone #:
Fo��use only- Do not write in this area, to be completed by city or town officiaL
City or Town:
Issuing Authority (circle one):
L Board of Health 2. Building Department
6. Other
Contact Person:
PermitfLicense #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
ft
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all emPloYors to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every p=rson in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, associ.Wion, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including t1ae legal representatives of a deceased employer, or the
receiver or trustee of an individual, parmership, association ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartuxents and who resides therein, or the o ' ccupant of the
dwelling house of another who employs persons to do maintexiance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be�ause of such employment be deemed to be an employrr."
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 coxnpliance with the inmwance coverage required."
Additionally, MGL chapter 152, §25C(7) states 'Neither the c:-ommonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work uni:il acceptable evidence of compliance with the insurance
requir=ents of this chapter have been presented to the cont-aLcting 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 (LLC) or Limited Liability Partnerships (LIT) with no employees other than the
members or partners,. are not required to carry workers' compocasation 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 applicafion for the pemfflit or license —;- being nqu--s�zd, not the D—epartm-ent of
Industrial Accidents, Should you have any questions regardfixg the law or if you are required to orftmi a w'orkers'
compensation policy, please call the Department at the numbi--i- listed below. Self-ingured 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
Please be sure to fiM in the permit/license number which will be used as a reference number. In additiorL 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 prov—idtd to the
applicant as proof that a valid affidavit is on file for future perinits or licenses. A new affidavit must be filled out each
year. N�%ere a home owner or citiz= 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.
T'he 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 Departmen 's address, telephone and fim number
The Commonwealth of Massachusetts
Dcpartment of Industrial Accidents
Office of IRvestigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 4-06 or 1-8 77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
vrvrv, mass-- gov/dia
Date.. .......
TOWN OF NORTH ANDOVER
0
aimm. ". PERMIT FOR WIRING
CH
This certifies that ............. 41 1.,
............. kQ ......
.. ...........................................
has permission to perform ..... 5. 1-t=.= . .............
wiring in the building of ...... ................
at North Andover, Mass.
EL
ZRI'CAL INSPECTOR
Lic. No. .......... ...........
Check# -374%1
16
Commonwealth Of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupa
Fncy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (1_,.1,1-1A
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (ME ) 527 C R 12.00
q1EASE PRWW NK OR YYPE ALL.DWORMA TIOA9 Date: 21) 0-
I 'm4
City or Town of. NORTH ANDOVIER TO the Impec Ires:
By this application the undersigned gives notice of his ns ector Of *
Location (Street & Number) or J19r intention to perform the electrical work described below.
Ar/ -A -K -s W y
Owner or Tenant
.4 pho e No.
Owner's Address 7
?
Is this permit in conjunction with a bafidin ermit Yes No
n (Check ADnronriate 11- 1
urpose of lluffdmglEhj�� �/? - -
Existing Service Amps Volts
New Service lb2_ Amps Volts
Number of Feeders andAmpacity&/#/`/ 4116
'7149
Location and Nature of Proposed Electrical Work:
Utility Authorization No._!FJV�7�2 /
Overhead El Undgrd[F-�
Overhead El Undgrd [a
va W / (-0aw"i'v
tL?
No. of Meters
No. of Meters Z ----n �1
5vL 4V,0 -Z, (
Ic
No. Of Recessed Luminaires
u f0110144n
J "2"7
.... �F
o
table rnay be waivSd by the Inspector of Wires.
No. of Ceil.- Sus . (Paddle) Fans
No*
0. Total
No. of Luminaire Outlets
S"p-
No. of Hot Tubs
T
Transformem V17 A
n
Generators KVA
No. of Luminaires
Above 1.11-
wimming Pool d 11
001 b 0 !� �7
�i 111 iil �j; l,��;
.0., :11 y
9
No. of Receptacle Outlets
_A
No. of On Burners
atte Units
L�n �f --
FIRE ALARMS of 70— es
No. of Switches
No. of Gas Burners
111U..of Detection and
No. of Ranges
No. of Air ConcL Total
Initiating Devices
Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump mber Tons
Totals:
0- Of Self -Contained
No. of Dishwashers
Space/Area Heating KW
Detection/Ale 'mar Devices
Local [] lViLunicipal
No. of Dryers
Heating Appliances KW
Connection E] Other
Security Systems:
No. o Wa
KW
No. of
No. of Device- quivalent
Heaters
Signs Ballasts
Data Wiring:
No. Hydromassage Bathtubs
No. of Motors Total 11P
No. of Devices or Eguivalent
Tele mmunications g:
OTHER:
s or nivivalam#
-4uach additional detail irdesired, or as required bv the Inspector of Wirej.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start Inspections to be requested in accordance with MEC Rule 10, and Upon completion.
INSURANCE COVERAGE: Unless waived by the Ov-mer, 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.
CHECK ONE: INSURANCE &— BONDE3 OTHEREI (Specify:)
I CaWfy, under theyaws and enalftes ofpeijury, that the informadon on this applicadon is &ue and coTplete-
FIRM NAME: r . V7 C. LIC. NO.:
Licensee:
(If applicable enter "exempt - in the lice Signature LIC. NO.: r_-
nse number line.) &�—� �e
Address: Bus. Tel. No.:
AIL Tel. NO.:
*Per M-G.L c. 147, s. 57 - -6 1, security work r6quilres Departrnent of pub
lic Safety "S" License: Lic.No.Aw�
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) 0 owner
Owner/Aggent El owner's agent
Signature Telephone No. PEAWT FEE S —7
The Commonweizith of Ayassachusers
Department qfr12dun7ial Accidents
0
-fficc Oflffvesz�,-aiions
.600 Washington Street
BOSIOPZ, M4 02111
www-rnass.,a,or1&a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri"
Allolicant jaformnfinin clans/Plumbers
Please Print Legubl,
Name (Basiness/or,-anization/IndiNidual): A
Adc.liess:—C�f (�-tZ2JV11val— ZV/O
City,'S�ate/Zip:,&
Pbone #: C 14
(21 9E ff5—);7
,4xA —
Y y,- 1ILL employ , Check the appropriate box:
am a employer with 4. [] I am a c, era, contractor
gen and I
emPlOvees (full and/or part-time).* have hired the sub -contractors
2.E1 I am a sole proprietor or panne7- listed on t1le attached sheet I
ship and have no employees These sub -contractors have
-1--g or me m any capacity.
[No workers' comp. insurance 5
requirecLj
I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] I
workers, COMP. insurance.
We are a cc),poration and its
Officers have -exercised their
right of eXeMptiOn per MGL
c- 152, § 1 (4), and we have no
em*Yets. [No *orkers,
COMD. in�ranco-
-Any
that box ;a, must alzc., 1U. out ihe se--tm 'L--'.
Homeownert Who shov!iag
Type of project (required):
6- ��, con=ction
7. E] Remodeling
8. 11 Demolition
9. Building addition
10. Electrical repairs or additions
1-0 Plumbing repairs or additions
12.7 Roof repairs
IS. D other
VU indicating thny — doing all' ru"�Y z-- �—Mom
'ContractOM that "h=h this box must attached an additional sb w '"aud Thea hire outside camra--,ors 11�s' , submit a new affidavit indizating such.
am an employer th& is providing workers I---' showing the name Of the lub-contractors amd their work=' coMP. Policy information.
Compensation U"SzIrancefor MY employees. Below is tjlpo&�
informado& andjob site
Insurance Company Name:_
Policy # or Self -ins. Lic, f.
(f,
Job Site Ad.dres 17S
S
City/State
izip_§-- 4�4�
Attach a copy : the workers� compensation Policy declaration pav (showing the policy n '
Failure to scUure coverage as required under Section ? ,e amber and expiration date).
5A of MC:jL C. 152 can lead to the imposition of
fint up to $1,500.00 and/or one-year imprisonment, as well as civil penalties criminal penalties of a
gainst the violator. Be advised that a cc)py of this smtement f a STOP WORK ORDER and a fine
of up to S250.00 a day a. in the form o
Investigations of the DIA for insurance covemge v=ification. may be forwarded to the Office of
I do hereby cerz�5, under andpenalzies ofperiury MW the information provided above is
S el
ue and correct
10, V �7��P_ 1
iLone LZ25
Official use oniy- Do not write in lhh� area, to be completcd hi, ciz�y or town OtFiciaL
City or Town. PermitUcense
lssuill' er Authority (circle one):
1. Board of Heattb Z. Building Department 3. Citv7ovm Clerk,
6. Other 4. Electrical Inspector �z. plumbip�
IUSDeCtOr
Contact Person:
Phone
Permit NO: 7 q-��
Date Issued: �12 / // 0
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Z t
I IMPORTANT: Applicant must complete all items on this pa2e I
LOCA
el
)) k, 14(
L. Print
L .4, r 's
PROPERTY OWNER cliest,
Print
MAP 210 PARCEL ZONING DISTRICTil � Historic District
Machine Shop'
yes (n�
TYPE OF IMPROVEMENT
PROPOSED USE
1-��
Residential
Non- Residential
--SNew Builclin�
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial—
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WOR�,TO BE P�EFORIVIED:
L )6%,%t f A ( mt, 1, (14.e
�� Q rr/kQo
de , 'fication Please Type or Print Clearly)
OWNER: Name: mq, I
AddresslLz�'Ai,L-� r4, 4, k�,,-4
t
CONTRACTOR Name: -4k 14 �,t Phone:
r
Address: \,i L
Supervisor's Construction License: Exp. Date:
Home Improvement License:
rN
ARCH ITECT/ENG I NEER Phone:--/,�,
-- �-, � , �. r to -Y,
Address: L -T- F /1 /1 r/ MZJ 02U4 Reg. No.
FEE SCHEDULE. BULDING PERMIT.,
'112.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
f
Total Project Cost: 1.1',�,L Y(Z FEE:$
Check No.: Receipt No.:
NOTE: Persons contracting with unrpgistered poIntractors do not have acces;-twth"e guaran0und
Signature of Agent/Owner Signature of contractor
C.�
'�Libmitted
Plans '3 jhnnittp�rj
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
- -1
Public Sewer,,,,,
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATEAPPROVED
z'
CONSERVATION Reviewed on , �: N
!v- j
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: — - Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Com
Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locateci 364 USgooC1 btreet
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories.- Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use)
LI Notified for pickup - Date
. ..... . ......................... . ....... . ...... . ...... . . ................... ............................. . . . ......................................... . ................. . . .............................................. . . ...................................... . . . ................. . .................................. .............. . ....... ............................... ..................... . ...... .......................... . .... ...................
Doc.Building Permit Revised 20 10
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
• Building Permit Application
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
• Copy of Contract
• Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
u Building Permit Application
Li Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
• Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Mass check Energy Compliance Report (If Applicable)
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
• Building Permit Application
• Certified Proposed Plot Plan
• Photo of H.I.C. And C.S.L. Licenses
• Workers Comp Affidavit
• Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
• Copy of Contract
• Mass check Energy Compliance Report
Lj Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2008
Location
/DaNo. te
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ 0
D
Building/Frame Permit Fee $ 'Z
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # .0
Building Inspector
AcHUS
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 745 Date: August 5, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 3 Ciderpress WU North Andover, MA,
Lot I
MAY BE OCCUPIED AS one unit of a 4 -unit TownHouse IN ACCORDANCE WITH
THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to:
Fee: $100.00
Receipt: 23192
Tom Zahoruiko
Meetinghouse Commons LLC
North Andover MA 01845
Buirding Inspector
1E D
0
APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
-7
0"ATE ]BUILDING PERMIT It
ACHU
ADDRESS/LOCATION OF PROPERTY:
Map_10Y C, Parcel —Lot Number(r 3 tr-,Dws�
SUBDIVISION: M"L41LOI
0 - TIA A
DATE REQUESTED FILED/READY FOR �NSYECTION:
CLOSING DATE ON PROPERTY: %/W) 0
ALL WORK AND SIGN -OFFS MUST BE CO 9�ITHIN THIS TIME FRAME. A
REINSPECTION FEE OF TWENTY DOLLAI' �S P(LE17ILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL��PPLIC62LE CODES
i,
'kl� APPLICAI�_T SIGNATURE
Permit Issued to: Me(4;ol�� 622�014"j I C
Address:
ROUTING
CONSERVATION
PLANNING �j I A CH qdR F1
DPW-WATERMETER
SEWER CONNECTION
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
SIGNATURE
File: Application for OC form revised Jan 2007
RT
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 745 Date: August 5, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 3 Ciderpress Wgy North Andover, MA,
Lot I
MAY BE OCCUPIED AS one unit of a 4 -unit TownHouse IN ACCORDANCE WITH
THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to:
Fee: $100.00
Receipt: 23192
Tom Zahoruiko
Meetinghouse Commons LLC
North Andover MA 01845
Buirding Inspector
t%ORTH
0
APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
BUILDING PERMIT # -7 q -�'
ADDRESS/LOCATION OF PROPERTY: 3 C,4�5QQ IZ
Map- C, Parcel Lot Number(i -3 C, Ar-,D�rsg "I
. - 1 /7 1
SUBDIVISION:
DATE REQUESTED FILED/READY FOR
CLOSING DATE ON PROPERTY: 9
),0
N,
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REOUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLET"THIN THIS TIME FRAME. A
REINSPECTION FEE OF TWENTY DOLLARS 0.00) ILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL—APPLICAKE CODES?�,,
APPLICANT SIGNATURE
Pemiit Issued to: 6 C
Address: US C�,,It�4
n4lim 0 1 �
CONSERVATION 0
1 212-416
PLANNING N) I A 6� W _F1
DPW -WATER METER o'XIAO'be
SEWER CONNECTION
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW
SIGNATURE
File: Application for OC form revised Jan 2007
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%Uss-Ichusetts - Depat-tment f)f pl,I)lic S;lt,Ct%
Board of Building Re,-mlati(Ins jill(I �,�
ta It (J; I rds
Construction SuDervisor Licenz�—
License: CS 55417
Restricted to: 00
THOMAS U ZAHORUIKO
115 CARTERFIELD RD
N ANDOVER, MA 01845
Expiration: 4WO12
Tr.-': 21090
� Plans �Submitte
1
641
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Signature,41
Zubl:ic�S�ewer
Taming/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS tJ1A � Z -M COO -B
CONSERVATION Reviewed o
Signature,41
COMMENTS
uad plu cl-�-
&6-21 0,IZ,
-A ,-I c ZY
HEALTH Reviewed on
S ature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submifted yes
Planning Board Decision:
Comments
Conservation D ecision:
Comments
1�' A
d
Water & Sewer Connectiontsinnatur"Dgte7.4-,/f,��(�/*���
ri vewa'FvTermit /11//0
111fll
DPW Town Enginedr: Signature:
'V/
REScheck Software Version 4.3.0
Compliance Certificate
Project Title: Meeting House Commons
Energy Code:
2006 IIECC
30.0
Location:
North Andover, Massachusetts
Construction Type:
Multifamily
3769
Building Orientation:
Bldg. orientation unspecified
Conditioned Floor Area:
3399 ft2
Front Walls: Wood Frame, 16" o.c.
Glazing Area Percentage:
7%
0.0
Heating Degree Days:
6322
Orientation: Unspecified
Climate Zone:
5
Construction Site:
Owner/Agent:
Building I
Tara Leigh Development, LLC
North Andover, MA
45
115 Carter Field Road
North Andover, MA
978-6876-2635
Compliance: Maximum UA: 1174 Your UA: 1165
Designer/Contractor:
O'Sullivan Architects, Inc.
580 Main Street
Suite 204
Reading, MA 01867
781-439-6166
Floor 1: All -Wood Joist/Truss:Over Unconditioned Space
3769
30.0
0.0
IZ4
Ceiling 1: Flat Ceiling or Scissor Truss
3769
30.0
0.0
132
Front Walls: Wood Frame, 16" o.c.
1778
19.0
0.0
91
Orientation: Unspecified
Window 3: Vinyl Frame:Double Pane with Low -E
137
0.330
45
SHGC: 0.30
Orientation: Unspecified
Window 4: Vinyl Frame:Double Pane with Low -E
39
0.280
11
SHGC: 0.27
Orientation: Unspecified
Door 1: Glass
80
0.280
22
SHGC: 0.42
Orientation: Unspecified
Sides: Wood Frame, 16" o.c.
7840
19.0
0.0
463
Orientation: Unspecified
Window 5: Vinyl Frame:Double Pane with Low -E
104
0.330
34
SHGC: 0.30
Orientation: Unspecified
Window 6: Vinyl Frame:Double Pane with Low -E
26
0.280
7
SHGC: 0.27
Orientation: Unspecified
Rear Walls: Wood Frame, 16"o.c.
1922
19.0
0.0
88
Orientation: Unspecified
Window 1: Vinyl Frame:Double Pane with Low -E
343
0.330
113
SHGC: 0.30
Orientation: Unspecified
Window 2: Vinyl Frame:Double Pane with Low -E
13
0.280
4
SHGC: 0.27
Orientation: Unspecified
Door 2: Glass
40
0.350
14
SHGC: 0.31
Orientation: Unspecified
Door 3: Glass
60
0.280
17
SHGC: 0.42
Project Title: Meeting House Commons Report date: 01114/10
Data filename: K:\Zahoruiko\Meetinghouse Commons - No Andover\TownhouseskCD's\Building lkBuilding-l.rck Page 1 of 2
Orientation: Unspecified
Compliance Statement. The proposed building design described here is consistent with lans, specifications, and other
the In )I
calculations submitted with the permit application. The proposed building has been designel6tuoi megelpthe 2006 IECC requirements in
REScheck Version 4.3.0 and to comply with the mandatory requireimeq!ts�l�istedin t e RES eck Inspection Checklist.
4 //1 v/, v
AWo Aeoef Daie
Name - Title I /"' nature
Project Title: Meeting House Commons Report date: 01114/10
Data filename: K:V-ahoruiko\Meetinghouse Commons - No Andover\Townhouses\CD's\Building 1\Building—l.rck Page 2 of 2