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HomeMy WebLinkAboutMiscellaneous - 35 CRANBERRY LANE 4/30/2018Date...../S' ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1 This s certifies that ........ ........................................................................................................... has permission for gas installation ..^ r✓tre, in the buildings of .......' �........................................r' %.,,,,,,, North Andover, Mass. at ........3................................ Fee ....' .............. Lic. No. e% j / Ce / GASINSPECTOR Check #� �� 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITY s¢l1 ,4 ✓ MA DATE 12- 8-1 S— PERMIT # )Mll JOBSITE ADDRESS 3S^ ere, y-, 6e rry Ari -2 OWNER'S NAME `����r S '6, �-e-e y% ADDRESS r✓t TEL 6,2j -66r4AX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO ©� APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES © NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X❑ OTHER TYPE INDEMNITY ❑ BOND ❑ 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 El AGENT F-1SIGNATURE 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 a • c m ate to the best of ovrledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit II Pertinent pro ' ion f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE MP ® MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION © # 3631C PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Merrimack Valley Corp ADDRESS _ 15 Aegean Drive Unit # 3 CITY Methuen STATE MA ZIP 01844 TEL (978) 689-0224 FAX CELL EMAIL pviens(@mvalleycorp.com 3 1.ne Commonwealth of Massact-rusetty Office of In vestigations 600 Washington Street Boston, AM 02111 www. mass'.gov/ilia Workers' CoMpeitnsatio1: Iiru UT2 uce Affidavit.- Builders/Cerra acE ars/Electrieialrts/Piurube>rs p Acaut Information Please Print Legibly Name Business/Or anization/Individual : �' 1 /� Address: City/State/Zip: , '4�1_ `.'r,�` %�l'j� C:"�/✓c`�A/ Phone #: Are you an employer? Check the appropriate box: .0 1 am a employer with 4. ❑ I am a general contractor and l employees (full and/or part-time)." 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all wort: myself. [No workers' comp. insurance required.] i have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.! 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs of additions 1 LEI Plumbing repairs or additions 12.❑ Roof repairs 11L,�' ttherA:�—�1S �= ,,, �c r '.Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit irdicatittg such !Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. �.-- L, Insurance Company Name: :a Policy u or Self ins. Lic. #: ;����_z � e�� � � Y Expn-ation Date: Job Site Address: 3� 8r0.V\ 6_e fry J4.14 -Z City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy cumber 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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD{ ORDER and a fine of tip to 5250.00 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. l do he7-eb4,certify i.ncder the pains and penalties ofperjury that the information provided above is trace and correct Phone P': Official tis e only. Do not write in this area, to be completed by city or town offacial. City or Town: PermitlLicense # 12- - & - l 1 -- Issuing Authority (circle one): 1. Board of Health 2. Building Department ?. City/Tov;n Clerk 4. Electrical inspector- 5. Plumbing Inspector 6. Other Contact Person: Phone #: R COMMONWEALTH OF MAMACHUSETTS. ,. DILY114141 LIKO Wil a141:1• BOARD OF PLUAB EAS A#D 9 A S F ITTI:R.S ISSUES THE FOLLOW RIS L KENSE LICENSII AS A JOURNEYMAN PLUMBS PETER G VIENS 9 BLUEBIRD LANE u ATNINSON { 03811-2302 21 k 5 05/Q j./ 16 - . 213586 t y Peter Viens Cert # 102.3121001-12 Expires: 10/23/2015 Certification N.F. P.A. 99-2012 ed. ASS 6010 Installer & ASME IX Brazer State of New -'.,Hampshire GAS FITTERS LICl NSE NAME: PETER V1ENS ;a ENDORSEMENTS: STN, STP DATE ISSUED: 10/t5/2013 DATE EXPIRES: 11130/2015 LICENSE #:GFE0700587 OSHA 600316337 U.S- Department of Labor Occupational Safety and Health Administration Pcter Viens has successfully completed a 30 -hour Occupational Safety and Health Training Course in Construction Safety & Health rT er ace 6687 /2ti ,9%.COMMONWEALTH OMMONWEALTH OF MASSACHIS , .S SGARD O PLUMB EAS ,AND GASFITTEli R$ ISSUES THE FOLLOWNG LICENS t (U SED AS A MASTER PI, UMBER PETER G VIENS 9 BLUEBIRD LANE :ATI€ I NSON .ISH 03811-2302 121: t.6 &01/16—.. 213585 � Commonwealth of Massachusetts Department of Public Safety Hoisting Engineer License: HE -110323 tl► !r PETER G VIEW 9 BLUEBIRD LN ATKINSON NIf 03il1 �- Expiration: Commissioner 11/13/2015 State of New Hampshire MECHANICAL IDENTIFICATION NAME: PETER VIENS LICENSUREGISTRATM #: ow 1 . SERVICE GFE0700587 MASTER 3249 t Commonwealth of Massachusetts Department of Public Safety License: PMU-001088, Pipefitter Unrestricted Master Peter G Viens 9 BLUEBIRD LANE1 Atkinson NH 03811 .\\,. Expiration: 1113/2016 Commissioner Date......... ... .. ............. //i TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 45�e64 5 'e .............. I ....................................................... .................... . has permission to perform ....... ................................................. wiring in the building of ... ........................ .4 ................................................ ......... at .................. .,North Andover, A*S. ,)Fee..4/5- ..................... Lic. No. 4 .. ...... ................. 'C' Check # S SJ f Commonwealth of Massachusetts , a Department of Fire Services QM BOARD OF FIRE PREVENTION REGULATIONS Official ,U, -,se Only Permit No. � � 4, t 7-- Occupancy and Fee Checked tev.1/071 (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 PRINT ININK OR TYPE ALL INFORMATION) Date: —/J 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,)` ".� S C J3` -212/?' L %'� 1J L; Owner or Tenant _ P� 7� S /J el 14 Telephone No.�7 % -� Owner's Address S 6 n'1 E Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box)63 Purpose of Building S•'t"l G l� t" r/� 1)1"t -e1/' "t Utility Authorization No.l L� �D�� f - Existing Service Z 00 Amps f Z d / aY 0 Volts Overhead ❑ Undgrd No. of Meters % New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,Z N S +,4 1( ;16 K s -V 5 r4l >J O 13,Y 4- t4(/'f-6 M +; e 7-4,1 1-1 i I -A Sk4i'f-eId 41,J Aje4I siiLf v11 /t -aa) -c. Com letion of the following table may be waived by the Inspector of Wires. V!S- v Attach aaamonal aerau IJ aeslrea, or as regitereu uy uce enoyc�.�i j .. •• •• Estimated Value of Electrical Work:S8 6 - c7 (When required by municipal policy.) Work to Start: t% Z' 1 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify, under the ams and penalties of er ury, that 1z information on this application is true and complete. FIRM NAME: f -e C k /c -q LIC. NO.: �/ �% ©JN L 4 qt Licensee: Fe l)erl f Z l• I? 5& +A Signature - LIC. NO.: (If applicable, enter "exempt" inthe license number line.) ` Bus. Tel. No.: J Address: A4; ,n �o-4oatJ j (k3 i, Alt. Tel. No.:4 79 '3ZS-c' Vf *Per M.G.L c. 147, s. 57-61, security work 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 (check one) ❑ owner ❑ owner's agent. Owner/AgentaK PERMIT FEE: $ / Signature Telephone No. P No. of Total No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators v KVA No. of Luminaires Above In -El Swimming Pool rnd. rnd. o. o mergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners InitiatingDevices No.. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: - Detection/Alertingy Devices No. of Dishwashers Space/Area Heating KW Municipal El Other Local ❑ Connection No. of Dryers Heating Appliances KVV Security Systems:* No. of Devices or E uivalent No. of WaterKW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: V!S- v Attach aaamonal aerau IJ aeslrea, or as regitereu uy uce enoyc�.�i j .. •• •• Estimated Value of Electrical Work:S8 6 - c7 (When required by municipal policy.) Work to Start: t% Z' 1 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify, under the ams and penalties of er ury, that 1z information on this application is true and complete. FIRM NAME: f -e C k /c -q LIC. NO.: �/ �% ©JN L 4 qt Licensee: Fe l)erl f Z l• I? 5& +A Signature - LIC. NO.: (If applicable, enter "exempt" inthe license number line.) ` Bus. Tel. No.: J Address: A4; ,n �o-4oatJ j (k3 i, Alt. Tel. No.:4 79 '3ZS-c' Vf *Per M.G.L c. 147, s. 57-61, security work 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 (check one) ❑ owner ❑ owner's agent. Owner/AgentaK PERMIT FEE: $ / Signature Telephone No. ❑ 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. ❑ 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 ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass V Failed Re- Inspection Required ($.) ❑ Inspectors Co ments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) O InspectoA Comments: U r Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6e 1,e (Z Address: t! dLtjj' STb•-cam City/State/Zip:" 444yP o A & etA Y V Phone #: lj 7 `/- 6 �-3 S �d / Are you an employer? Check the appropriate box: 1. B"I am a employer with 6 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working f6r me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 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. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. " contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site !formation. / f isurance Company Name: r- r �7 tiJ y -.;:-p SJ a 0 t✓C,t P© olicy # or Self -ins. Lic. #: %" e 3.3/ f/ F,5 1 Expiration Date: 5'— F _/ y )b Site Address:_ .3 S 'f 41Wy 141 A4 Nd 141J0dt:H City/State/Zip:AA) ANOa t1. 1 ,M 4 tl/ F l <' Itach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify vnder the pains and p a es of perjury that the information provided above is true and correct. Date: Official rise only. Do not write in this area, io be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone S I 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 employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the 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 (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 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. Please 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 filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Co; monwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 evised 5-26-05 Www mace nnv/din GENERATOR APPLICATION DATE: /— / - /3 LOCATION: �� �Q�����z L�^�P• OWNERS NAME: V-e-'�"` 5y44a' GENERATOR kw c -2a k vJ NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: fire ���� z� e 51-C6 ff 1ff PHONE NUMBER: oq7R 3 % 5 , 0 �IV61. LECTRICA RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR:LP� S//� % ��^/fi �P�ti Zd "'ZONING DISTRICT: *CONSERVATION APPROVAL",--N"lv- la1r3 &At��P hlu-JF4 I -J Lpj-�- bVi w �w GENERATOR APPLICATION DATE: /— / - /3 LOCATION: �� �Q�����z L�^�P• OWNERS NAME: V-e-'�"` 5y44a' GENERATOR kw c -2a k vJ NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: fire ���� z� e 51-C6 ff 1ff PHONE NUMBER: oq7R 3 % 5 , 0 �IV61. LECTRICA RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR:LP� S//� % ��^/fi �P�ti Zd "'ZONING DISTRICT: *CONSERVATION APPROVAL",--N"lv- la1r3 &At��P hlu-JF4 I -J Lpj-�- bVi go ,rD w W� North Andover MIMAP 'a Wetlands Interstates �.2.1l� U1 :''S�%l.:-.':::'• :,'_Ct.. iii-.. .'.'.':.: •' i 0.59.0-0048 695?l 059.0-0078 :h. 059 -0079,- I ' atu '`:. OBBLESTANEIt� \t s 3 District L r Easements 6 Busine 0 MVPC Boundary q6,59:6= _. Business Disldcl Zoning Overlay •-: �kkr.':`•:•-.. •. •• ••-• �iltc •:�.... u.Ur. •.:••::.3�i,CE.'`:.•.. �lci..:::::`�:al�i.':•:°.•• .. ?00<�,a. B Downtown Overlay District -:_.._. ......; qtr ::_",i; •:= :< >Nlcri::_:";I; .: r_: :: ...... 0 Corrido 43;COBBLESTO,NECIR _ •.:'szJu '11t'.`'::::" ._..•..• i,..:':aJcf :"':::'1r.:.,ti- x6r� . •-.. Development Dist r: Hydrographic Features Industri Al 1” = 82 ft Industri 12 District 0 Indus ri 13 District : �_�':::_ C Industri 059,0.-0083 fo ••-.++• ' ::::= .1,... ' ce 1 District ce 2 District 059.0-0082 059.0-0092 Y R3 059.0-0081 57COSBL_ES„„TONEtGIR, 059.0-00714VC– \— o' RANBE9RY'LN; 059.0-0070 35 CRANBERRYLN 123 ,...r--•-�” 059.0-0072_..._,_ ,ryq 182' q 1059.070073 059.0.0059 r- Rail Line 'a Wetlands Interstates Exempt Lands — Inlerstale a Busine — Major Roads Roads s 3 District L r Easements 6 Busine 0 MVPC Boundary ORT ❑ Municipal Boundary Business Disldcl Zoning Overlay 13 Planne " BAdull Entertainment ?00<�,a. B Downtown Overlay District Development Dist 0 Historic District 0 Corrido ® Water Protection O _ ❑ Parcels Development Dist r: Hydrographic Features Industri Streams 1” = 82 ft 059.0 -0058 - April 1, 2013 11 059.0-0069 ►.\ 25 CRANBERR,Y,'LN\ 059.0-0057 162' j / 059.0-0022 57rOLD VILLA;GEyLN� 1 Zoning Busine s 1 District a Busine s 2 District O Busine s 3 District 6 Busine s 4 District ORT O Genes Business Disldcl f 13 Planne " Commercial Dev ?00<�,a. . Corrido Development Dist • 0 Corrido Development Dist O _ O Corrido Development Dist 1' Industri 110istncl « Industri 12 District 0 Indus ri 13 District �c t C Industri I S District ••-.++• ' Reside Residej ce 1 District ce 2 District •�l '��.�c .A'.. 1SSACMUS�tt`' C3 R—ide j de ( }ede Yv de „age ce 3 DI:ric ce 4 District ce 5 District ce 6 District esidential District \• Horimntal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Aflairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION Date. '!�1:?....... ti0 � f ` TOWN OF NORTH ANDOVER • PERMIT FOR GASJNSTALLATION �i This certifies that .. ,#O.h ........... has permission for gas installation .. P 4 r. ... y t�l! .......... in the buildings of ..5',x4 /�. r. .......................... 3. !: p 4.r��!� t�� at ... ... .. , North Andover, Mass. Fee. Lic. No../Ul d{... .... �..� .`'`''` GASINSPECTOR Check # /(I) 6124 t MASSACHUSE'I'iS UNUDRMAPPUCATONFOR PERNIlTTODO GAS FUHNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS rr , Building Location "' Or4V �prr �t.J• Permit # all L / l ' Amount $ 3 p �- �•I"� t �% Owner's Name New d Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) Check o : Certi 'c to Installing Company Name Corp. Address LqF f ❑ Partner. Business Telephone / ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy o . 's substantial equivalent. Yes ❑ No ❑ If you have checked }_es, please indic a type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ 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 ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) to above apptucatton are true and accurate to the best of my knowledge and that all plumbing work and installations pe orme d r Permit sued for this application will be in compliance with all pertinent provisions of the Massacl tts �taV�s Cod�Chapter 2 of the General Laws. Title City/Town IAPPROVED (OFFICE USE ONLY) rnature of Licensed Plumber Or Gas R e Per 4❑ G ter icen eNumber Master ❑ Journeyman IN d w c H x x W S z O w rOZi a 00 W ' Fw+ x w w A w U a H zCIO H za O rn O x w A c7 a UO a0'. A a F O SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Check o : Certi 'c to Installing Company Name Corp. Address LqF f ❑ Partner. Business Telephone / ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy o . 's substantial equivalent. Yes ❑ No ❑ If you have checked }_es, please indic a type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ 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 ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) to above apptucatton are true and accurate to the best of my knowledge and that all plumbing work and installations pe orme d r Permit sued for this application will be in compliance with all pertinent provisions of the Massacl tts �taV�s Cod�Chapter 2 of the General Laws. Title City/Town IAPPROVED (OFFICE USE ONLY) rnature of Licensed Plumber Or Gas R e Per 4❑ G ter icen eNumber Master ❑ Journeyman IN d Date ..... ~.... ..... .. d...1. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that aI :.'4 z L F -T `^� P ..................... .............................................................. has permission to perform..............................1%P.� )%P.� ................................. wiring in the building of 5„/.�./o� k. "/t. .................. ............................................. .3 s C�1�%/i� �/. 4,61 ..... , North Andover, Mass. 00 2.o1 oq Fee... / :5...".`. Lic. No... .......... ................. ........... .......................... . ELECTRICAL INSPECTOR Check # 7571 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. -7,j % Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: VC40r) 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) c f qn herr&% L00f Owner or Tenant A -t Telephone No. 971- G IF -6 (,s-&'2 Owner's Address Zkklh t Is this permit in conjunction with a building permit? Yes t No ❑ (Check Appropriate Box) Purpose of Building ej,Q 7tc Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Cmmntotinnnft%ofnllnudno. Al 1 r1,...L..r..____._ _P No. of Recessed Luminaires - _. ---__._.. - ..._ ....,...... No, of Ceil: Susp. (Paddle) Fans .».,.., -- — ­.vc" � one uw cuvr v rrue�. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: I Number ... Tons I KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances Kir No. of Noof . Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:_} I0�ul\ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) Icertify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: t,7,WL Q\tC_V,,C,,\ LIC. NO.: a' Licensee: Signature & LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 9�0'-4 i�–�G� Address: .9 J`^.;l�u^1��P L4•,., ./1/�/� Uj�1Q'�° �---�— Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work 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 (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. -PERMIT FEE $ �\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information � Name(Business/Organization/Individual):_ G. �- v%Please Print Leibl � �\���,,,1t �� Co1r�� Address: � ','�t r/t' City/State/Zip: L �,� �/�- d 1904 Phone.#: Are you an em to er? Ch k p y ec the appropriate box: 1. ®'Tam a employer with — 4. 111 am a general contractor and I who employees (full and/oart-tune).• r p 2. ❑ I am a sole proprietor have hired the sub -contractors listed or partner- on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 3. ❑ I am a homeowner doing 5. El We are a corporation and its officers all work have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] •My applicant that checks box #1 must also fill out the section below s t meown Hohowing their worms• Type of project (required) 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 LQ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other eB submit this affidavit indicating they are doing all work and then hire outsidec�ha tors must subnnt anew affidavit indicating such. :Contractors that check this box must attached an addition al sheet showing the name of the su employees. If the sub�ontiactors have employees, they must provide their workers'policy tr mber. and state whether or not those entities have comp. policy number. — .,"FAUycr rnar rs providing workers' compensation insurance for my emplo information. yees Below is the policy and job site Insurance Company Name: /%/,, � i Q i- (l,, . I L.; _ Policy # or Self -ins. Lic. #:_ a W v N Ll �S, q �� Expiration Date:_ o U C� Job Site Address; '� 5 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy Failure to secure coverage as required under Section 25A of MGL c. number and expiration date). fine up to $1,500.00 152 can lead to the imposition of criminal penalties of a 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 Investi ations of the DIA for insuran a Covera a verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct LOLG: Q' Phone #: Official use only. Do not write in this area, to be completed by city or town officlaL City or Town: Issuing Authority (circle one); Permit/License # L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PlumbingInspector 6. Other P Contact Person: Phone #: Date. /� -/91 ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTAL/LATION SA -i V This certifies that.. has permission for gas installation . 1*1 r... , . , , , . in the buildings of ..Y Zl- .................................... at North Andover, Mass. Fee:� ,.—.. Lic. No./o?2? . . ..... GS INSPECTOR Check# 66G7 _r_ a _w is MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: N16-r� �dwey'- Date: Permit# (9 (s Y Building Locatio (�i '� h_,CP Owners Name: -P56 Type of Occupancy: Commercial ducational Industrial Institutional Residentiaix New: Alteration:'. Renovation; I Replacement: Plans Submitted: Yes No • FIXTURFS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesX No. If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy XY Other type of indemnity' „F Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Aaent By checking this box ❑; I hereby certify that all of the details and information I have submitted for entered) regardina this aoolication 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 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: BY'. Plumber Gas Fitter Title Signature of Li a ed riumberlGas Fitter . Master �.' City/Town.- Journeyman LP Installer License Number: eononvcn inccirc �icc nw vi Z LLI Y W W O LU Lu yv Cn _ ~ 0 M W rn W vi O W O A Z W Cn W W z 0 IWQ- m W O'~� Q O U z F- IX > F' Q z W O W W w z W 0 = w o It 4. > Z O W W Z } IX w IX D to Q J F- N O Z -� O Q Q m W O Z w w > O Q O 0 � F Z H O W z w a F Q !— _ a I— U o o W C9 O 2= O a a IX H>> O SUB BSMT. BASEMENT —i'FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 TH FLOOR 7 1H FLOOR - 8 FLOOR f. 1 Installing Company Name. j. 6 ry-.1 C,;� V`,Q 1 I ' CII _ Check One Only Certificate # Address:/�/4( /') ,.CitY/Town:�( State: MA �/ Corporation j{ Partnership Business Tel: �f�%��-�1� Fax: 7t Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesX No. If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy XY Other type of indemnity' „F Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Aaent By checking this box ❑; I hereby certify that all of the details and information I have submitted for entered) regardina this aoolication 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 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: BY'. Plumber Gas Fitter Title Signature of Li a ed riumberlGas Fitter . Master �.' City/Town.- Journeyman LP Installer License Number: eononvcn inccirc �icc nw vi `UPW ;Oka, � Date. wZ1%.; ...ri—... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SACHUS This certifies that .. ........................ has permission to perform ..... ........ plumbing in the buildings of . ........................ ........ North Andover, Mass. Fee,.�. . Lic. NVq.iii. ..... ........... PLUMBING 14iCCTOR Check # 54135 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING We or print) NORTH ANDOVER, Building Locations Date Permit # 3 t Amount s Owner's Name Pejq s4 44,eetj New 03-1*"' Renovation 0 Replacement Plans Submitted LJ L`TYTTTDI Q (Print or type) Check 9XIV. Corp. �� Certificate � � Installing Company Name �+ � Address C t1 Partner. Business Telephone Firm/Co. Name of Licensed Plumber: w, //t *!1 h ------ Insurance Coverage: Indicate the type . insurance coverage by checking the appropriate box: Bond ❑ Liability insurance policy Other type of indemnity Insurance Waiver: I, the undersigned, have been mgd'eraware that the licensee of this application does not have any one of the above three insurance Yignature Owner 11 Agent El 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 grformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac#usetSta P ing Code and Chapter 142 of the General Laws. Type of Plumbing License License Numoer Master Journeyman ',D (OFFICE USE ONLY 41600 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....�rf ... (J . 4 .. C' .1 /�- /I'(- /w, rct / y q C - ......... .. . .. ................................................................... -4 has permission to perform ...... ..... ...... t - wir'Tg in the building of ........... ....................................... at ......... 3.-,-," ......... i!?.`......... ... North Andover, h4afs7 Fee ..3..� .. ao... Lic. N .......... ..... ....... ............... LECMI AL I PECTOR Check # TH&COMMONWF,ALTHOFMA S4CIIUSETTS Office U o iy DEPARTMEA7'0FPUBIICS4FE7Y BOAROOFFIREPREVEIV77ONREGULWONS527CY1R12,� Per o. Occupancy & Fees Checked •APPLICATIONFOR PERMIT TO PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date_ .Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street .� -" Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Yeso �r­! (Check A Purpose of Building � pproprlate Box) Existing Service �� AmpVolts New New Service Amps / Volts Number of Feeders and Ampacity Utility Authorization No. Overhead Underground L:J No. of Meters Overhead Underground No. of Meters Location and Nature of Proposed Electrical Work 4/IAe�5- .5 No. of Lighting Outlets No. of Hot Tubs No. of Lighting Fixtu s Swimming Pool Above No. of Receptacle Ouets No. of Oil Burners round i No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total No. of Disposals No. of Heat Tons Total No. of Dishwashers , l Pumps Space Area Heating Tons No. of Dryertl Heating Devices No. of Water Iaters KW No. of No. of No. Hydro Massage Tubs Si ns Ballasis No. of Motors Total HP No. of Transformers Below Generators mound No. of Emergency Lighting Battery Units FIRE ALARMS TotalNo. of Detection and KW Initiating Devices KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW LocalMunicipal M Connections Total KVA KVA No. of Zones Other ----�� hsumIceCOMr,W_ Pt1141atYtO11P1HgLtiCPInHItSpfNj ,S �1I�1W5 haw aamatLiabkyh l}ky Conpi�C CovwWoriisabstan legtrivalai YES havuWbmWdvandproofofsatnetDdrOlf"_ WS Er NO haddngthe box IfyoubavecltedcedYESpleaSeui&YethetypeofoovragebY VSURANCEBOND OTIC y) L p�J ------------ k&toStatt Es dVahieofF7eft1calWbik $ hl5pearonDa�Regtles�d Ro gh Final ig�rledtmdei-�Pt3taltiesofl�ituv, _ LIMWNO Bu%mTe1.No. 9 7r dr2 6 2-4Z ARTUNo A'NII SINSURANCEWANER,Iamawatethattheliceme esnothavetheit�stlt xCovaageoritsst�aMal dthatmysignahueontbspemvtapphcahtinslegttitarlatt � � bY�Gerlelallaws lease check one) Owner Agent p ­779—nature of Owner or Agent Telephone No. —PERMIT FEE G Location gs CLAN 6 P hr� )A) No. / fV Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3-? 0 Check # 15825 11,4,z4 Building Inspector 1.1 Property Address: f C L4-A�1� 1.2 Assessors Map and Parcel Map Number Number: Parcel Number - 1.3 Zoning Information: Zoning District Proposed Use 1.4( Property Dimensions: �J` Lot Areas / ZJ Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Recpfired Provide Required Provided Required Provided 1.7 Water Supply M.GLC.40. 54) Public Private ❑ 1.5. Flood Zom Information'1.8 Zone Outside Flood Zone Municipal SeweragpD sposal System: &,-" On Site Disposal System ❑ SECTAON 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record -A 41P Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed ConstrucVn Supervisor: ti License Number Address /�l`71/l� / �/ �G 7a �� Expiration Date Signature VTelephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ r Rad C- ��-/ Irl ��6 �ra Al � Company Name Registration Number Address t f / / I v 4_ lI (� �J i _ Z v Expiration Date Si nature telephone 00 M z 0 rn 0 z M 90 0 mn ic r v rn _r ^z Y/ SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) 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 ....... ❑ SECTION 5 Descri do f Proposed Work check all applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) b]/ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - FSTIMATF.D CnNRTRTTCTTnN cncTc Item Estimated Cost (Dollar) to be Completed bypermit applicant = OFFICIAL:USE ONLY .? 1. Building a -S-0`D (a) Building Permit Fee Multiplier 2 Electrical / JJ—U D (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) O / 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 3 A- I NJ D Check Number aEl,11V14 /a V WPIEK AU 1t1VK1LA11Uf4 10 BE UUMYLE' ED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �d u % e ` , as Owner/^ thorized A e of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORI�Z'ED AGENT DECLARATION 1.�z4::gy as Owner/ orized Agent o 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 Owner/. R103 Date SIZE ASEMENVOR SLAB -0F FLOOR TRABERS )—i< 1 1� 1 2 RD 3 SPAN / — - DIMENSIONS OF SILLS VVA DIMENSIONS OF POSTS DIIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS / G SIZE OF FOOTING X -).0.4 MATERIAL OF CH WINEY IS BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE rumivl U .- LU I RELEASE FORM INSTRUCTIONS: This form is .used to verify that all necessary approvals/permits fror Boards and Departments having jurisdiction have been obtained. This does not retieVE the applicant and/or landowner from cu'mpliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT zca �zr LOCATION: Assessor's Map Number. % SUBDIVISION STREETG/�je y PHONE PARCEL7d / LOT (S) ST. NUMBER,�Ar7 *****************************************OFFICIAL USE ONLY*********************************** I HtcUTJTENP�NS OF TOWN AGENTS: CO TOR . DATE APPR0V9D DATE REJECTED 1_0V1641n C6*111 j DTE REJECTED COMMENTS�� aC�h�� FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO ATEA_ Revised 9\97 im MORTGAGE INSPECTION BAY STATE SURVEYING ASSOCIATES INC. 100 CUMMINGS CENTER, SUITE #,318.1, BE1lE2LY,MA.. D19i5 LOCATION :..NoRT14 A4NDOVE R M4, .................................... SCALE : V' - 4o DATE:..7�..?- .1 ....... REFER- . ENCS ..........................G:S i ........... ................... ..................................................... TO. .Sf �i5m FIvF MoRTGAGe- Co2P. The location of the buildin91s) as shown. tither canpiica with the local zoning setbacks at the time of construction or is exempt from violation enforcement actlon under Maas. G.L.. 1911e VII Chapter 40A Section 7 ROTES: 11 This is a mortgage Inspection survey and not an lnaftwent survey. therefore this plot plan is for mortgage Inspection purposes only. 2) This survey Is bssed on wtvey marks of others. 31 Bushes. st rubs. fences and tt•es Unes do not neftsnrily Indicate pMperty lines. 4) Whenever an ofrird Is 1' w less. an Insa is ent survey Is racontmandad to determine property Unes, and any possible ent2 schments. 51 Offwts shown ars appmKimats, and are to be used only for the detarminatlon of zoning, Not to be used to establish property lint 61 In my professional opinion the building(&) are not located in the special flood hazard Zone, a* d.nned by H.U.D. MAW Z600r A �ROEltfr, `' O �• L o7 4 (AP'EA:t Z4 000 YC" ZSTOR�� 3S /,Wood/�, 3 97 7,0 ZS, o D STRF�T" CRA NEERR Y L ANE 'Z -Z 61ZA N. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02191 Workers' Compensation Insurance Affidavit Print ggy 4valr9iJ7 //,' Phone 2 am a homeowner performing all work myself. a sole proprietor and have no on6 working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. 29mpany name: Address City: Phone GoMParnr-name: Address City: Phone #- Failure to secure coverage as required under section 25A or MGL 1552 ran load to ft i A%sdton of criminal penalties of a fine up to sl.500.00 and/or one years' imprisonment as WOR as dhl penalties in the form of a STOP WORK ORDM and arm o/ 31110 understand that a copy of this statement may be forwarded to the Office of M of($1W.00) a day against me. i . vestigations of the DA for coverage verification: I do herby certify under the pains and penaties of per that the i»fonnafim provided above is bve and.correct Signature - Date i r ;i Print name ti Phone # Official use only do not write in thisarea to be completed by city or town ofrzw, Building i�Oheck if immediate response is required Building Dept Eln9 Dept p Licensing Board p Selectman's 0ffce Contact person Phone # D Wealth Department ❑ other Til WORKMAN S COMPENSATION v North Andover Building -Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: /}i h -7-4X L 6 N -j 01k/, (Location of Facility) Signature of Permit pplicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector a 1 x q d O m ,c: w V)v V) p z z ro 'C w° T U —C,a" w O V id w o W U W W w P4 U C� id x o u z C7 °° O a n C u. z w �: w G 7 W z cn v Q O cn UJ z p_ c y- o cts o = c ` O y wv •dam d c A A m C is s o • y O CD O : w0. N C .� .O O • 300.2 wr O t; cm E *mm a I �• CA CD 3 •r ) o Em 4ey m >0cm= = = .!2 O cm r xc �cm c a �' •d O t m -Art. C.3 L w•—Z o c C _ CDCL 0N CO) r SLS o WLIL C r Z H .y O C Z w .E �mwc, o v m g ti d O'S OC = CO) z 0 W w P-4 cn cn Q e€a ca g