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HomeMy WebLinkAboutMiscellaneous - 35 MEADOW LANE 4/30/2018Location 5� No. Date S JUN TOWN OF NORTH ANDOVER Certificate of Occupancy $ SLJ Building/Frame Permit Fee $ SE ''Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ IW Connection Fee $ TOTAL $ ��-'g• U Cl -9- /o i L 616 f iso Building n-specto'r' Div. Public Works Location No. ' — Date TOWN OF NORTH ANDOVER Building Inspector Div. Public Works p Certificate of Occupancy $ Buiiding/Frame Permit Fee $ Foundation Permit Fee $ Othw Permit Fee $ ► ,,- , ► .- $ Connection Fee $ �- Water Ica Connection Fee $ TOTAL $ Building Inspector Div. Public Works ]PEXMIT *Nb. s APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. '/ PAGE 1 MAP qJO. LOT NO. f, I 2 RECORD OF OWNERSHIP iDATE BOOK PAGE ZONE SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING OWNER'S NAME. /a NO. OF STORIES / XNSIZE OWNER'S ADDRESS BASEMENT OR SLAB /,7 n �/A �.✓ //l7/1 �,�J Cvl/ Cfe C higoo, ARCHITECT'S NAME A/ Tj SIZE OF FLOOR TIMBERS IST 2 r 2ND /, 3RD BUILDER'S NAME/J /CEJ SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS POSTS //l e400o DISTANCE FROM STREET 72 DISTANCE FROM LOT LINES — SIDES y� / REAR Cv J GIRDERS y``'am '/fiL/Z AREA OF LOT Z� 6 /psyl' FRONTAGEO Old &V HEIGHT OF FOUNDATION / THICKNESS IS BUILDING NEW /v, SIZE OF FOOTING ��-cC X a IS BUILDING ADDITION �Cf MATERIAL OF CHIMNEY` —f IS BUILDING ALTERATION A1J IS BUILDING ON SOLID OR FILLED LAND snV// WILL BUILDING CONFORM TO REQUIREMENTS OF CODE //r IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER yCJ' 0 IS BUILDING CONNECTED TO NATURAL GAS LINE " INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED s/--/, Zy ATURE OF OWN OR AUTHORIZED AGENT FEE 4! 7m:,.J'� A PERMIT GRANTED 19 OWNER TEL. # 6�•? i�•77% CONTR. TEL. #tR4=6395 CONTR. LIC. N_Ct y.3 r0 j 3 q.. PROPERTY INFORMATION LAND COST EBT. BLDG. COST FSO EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN V� BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY jo Si ORIES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH d 1 2 13 INE CONCRETE CONCRETE BL K.P BRICK OR STONE HARDW D PIERS PLASTER _ _ DRY VJALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T AREA Y, 1/7 1/ FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WAILS I g FLOORS CLAPBOARDS B _ 1 2 3 �_ _ _ _ DROP SIDING CONCRETE WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING _ EARTH HARD\rJ'0 COMMON VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK N MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY _ STONE ON FRAME SUPERIORI� POOR _ ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD A TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ to 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. E m a n c a (ti U O C c i N rn c L N O y m Cl) i 0 3 $ N E LO .. rn U m = m 070 O D N 7 2: U O N _ O 0 2 N N mffi T _aco o m O ai m .O Cl) 7 01 .O E ° mD o = N E E mIm�mc°mcaGa� 'p T tp C to d tD(pp N� Oy�'C N Y o _ 0 m a m p .0 at �c y o 0 0 >,E m m m - r� O � 11 ffi O A N Q oma�a.�T.?? p m a m Q- 0 m 0 m c 0 c 0 0 0 m a o o a) m N m a r a m O O o G o r N 7t L/1 c QQmm �U�=00 ODCZ y Cl) N R LL C:J N (7 V (n (O r 10 V) (n - :.> E m v a v �E v \�\\ U 2 N tD 1 o c 1 ® a c 01 C � � U G m—N u � N �nS o c ��N o.c \ �c°R o LL o.� ; �m'b vCC b. -0 0 10 00 / N 00 W a m 'E N LL m LL N 'x E�v C N fr. A N'i O c m m 0mm �\ g y m 0 l ,�EnaE m �V -6E cm$ n� U 0. 2.2 ll a� CL 3 a in 2 �E v av m c um W N m� W C = I 01 C � � U G m—N � N �nS v°E Z C Q N 'x co LO i N M M Z Cl) a L CL L O M Q O A a co c - os m y N y 0 v O E O I � U A � N y O Z C Q N 'x C L C O C1 (f� J R 3 O Qy�yjl � Es E O O � M ro v c d v 3 v Z � -Z� - ; s %\. 7)& \k/ /E k#} !!D _{ f)! ;e !t7 ;) tk! !7 \ 2 } fo \\ c 0 2 > 2 @ @ V � � § * % E VC) / {/ H a # § . ) 2 ■ E ■ « �m3 1/, n -- G c v 1/, n -- M 0 R T 6 A 6 E INSPECTION PLAN City/Tovn:UQj:2,-jjjj-\ ��1 ;State: --Nom'`----- Date:_ UN. _ ` =---- Scale:---l�� =- 3 U , ---- 1 - Owner: -------- Buyer: i_O N G Deed Ref.Ll_Z�r --------- Plan No.__4- 5 �------- Drawn per City/Tovn of ---------- Tax Assessors Map. N / F V P- k � <_- c) t._ C- i -i' T=- � 0-r is 3 ----------------------------------- I hereby certify that the above Mortgage Inspection Plan was prepared for use in connection with a new Mortgage and is not intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge , walls or building lines. No responsibility is extended herein to the land owner or occupant. The location of the original building(s) as shown herein was in compliance with the local applicable zoning bylaws in effect when constructed, with respect to horizontal dimensional requirements, to lot lines or is exempt from violation enforcement action under Mass G.L. Title Yll, Chap. 40A, Sec. 7, unless otherwise shown herein. Subject building(s) lies in a flood zone designated Zone:__ G __________ and shown on FIRM map Community -Pane) t_ 2_S _ �,_ __« _ - z__ & Dated: �_f 5 f 8 Job No._9 __i JCD, INCORPORATED, LAND USE & DEVELOPMENT CONSULTANTS 4 AUTUMN LANE, METHUEN, NA 01844 508-683-9932 DCD O(n MKZ W I o CA M p m W D ��RIP�HI�iRAt✓Tfl _0 C N a o r`n C O D N io1A Registration 101111 �p 0 m a o Type - INDIVIDUAL 0 c „ Expiration 06/25/94 ! >xax .s v = -�+ v m a mmDN -.,O Ln cc W r Marc Rinaldo o xm i, o �a� z s �o G) 1 Q• Un s. -1 —h y= Marc W. Rinaldo !p N D zj 12 Kensington Ave , m ' Z N %10 A "' Methuen MA 01844 Zm � Z " fV ADMINISTRATOR '� O ' 3NI1 ONON M0.1 - s 3-+3 C7 m n W oO MW W T a O m �° CA i xXn W n Co -40> o am 00 M m z i< ? O 3 m r 3 Z cn IDz >"= °O D ►r a0Z t 3bG7z N ` Z Z W am O -P LCP"m m GO i MCA tll a Z aozo � cm = r M i�Z z O ; m o P r. ►-� AC W Z to < N rte, m 01) Q a !n D „ a;o D m Rf ° z f SL 0 Z m N D OF 3NI1OWN 010. 3 �W z mmm Co ooZ�� n ~ � 0 N rG) ZD-�m a C f G) CO r- -4 0O I m mmm �D Z� 1D Z mp0 m�=� DCD O(n MKZ W I L� rA x o a O w u aQi cn 0 PW z z 'O O w O a v G U �y w o z "� aw .0 on O u: G w R. w iw.i W oD O w' u E v) G w p U a ao O cG �. C x w x w W y 7 r� z .~ w (� v -� O 0 t3uml H �O F-1 . c c 6! C :;F O • c ' O i C N +3 O ACc0 3 �R m c Ci N CF CD a N E c cm •; N A m m o ' 3 N QI rs � m N c E N m m o N m CO • o�oc o,cs � C113H 0 Ab cca�:Z c o 0 a Q m N m C CD F- W � G yL..� LL �m % cO •N �E c3.0 L3C W COD CL. o� O GO _ cc N O H L D O 9 'Z3 Ifid 0 N C4 n co co J Q z o E LL- o o Z cLU Cl - CL C z F— a) C—) z w a) — o mm CW z > o co o� o co r CD co i cc O a CL �a y �cqo Q CJ .c m Z co z E: LD ca C R C cc cc: W CO2 C3 C z z � � J W W CL. U) isio HilM Hsm-i 8XZ Id -Z M Cil N 0 C +Z {�1 i ctS � E,h y / O. g � co 7 mv-- �C3') :3) a O yr- 15 U i� Z3 fn (A O 0 C +Z {�1 O E,h y / a ...r Q) 4) .U) cv M M Q r- N 7 to tin Q a vW, ar b I ch «s rt C cad use N a• 0 _ C a ...r Q) 4) .U) cv M M Q r- N 7 to tin Q a vW, ar b I ch SN lV 9 (0 I. L roL oems>� 0 �.�CL co N o (A za=- �8 � �� w a s Q iL�ypeti ALL k+ Wa �N (C c O b V m E m 4- 14 ---- -� L 4 Q c1 N L�7Q1 LY¢2 C I � Imo/ e .0 'C3 c O b V m E m 4- 14 ---- -� a a 1 Date A . .d.!....4 ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that t23A...... � }.2:,1 s�n................c-�.!..- .��?� ...... has permission for gas installation .�..... an.5...JV.a-� P� ...... 4....,o� in the buildings ,of ...... -''.......... J................................................�............ at ....... -`�? .......... `�..!. 'Q.. cv �! !.......1-. �......... , North Andover, Mass. Fee (.> :�..... Lic. No..��� . . ................................................ GAS INSPECTOR Check # 1(0% n i -^ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 4/1512014 PERMIT # Z� JOBSITE ADDRESSI 35 Meadow Lane OWNER'S NAME GOWNER ADDRESS I Same TEC 1FAXI TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ® RESIDENTIAL[] PRINT CLEARLY NEW: ® RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOQ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ m 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 i UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace 1 Gas Meter x and Pi in as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO [j I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] 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 ❑ AGENT 0 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 applicat4willbe pliance with all Pertinent provision ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER-GASFITTER NAME Joseph Marino LICENSE# SIG ATURE MP 0 MGF ® JP ❑ JGF ❑ LPGI ❑ CORPORATION EJ# 3285C PARTNERSHIP[j# LLC ®#� COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501::]TEL 1_(508)_832-3295 .._........_..-•------ FAX 508-926-4347 CELL 508-832-4614 EMAILJMarino@RHWhite.com w F O z z C F u w a z w a z❑ z O d❑ � W o o W F a 4t z w z aW > .. N a W w C4 w d w N W a � c a � U J F a Q`ss U 111 z w LL F O z z 0 F U W a � � N C�7 O I q.Y •CD41. ......... ... (D LLI LLM Co .. rnLLk Z. LL 010. CU. z < LUm --Z LU W CD in :5 'My..• WvcO--,, I MY 0 lu mw,ia4,4 5 b4/ b:i/ 1b14 14:U4 bU88J2b 151 KH WHl I L (DUNS I KU(J I HACiE 02/02 ACCARD PATE (MMIDDryYYY) CERTIFICATE OF LIABILITY INSURANCE page 1 of A 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SU13ROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conferrights to the certificate holder in lieu of such endorsement(s). willia of Massachusetts, Inc. C/o 26 Century Blvd. E. 0. Box 305191 Naghville, TH 37230-5191 R. H. White Construction Company, Inc. 41 Central Street P. 0. Box 257 auburn, MA 01501 1' G'.LTJ INSURER(S)AFFORDING COVERAGE NAICR INSURERA:The Charter Oak Fire Snsuran49 Company 25615-001 INSURERS;TravclArEl property Casualty COMpany of Am 25674-003 INSURER C. National Union Firg Sasuranaa Company of 1,9445-001 NSURERD;Tr*velere Ind=nity Company 25658-D01. •_••�--�� ..arcr�rn.M IvulrtDcM;aU:4ryetsU REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE DD sub POLICY NUMBER LIMITS POLICY EFF POLICY EXP A GENdSALLIAeILITY NAR wvnl VTC20C0 977X9948-13 9/1/2013 '9/1/207.4 EACrIOCCURRENCE E 2.000.00( B C D D IMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GEN'LAGGREGATF LIMITAPPLIES PER; POLICY PRO LOC AUTOMOBILE LIABILITY X ANYAUTO NED AUTO AUT08ULED X HIREDAUTOS X NON -OWNED AUTOS % C 05 o Ded X Co11 Ded Soo UMBRELLA LIAR I X I OCCUR X EXCESS LIA6 71 CLAIMS -MADE DED I $ RETENTIONS 10,000 AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNFRIEXECUTIVE'WN N(A OFFICER/MEMBER EXCLUDED? below Evidence of Inmurance 977K955A-13 9/1/2013 19/1/2014 BE8766140 X9/1/2013 9/1/2014 VTRKUB 3205A105-13 19/3,/2013 9/1/2013 19/1/201,4 VTC2RT]B A203A71A-13 9/1/2014 more ep eco MED EXP (Any one pereon $ 10100 0 PERSONAL &ADV INJURY S 2_ n n n_ n n n 2,000,000 BODILY INJURY(Perpereon) $ BODILY INJURY(Peracoldent) ,; AGGREGATE E.L.EACHACCIDENT is 3_000 000 E.L.DI8EASE-EAEMPLQYF_E $ 3-000,000 EL,DISEASE-PoLICVLIMIT is 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Co11:4197604 Tp1:1694012 Cert::20267680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Date.�.� ?��. .. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION y This certifies that :4 . .... ..©`. 4 p r S has permission for gas installation . �.��., �r-c"................... in the buildings of. -a O ............................... at ....- . ....... . .. . , North And ve Mass. i .� � Fee .�...... Lic. No. ���7`�... ........ .... ... 31 Zq GAS INSPECTOR Check # 84Or0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " CITY AN4eUt'/Z { MA DATE ll-�Z`Iz- PERMIT# - - - L� JOBSITE ADDRESS 35 ,M OWNER'S NAME [ ,�riM L GOWNER ADDRESS TEL[ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: [j RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NOQ APPLIANCES Z 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 r T 1( -- E FIREPLACE FRYOLATOR- FURNACE _ _.___vJL-_r r_( GENERATOR GRILLE-G� -_ .INFRARED HEATER_ - f -- - =-- - - — . _- - f LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER z» �. I= ROOF TOP UNIT TEST _---_- ___ _._-J UNIT HEATER UNVENTED ROOM HEATER.-)!_ WATER HEATER _ 1 i I---.IE -- __._. ! _ �^ .I. _ ` _T(.._ .. _ I-. ..� OTHER (. l- --�1 INSURANCE COVERAGE have liability insurance its the MGL. Ch. 142 YES'(-] NO a current policy or substantial equivalent which meets requirements of 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 Q AGENT= _s l' SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 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 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tri --- PLUMBER GASFITTER NAME Al -6--r /a �!� LICENSE # /0 72 ( SIGNATURE .. 6-- _ = _mss_ MP 00 MGF El JP D JGF LPGI 0CORPORATION Ell# - PARTNERSHIP D#[=LLC#�_ COMPANY NAME: =ADDRESS/wr CITY T /t,i�c/---- ..__..__. i STATE �ZIPFAX CELL EMAIL O z 0 F U W _ r z O N N W } ~ W O� a Z LU CO) W 5 oLU w L W CO Oz a a I-- Ln U _ �y J H a a Q Es' � w EE w H O z 0 H U a c�7 4 b � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 UV. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organization/Individual):___/r-1' , /,. // Address: 7 /N,e 4 ,, f4 /til City/State/Zip: PY4' f f Phone #: z yG S/2_ Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I ` employees (full and/or part-time).* U�I have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ 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.] t employees. [No workers' comp. insurance reouired.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t 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. i am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy # or Self -ins. Lic. #: Expiration Date: .ob Site Address: City/State/Zip: kttach 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 ine 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 nvestigations of the DIA for insurance coverage verification. do hereby certifunder tl:g pains and penalties of perjury that the information provided above is true and correct. Date: e`V — 2 -z - / 2- e,3 _7S,7- Official 7S,z Official use only. Do not write in this area, to 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 #: r 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www,mass.gov/dia . ,,... alnyeu!S W cn 'Lu m N N.N '. co N n _ Q W� ~ "D Cl)i .L.0 u.� � r10 C `= W W U. (�� 7-1Z 1 O �� > Q:., Z m° w IN a Lu �¢ Z: a o W cn J .mom u. <t W Z O U) Zfn S2 Y O O.. N .JILJ : (A o �i kz O a_V w J jl i J Date .. % %-Z 2- .!. 2 - This certifies that .......L?tj ,C . . , , has permission to perform .... �.. a�4 �, j� ............... wiring in the building of ....1_04�Gj......... I ................ at .. 3.71tfZb0w , , ...... , , , , . , North Andover, Mass. _Fee ., . S7 . Lie. No... ...... ? ELECTRICAL INSPECTOR :heck # 11246 Q Commonwealth of Massachusetts 011,1cial Ilse 0111% Permit No. Department of Fire Services Occupancy and Fee Checked yi BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK :VI �%ork to be perlbnncd in accordance %%ith the A1as;achusetts lilcctricaI Gude (M14 .C). X27 ("M11 12.00 (PLE'ASE PRGVT /.V hN`K OR TYPEALL INPORr11.1 TION) Date: /I I Z,'27 z - Cit,' or Town of. --A, dpi'' To the In.yh'tor of,f?•'re.v: lay this application the undersigned gives notice of'his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address �b�/T/eers /U/UhrJ� Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Z Amps /w/ z �/1% volts Yes ❑ & No F (Check Appropriate Box) Utilitv Authorization No. Overhead ❑ Undgrd ❑ No. of !Meters Overhead Undgrd ❑ No. of deters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: %ieTy C t7/GCP/r217 � S �1UY�Llr Completion o/the follou•inE table mar he waited by the Ins iec•tor o f 11 No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. s 'Total Transformers kVA No. of Luminaire Outlets No. of Hot Tubs Generators KNiA No. of Luminaires AboveIn- Swimming Pool 'rnd. ❑ rnd. E]Battery o. o mergency Lighting Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARitiiS No. of Zones No. of Switches No. of Gas Burners ' No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of NVaste Disposers eat Pump Totals: tum er Tons IoW No. of Self-Containe Detection/Alerting Devices No. of Dishwashers Space/Area Heating IOW Local 11Municipal E] Other Connection No. of Drvers Heating Appliances KNN' Security Svstems:" No. of bevices or Equivalent No. of Waterh`�, Heaters No. of , o. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTII ER: r� Anac•h additional detail if desired. or as required hr /he hrspeetor o/'Il' Estimated Value of L:I ctrical \1 ork: y(� /� ys (When required by municipal policy.) �Vork to Start: j! � jt_ Inspections to be requested in accordance with M1 -IEC' Rule 10. and upon completion. A INSURANCE COVERGE: Unless waived by the owner. no permit for the performance of electrical work may issue unl the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. Th undersi,ned certifies that such coverage is in force. and has exhibited proof'ofsame to the permit issuing office. CHECK ONE: INSUI DANCE Q BOND ❑ OTHER [I (Specify:) 1 certify, antler the porins and penalties ojperjurr, that the information on this application is true and complete. FIRM NANIE: LIC. NO.: 17238A Licensee: Richard J. Are] Signature LIC. NO.: 2751.4E t/l'applic•ahle. e1Ner "crempt" in the lic•en.ce number line.t Bus. Tel. No.: 978-372- Address:773r NA Alt. Tel. tio.: R7R-3(1')-4 0 "Security System Contractor License required for this +rori tf applicable. enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normal] required by law. By my signature below. I hereby waive this requirement. 1 am the (check one)❑owner ❑ owner's ag Owner/Agent PERMIT FEE: S Signature 'Telephone No. Date ...1 ........................7 4 (00,�RT" ;•t�``° TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . /„ f,/ has permission to perform........�ts���r ....................................................................... wiring in the building of....................!'rl............................................... at ............3!�!w.......1-- ,North Andover, Mass. ............. Fee ..... . .. Lic. No. :y .........................�Il ...... � ELECARICAL INSPECTOR to Check # / S-77 1�9 2- 7 8 4 So,' ' 784' Offiainl Use Dnly^� mm�tnrruraa EL. o � a�ea.c u,oa J ''''") Pcnnit No. -� ..LJr+/rarlmunl n��irA �J or�rcad Occupancy and Pet: Checked ,V� i30A RD OF FIRE PREVENTION REGULATIONS (Rev. 1/071lk� (leave binnk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort: to he performed in nccordnocn w1ill the Man:melwaeus Eleeu•icni Code (MEC), 527 LIAR 12,00 (PLEASE PRINT 1N IN,' OR TYPEALL INTORIIII'lT1ON) T)a te: IL al J_ b% City ov Town of'; NL)Y,4-1k RIO&Y-(tet" To 11m, h spet2mr of flUTIs, Hy this. application the undersigned gives notice of his or her inten{ion In perform (hc elccirical work described below. Locnflon (Street L Number) Owuor or Tonant Owner's Address to this pormlt in conjunction With n building pormit7 Purpose of.Buildiq Lxlsting Sonvico , mps / Volts Nuw,r,ervice Amps / Volts Number of Feeders and Ampaclt, Location and Nature of Pro osed EloctrJcal Work; Talc phonc No, 4-JS—kSj •q%?77 Ye ❑ No l,,Zj) (Check Approprinte Box) Utility rUrk'Irnrizntiau No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No of Meters Comrolellrm ofthe folio)+dna lable mfaly be waived by the Insoecror 00VIre:7. No, of Recessed Lumlimires No, of Cell.-Susp, (Paddle) Tans INo, nl ntal Tronsforriim KVA No. of Luminaire Outlets No, of Hot Tubs Gonoratorn l(VA No. of Luminaires Anave In -u• (Swimming Pool vrid. 2rnd, of +mergency rbnun� IBattor+,v Units INo. of Receptacle Outlets No. of 011 Burners 11PIRE ALAaNJS INo, of Zones No, ofSwltches No. of Gns Burners No, of Detection and lnitiniin�, Devices No. of Rnnu(es No. of Alr Cond. Tna I INo, of Alordno DiDide n Heat ('tunp Numner I ons Jti W No. of ,',e f-Lonm)ned No. ol'MInste Disposers . .................. Totals. DctectionlAlcrtine De:iceti No. of Dishsvashers Spaee/Aron xloatirng K'v}r �j fvkuuClpal �LBiisf❑ COnne�ti0n 01112r r l;Ientin1 A phonces , ; e p. I<lh Seetlrlt�' Systems:'' �r Nu. ol'Dryers No, of novices L nivalont No. o 'Dter1Clhr No. ui Nn, of UnI Henters SI_ns Ballitsts No, of Devicos nr Equivalunt No. Hydromnssngc Bathtubs No, of Nlotom Total HP l elecommunieutions Wirtng: No. of Devices or E ulvnitmt OTHER: I (Irrrlr auclifurral drrl17l1 i/ (1esired, 01'a.? required by Or lnspeclur orll'h•es. Eslimntod Valuo of Lleclricn) Warlr. L4al. Oc, (Vdhen required hp municipnl polic),.) Wort( (o S(url: Inspections to he rcqucs(ed in ncoordnnce, Will) MEC Rulc 10, laid upon c0111ple(ion. INSURANCE COVERAGE 1h11ess waived by dw owner, no penni( (or the perforrnnnec of elCC1Vicnl wort: may issue unless (he liccn:;cc provide; pronf of linbili(y insurmnce including "eompleled operntio,i" covcrt)gu ur its aubsmwiRl equivnlenl. The undunigncd curti(ic5 (lint srneh coverage is in Force, unit hus oxhibiiod pruol'of name In (he pcmill issuing ofGc-c. CHECK ONE: INSMANCE BOND ❑ OTHER ❑ (5pcoil' the .:) I cCt'IIJj), /mdar e pnirfs full palifrllirs of petjilrp, Nita lire in fill'ntalia I orf lhi,v appiicnliarf i.,• rare at id cunipiele. FIRM NA11v1L; Y hl1' "J �r�YY1C ^! l S LIC. _ -- —, Licensee: - )O��s l 'TQ1�(1CC Signntiwv. — n n f LIC. NO.:D ffopplivnblc+. a _ _ Rus. Te.1. No j % S' FJ,7 % J Addresr,: L J J CU % % L.vr Lti r r[J ✓ M Alt. Tat, No.; i *her M.G.L. c. lel7, s, 57-61, security m,ork requires Deparlmmil of Public 5afelw "S" License: Lie, f ln. �, C�' UO-? OYYNER'S 11`1SUTLANCE WAIVER: ! am aware thm the Licensee does not have the hability inmimnec covernge nominlly required by lase. By my signnlore below, 1 hereby wnive, [his requirement. 1 am (he (check one) ❑ owner ❑ ovvMer's accnt. bwncrlAgcnt P 1'I It�I7' F'EL; 9 Signnlnre Tnlenhnne No. Date.... . ........... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...................... has permission for gas installation 4 ............ in the buildings of ........................... at ...... North Andover, Mass. G;'�'� ........ -�AS I NSP66T0 Check 45-3 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date /! 6 3 NORTH ANDOVER, MASSACHUSETTS Building Locations ` / ! C t�Ot� Permit # 2f Owner's Name New • v' Renovation ❑ Replacement ❑ Amount $ av Plans Submitted ❑ (Print or or �j� Address C�l Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE ec one: Certificate Installing Company Corp. G/c' ❑ Partner. irm/Co. Check I have a current liability Insurance poli or it's substantial equivalent. Yes 0 Nor] Ifyou have checked M, please in ' to the 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 I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installation performed under Permit Iss this application will be in compliance with all pertinent provisions ofthe MassachusGas,,Vgnd Chapte of General Laws. Title (OFFICE USE ONLY) Signature of Licensed Plum er Or Gas Fitter ❑ Plumber 4/3.,? 0, ❑ G s Fitter (cense Number Ea aster ❑ Journeyman r-- i� • 1 (Print or or �j� Address C�l Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE ec one: Certificate Installing Company Corp. G/c' ❑ Partner. irm/Co. Check I have a current liability Insurance poli or it's substantial equivalent. Yes 0 Nor] Ifyou have checked M, please in ' to the 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 I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installation performed under Permit Iss this application will be in compliance with all pertinent provisions ofthe MassachusGas,,Vgnd Chapte of General Laws. Title (OFFICE USE ONLY) Signature of Licensed Plum er Or Gas Fitter ❑ Plumber 4/3.,? 0, ❑ G s Fitter (cense Number Ea aster ❑ Journeyman r-- 12,7 N2 I J Date... ......... I TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. V has permission to perform ........... --CA.-Cll ................................................... wiring in the building of ............. ...................................................... at .........e .................. . North Andover, Mass. Fee..... Lic. No ............................................................................. ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4 Office Use Only Permit Na_ ?W5eon 07M5X.�� o7 �ss4e�uss77s Dt¢a+txarr 4 ,'-" Occupancy & Fee Checked w BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the (Please Print in ink or type all information) Town of North Andover Massachusetts Electrical Code 55227 CMIR 12:00 Date 7IZY To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number � -6—d--�t r&M 0 L) 1 Owner o Owner's Is this permit in Purpose of Buil with a building permit I Yes IES No ❑ (Check Appropriate Box) Authorization No. r Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) �� D(Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough FinalSigned under 7 FIRM NAME the Per�ltles`O/f�penry�p LIC. NO. -3 �0 Licensee f`I 1WW ��i 1 1! jv�J(�{� Slgnature LIC. NO. J O%, �f L1 � , /f / lZ Bus. Tel No. Address � � �}/ % Alt Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No.� PERMIT FEE $ of Owner or Total No. of Light8ng Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimminq Pool gmd ❑ gmd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices . Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers S ace/Area Healing KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heatinq Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) �� D(Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough FinalSigned under 7 FIRM NAME the Per�ltles`O/f�penry�p LIC. NO. -3 �0 Licensee f`I 1WW ��i 1 1! jv�J(�{� Slgnature LIC. NO. J O%, �f L1 � , /f / lZ Bus. Tel No. Address � � �}/ % Alt Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No.� PERMIT FEE $ of Owner or M 'I / FN-0 I J Date .................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that - . .�... �A................................................... v 1 has permission to perform %{ i1 ru �, wiring in the building of,:............. ::............. ................`............................ � J at............. .....................v, ................ ,North Andover, Mass................ Fee Yi .A ...... ..... Lic. .. ..... �� :::.:..... �, r ....._' —lJ.- .............. ELECTRICAL INSPECTOR 05/05/49 01:45 80.00 RAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office use Only The Commonwealth of Massachusetts Permit :b. Department of Public Safety l Occupancy 6 Fee Checked `7 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (.PLEASE PRINT IN INK OR TYPE ALL INFORMATION). DateJ City or Town of ``��a.r e� To the Inspector of Wires: The undersigned applies for a�plelrmit to perform the electrical work described below. Location (Street g Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No G ---'(Check Appropriate Box)' Purpose of Building Utility Authorization NO, (y Z Existing Service 4(2_0 Amps `Z Ci/ 2 a Volts Overhead Undgrd ❑ No. of Meters New Service 'Zt70 Amps "Z-io/ /2-0 Volts Overhead D-Indgrd ❑ No. of Meters 1 Number of Feeders. and Ampacity Location and Nature of Proposed Electrical Work R vk-�r � y No. of Lighting OutletsNo. of Hot Tubs No. of Transformers Total INA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators RVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency LightingBattery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No, of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal ❑ Other Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No. of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP D INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ N08 I have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Signed under the penalties of perjury: FIRM NAME Rough Expiration Date Final LIC. NO. Licensee e y e., k a C� t eAA4_.Q gnature IC. N0.' 2%�i 0 Address 2v j �t.. ��.,i 1n/1,� Bus. Tel. No. Alt. Tel. No. (.pl-1 3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as-quired by Massachusetts General Laws, find that my signature on this permit application waive this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S (SignfituVe of Owner or Agent rn r m n n D r D r C7 D �_ O z � m D � D m D n rn � � � O � O n z z m m rn r m n n D r D r C7 D �_ O z Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACHUS� This certifies that ...).w (� �: �I. 1�.' ..�. fJ / . has permission to perform .%:�. !:{lr r . ........... plumbing in the buildings -<.................... at,, < % North Andover, Mass. Fee Lic. No. .. �i PLUMBING INSPECTOR Check # � � �x 6325 Mx MASSACHUSETTS UNIFORM APPLICATION (Print or Type Mass. Date )G ,, 19 Building New ❑ Renovation ❑ FOR PER A`�� � MIT TO DO PLUMBING '� 2cc, _ Permit # Owner's 71 Type of Occupancy--AL� � E N tlr-) Replacement 200"' Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name �Aot'�E,27 40 . —cj'PW dTAP f0 �� Address c coAgCHmf4K 1 /.P, /r E TN Fn vYl t4 0 IT Business Telenhone /"r'7 (,a , I Check one: ❑ Corporation ❑ Partnership 9-0ir n/Co Certificate N� me of Licensed Plumber f r3r�T fry • 5•4•►�rvlv4 TrCI �r�' .e ` URANCE COVERAGE: I h ve ace Yes curreCj il� Insuran No ❑ policyor its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked ys, please indicate the type coverage by checking the appropriate box. A liability insurance policy Qr/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 I have submitted (or entered) in above knowledge and that all plumbing work and installations ormed under the application are true and accurate li the best al my pertinent provisions of the Massachusetts State Plum ' e and ��� �he for this application will be in compliance with all 9 apter of the eral Laws. Title re o censed Plumber City/Town Type of License: Master g/ Joumeymab ❑ APPi;ONEp O IC NL License Number --113—i— r SEEN MENEEKEENEENE ONE GTH FLOOR EMMIMSiiiiiiiiiiiiSUN MENNEN iiiiiiiiiii Installing Company Name �Aot'�E,27 40 . —cj'PW dTAP f0 �� Address c coAgCHmf4K 1 /.P, /r E TN Fn vYl t4 0 IT Business Telenhone /"r'7 (,a , I Check one: ❑ Corporation ❑ Partnership 9-0ir n/Co Certificate N� me of Licensed Plumber f r3r�T fry • 5•4•►�rvlv4 TrCI �r�' .e ` URANCE COVERAGE: I h ve ace Yes curreCj il� Insuran No ❑ policyor its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked ys, please indicate the type coverage by checking the appropriate box. A liability insurance policy Qr/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 I have submitted (or entered) in above knowledge and that all plumbing work and installations ormed under the application are true and accurate li the best al my pertinent provisions of the Massachusetts State Plum ' e and ��� �he for this application will be in compliance with all 9 apter of the eral Laws. Title re o censed Plumber City/Town Type of License: Master g/ Joumeymab ❑ APPi;ONEp O IC NL License Number --113—i— FE m m O 9 m m r O ie In 0 O n m c N m 0 z Location No. 2 2 S Date I 5 NORTIy TOWN OF NORTH ANDOVER 3?O�,t`•D •,hOOL p Certificate of Occupancy $ ov Building/Frame Permit Fee $ 5 • , �'�s'•^°'''�<' s�cMust Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ C-3 L) TOTAL $ Building Ins or 6 E i Div. Public Works .D 1 > m v D 3 m 7 0 mn N m n v v v a iZ Z D z - =) M L' Ln m w p t a n z i m — D n � z N T wI\ > G7 Y V m nz z G rZr, _ ' m T, Z z m r.rri YJ� i m z t O m ;o m m (n J v/ °.. V' O fN _ w v v _ i n z Z D z z m nz G rZr, _ ' m T, Z z m i > z t O m ;o m m (n m v/ °.. O fN _ m C) > m O m o 1�.Z7 m T z z m Z Z ` ) ' 3i m a n z rri n 0 z 0 �yy N Z D z C - - - - - - - rt'm z ZZ Z ci ci ci 21 r. J .T. y Z L M m C m n G n 11, Q — Z a, ? m x bS R z O z O m V m J m { y vLn z H _ m — C > ^ a. Z X X - a y Z m 7E x. Y ..w z 0 O N Ln Ln Y w .A0VT8A6F INSPECTION PLAN City/tour: �1O.P_ItiAN�QvEg States_-M.'�------------- Dates_- 2 -- 4--- 9 8--------- Scales---�� -_-'-� ------ Owners t- _ o rs G Buyers _�-til-�/�-------- Deed Ref . 3 5 o cel_ j_3? PlanNo. -_� 7 52'--r --- ----------- Drawn per City/Town of Tax Assessors Map. N le oC-i f,C_ t_(-- p� ?eRcN � K CAftA`E 1_ J � � � is •_ c" I 1\,( ) F KY P r� 1 CD T I S LOT Tos_1-16-11�I-�- --- hl ----------------------------------------------- I hereby certify that the above Mortgage Inspection Plan was prepared for use in connection with a new Mortgage and is not intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge , valls or building lines. No responsibility is extended herein to the land owner or occupant. The location of the original building(s) as shown herein was in compliance with the local applicable toning bylaws in effect vhen constructed, vith respect to horizontal dimensional requirements, to lot lines or is exempt from violation enforcement action under Mass B.L. Title VII, Chap. 40A, Sec. 7, unless otherwise shown herein. Subject building(s) lies in a flood zone designated Ione: %� _ and shown on FIRM map Community -Panel t_ 2_S C7 O q e Dated. � // o z ------------Job No. 8 - -56 7 ------- ---------------------- �-----4-----�-- - ---------`-------- JCD, INCORPORATED, LAND USE 6 DEVELOPMENT CONSULTANTS 4 AUTUMN LANE, METHUEN, MA 01844 508-683-9932 x • ,Date er c r TOWN of NORTH ANDOVER ,kRt F l AFFIDAVIT , x{ S= •31t CCr# d_ t r i ,- - , +den .9 Kpa apent to Le1LLL . c ua.- +l ;. c. 142 A �.ri� ai m, rem�ni, �_, °n , ,t��.,a..t,7'd-p-,�', -on, }l ��yZ�C� =Vtu vVj JQyp�`��mnLua.,u. '� ac camtar==t0 32j�/� L� tLZ= of 31 :t }�- �el}C�LS�t�1I �}�.��t,�.,�Zemva� �.� � � }� fs� 1GLa]� Q�" WL LLlic LLal11L�.L d�11 l.L1LL7_ r r[r to J�1L.irL1L[-+7 >~u++� �`.-�r 4AJ 1 4 �,—• ,• V.� .--- V +•,k �- S� c l oC b.d�v be da -p- by rggi-� amnnct=, W l Ill Mill ecepda-s,, $ .■ 1 ot}2'�' ! t a 'r r. s of WOrk: X9-{9 FSt Cos 4 AN lAdd *�, resS Of Work Owner of. Permit Application: Ac, l c2rtiiy that: { bhereby "} R, > x Registration is tlo.t required. for thie following reasort(s): rcr oEri Lbe Oli�i ` • 4 tiL Work oluded by law .. � �,_ - � �t t`h. � �•' f r ` J raider $1,000 Date , x r ' Knb\�ng not owner-oc ` ipZed K j Owner puLling own rnr„ , Other (specify) i :440 t ' 'Notice: is -hereby given that: R' u OWNE�tS -PULLING ZiiEIR NN Pa:Z P= OR DFALIW. WITH UNPMISDMM41 tFs MR APPLICABLE• DOME Il�R 'vT, 4aORK DO NOT HAVE ACCESS TO UEARBIZF,A ; ZION PFLGRAM, OR QWA= FUND UNDER MGLc. 142A_ Y •, t3• l M � f. _ .,fir hereb apply for a' ermit as the ggernt of the owner: Y. PP Y P � a;t ' Lti5, T M Contractor Name egistration x`10 .Date.. AOR: Notwithstanding ttie above notice, I hereby apply for a permit as the owner of the above property: x • ,Date er c r UKM U - LU 1 KtLLA.=_ I-UKM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and ^Apartments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ***"APPLICANT FILLS OUT THIS SECTION �PUCANT_ � 4 J U b�- bJ✓l PHONE - - y� JQcOCATION: Assessors Map Number 5 // ,PARCEL -ZZ_ i,SUBDIVISION LOT (S) -� �eREEIT ,3 ��-e �l ST. NUMBER 35 '*'"""OFFICIAL USE ONLY ENDATIO S jOF TPWN AGENTS: TION ADMINISTRATOR DATE APPROVED ,PATE RFJECTED- 2RIDrI MM/A A 91111 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED r COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE__ P'OOLCIM-1 /Vff.. ;,C' IC „,­ IHCIE TC -6 _, LREE �'D �25z- -� rr, 6 0 iL 7 L- A(ew G )r4 7- 'C. ':E :6- -wo CO) � d CA Cl) CD n Z y CL =• C CL _• y > CO O CD CDCL o Q % d CD o cn CD CD 00 os 23. C CD CA av y �• o Z CD � y v O � CD Z O � • CD O co t'7 0 O 4 E. I cn V J n O V J O Dt O -•CA0Q H d0 : O CO) a' O m C•� C 00dn m Z o =r -C H _I Tr =r m a?d CL O y CD O m y 0 O � m m > > O m coo O co Z C0� o H � a a � � gm CL m O c o H I o ei,, a c_ d C�7y ;w � . r✓1� O O1 CO) > > =r 06W CL CA N N O m C CO)cc (G�v 2 -! oC.) =o CD mo' z '0ocalor: Cl) NCD O o E d � Ci' nC.) : 0 m m �q W O cn w m g "X W Z W L z 0 N N • y 0 9 O C CD Location :L) Noy 17o Date 0 TOWN OF NORTH ANDOVER TOWN Certificate of Occupancy $ 8 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ T Water Connection Fee $ u TOTAL $ Bw ing Inspector Div. Public Works PERMIT NO. I -7 L -P ^- APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 440 - LOT NO. 00/7 I 2 RECORD OF OWNERSHIP JDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. rl LOCATION 3J /� PURPOSE OF BUILDING ��✓/_� �� / �A G� OWNER'S NAMETTI'17.5 %U� L- NO. OF STORIES , SIZE (S' OWNER'S ADDRESS T5 L.h e J• l 'il 1f(�C) L✓t l . /1�d /V N BASEMENT OR SLAB ARCHITECT'S NAME) SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SC 1..� SPAN DISTANCE TO NEAREST BUILDING A -Q, DIMENSIONS OF SILLS DISTANCE FROM STREET /% POSTS DISTANCE FROM LOT LINES — SIDES/ REAR jO " GIRDERS AREA OF LOT •34 FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND SoI'd WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER 'ooto/® BOARD OF APPEALS ACTION. IF ANY N IS BUILDING CONNECTED TO TOWN SEWER (I* IS BUILDING CONNECTED TO NATURAL GAS LINE A�10 INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 " ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS A PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED 4/AL7- BIG TURE OF O NER OR AUTHORIZED AGENT F E E 5 a PERMIT GRANTED r 6t9a4 L 2 Z 19 _ 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST ng/ S. 421C> EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL # CONTR. TEL # - 7 7 CONTR. LIC. #Z r H.I.C. ✓I/ BUILDING R,ECORD`_ ; 1 OCCUPANCY 12 INGLE FAMILY I STORIES I THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM 1ULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- PARTMENTS _RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH DNCRETE _ d 1 2 I3 DNCRETE BL'K. PINE RICK OR STONE HARDW D ERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT 11 %I '/� FIN. ATTIC AREA _ B M FIRE PLACES _ :AD ROOM _ MODERN KITCHEN _ 4 WALLS I 9 FLOORS .APSOARDS 8 1 2 3 IOP SIDING CONCRETE �_ OOD SHINGLES EARTH ;PHALT SIDING HARDVJ'D�— ;BESTOS SIDING COMMON STUCCO ON FRAME F WIRING 5 ROOF 11 10 PLUMBING 1 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. tL COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS C'AS OIC B'M'T 2nd ELECTRIC _ lot 13rd NO HEATING -v .' CA C � d O CD C7 Z y CD O n� � � C C2.-00 y a� d o p CD CDCL o r� Q %4C d CD Sr CD O CD C CD co) av y CD CD S v CA O 'CD Z O CD CD O z 21 (nPoo A - R R �" r :30 ro t r � X O Q�p S 071 �. � `moi. nOj R. o a� W v A z )Nq 0 0 c Location No. r Z Date tj NOR,h - TOWN OF NORTH ANDOVER p Certificate of. Occupancy $ Fee Building/Frame Permit $ 7Y b'•�ryp cMust'l Foundation Permit Fee $ zz . O Permit Fee $ Sewer Connection Fee $ 0 Water Connection Fee $ TOTAL $ Building Inspector �� TO ,pp©�,g 25.00 PAID Div. Public Works Location11 f � Nd. Date a HpRTO, TOWN OF NORTH ANDOVER Certificate of Occupancy $ + ; ; Building/Frame Permit Fee $ ��as�cHustt�' Foundation Permit Fee $ i. Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works u ,16gmmgr m O O O Z > 0° m n m r' m r m 1 n 00 ,16gmmgr m f a i Z > 0° m m m 0 m 1 n 00 a n � m �" m m c = A N - 0 i m n z z < ° g r r a ° 0 m C°° r r r O 0 m A Z n Z n m nmi C A m c c a L > 4 m m m c n n \; 0 i i N i O O Z A n w a > n 0 0 - uZi - 9 Z Z r O m f i i W 0 0 C N m A to Z of i a r0 ° i v H m 0 m n > n Inr o - z m i w a < c i m m c ; Q Z o „ F m i 61 0 (n _ A 0 Z m a r a 0 v m c :1 Z A m O n r a m i > o i v 0 A 0 p Z O a ,16gmmgr m f a i Z > 0° m m m 0 m 1 n 00 n a n o o m ZO m c m c m c>>>> m v 1 A r9i A z z < g a ° 0 m C°° r r r O 0 m Z n e z m A c n 0 2 N w 0 T m A z it 0 3 > 0 2 m f a m H> 0° O m> c n 0 r 0 N 0 t z r r m c m c m c>>>> m -ail 1 r= z z z Z> M .� ° 0 m C°° r r r O 0 m Z n Z n Z n M-4 A m A A m L > 4 m m m n i ui o> a Z 0 aaai n A 0 z a m 0 r O m f i i z 3 m z A m to Z m o r0 A A H L n > n Inr o - z _ m m a < � 4 O ; Q Z m i c (n ?_ i 0 a r c 0 :1 Z A m O a m Z 0 \ 1 v 0 <m p a O OI C 0 m � �. ZIP a o`V I on n 0 A m 0 Z m > > A 0 m Q m Z p C C C Z 9 O A rrrrO= D oq i Z a O w S m 8 a A v°°°> z z z z r o -n z r Z i-4 a m 0 m 0 0 0 0 0 0 m 0 m 0 a O 0 0 A A w O m Z Z z 0 a C D Z Z Z Z m'. 0 > 0 N i ; fa' gni m 1 0 z z "' i A 0 m -r r r a m Z 0 m m m 0 0 Z'n a A a O O O O A Z 0 0 0 T - m a i' 0 I C z z r n m > Z a ' 0 A A m C a r i D = x sm x I � Z Zlll i in 0 W 0 A O � I> m � A0VT0A8E INSPECTION PLAN City/1ovn:uQIHAN�o�Eg States--�------------- Patti _-2-- 4--- --------- Scale:---��� = -50 ------ Owners L—. o syG ---------------->->--------- Buyer: ----�-N��''-------- Deed Ref._3 5 0 f_ 1 3 T _�_ Plan No. '7 �._,_______ Drawn per City/Town of ,� /a Tax Assessors Map. L07 5 M3A rig Rc N�w D V tt C 1\-1 I F KY P R 1 C) T Is LOT 3 To:_. -A-- t--LP_Q_-�l_C FF` .-•-E_�1 ----------------------------------------------- I hereby certify that the above Mortgage inspection Plan was prepared for use in connection with a new Mortgage and is not intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge , valls or building lines. No responsibility is extended herein to the land owner or occupant. The location of the original building(s) as shown herein was in compliance with the local applicable izoning bylays in effect vhen constructed, vith respect to horizontal dimensional requirements, to lot lines or is exempt from violation enforcement action under Mass G.L. Title VII, Chap. 40A, Sec. 7, unless otherwise shown herein. Subject building(s) lies in a flood zone designated Zone: --------------- -- and shown o n FIRM map Community -Panel tS O� Dated: -f o -- -(o(,7 _2_o _____________________ __ ------- .---J- . JCD, INCORPORATED, LAND USE I DEVELOPMENT CONSULTANTS 4 AUTUMN LANE, METHUEN, MA 01844 508-683-9932 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/pe rmi4 from Boards and --partments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements, ''"APPLICANT FILLS OUT THIS SECTION T r �VPUCANT �.. A-vltj 4 `I u b -e- bir, tJ 40CATION: Assessor's Map Number 5 ,,SUBDIVISION II&RE ET 3 �r� drl Cy Al OFFICIAL USE ONLY DATIO S'OF I FOWN AGENTS: PHONE -Vj 171 4ARCEL_,�'— LOT (S) ST. NUMBERj5 5 TION ADMINISTRATOR DATE APPROVED - 3 ,DATE REJECTED TOWN PLANNER DATB APPROVED DATE REJECTED COMMENTS 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 INSPECTOR DATE C2 y 'O C O d COD c7 CD MZ CO) CD oo Cl. � � C CO) a� �o o v Co C� O Q CD CD O CD Ca a W C CD y C3. 0 y O CD v CA O 'O Z CD O CD O CCD tz Oq O C41crH C �o �'" pai � OZrI r G a. —• o m Cc, c� a C m c7 m2 c rte„ •� �y S iii O ME H T �a-•a 0 m �C m y CO) o m m C o a o c ;CD--� O !10 CD C may' CL 0.m CL mm co 71C"» O C_ m d m 3 H � � O O d N H CL o, C w - :qz !1 N cp N � m N i•1 CD c N O O ^` ^^ CD O v ?: c m CD vQ .i H C* -If d ?(Y 0 0 S � •o CL= 046 .. o ~" om 42 O `� w O C �o �'" pai � OZrI r G a. 'O n Gam. to 0. z� 0 )nq 0 9 0 c CD