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Miscellaneous - 35 OLD FARM ROAD 4/30/2018
N O Om cc cwii O � r v ' 00 > v o � o � O D _' O v 0 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. De P r� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) L' 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 LVK OR TYPE ALL INFORMATION) Date: 3 - G' City or Town of- iV6 r Vk 0 VCA To the Inspector of Wiles: By this application the undersigned gives notice of his or her mention to perform the electrical work described below. Location Street & Number 3f— old t Owner or Tenant OG ^ tC _R,-4 r8yo,-0Telephone No. Owner's Address 3 LO U e-rnn t Is this permit in conjunction with a building permit? Yes Q�No ❑ (Check Appropriate Box) Purpose of Building CY\\Ss iv� Y'I�/P re,, Utility Authorization No. r Existing Service `� Amps Volts Overhead ❑ Undgrd No. of Meters C New Service Amps ! Volts Overhead ❑ Undgrd No. of Meters I Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lig, �.� S { v� <<� l f�f �� j,,tr � bCie rKC ,f c Completion of the f )llowing table may be waived by the Inspector of 6Nires. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans . uNo. TransTotal Trsformers U KVA No. of Luminaire Outlets- D No. of Hot Tubs 0Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E]o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones Detection and No. of Detection No. of Switches No. of Gas Burners InDevices In No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: Detection/Alerting Devices No. of Dishwashers . S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Y Heating Appliances Kit Security Systems:* No. of Devices or Equivalent No. of Water KW ., No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs ': No. of Motors Total HP No. of Devices or Equivalent OTHER: } attach additional detail if desired, or cis required by the Inspector of Wires. Estimated Value of Electrical Work: !Sy `�� (When required by municipal policy.) Work to Start: V Q 60 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: STP l LVIrV y'Lpllsr LIC. NO.: Licensee: Signature LIC. NO.: (1/applicable, enter "exempt " in the license number line.)f Bus. Tel. No.: Address: 6 735 Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By, my signature ybelw, I hereby waive this requirement. I am the (check one) E]owner Elowner's agent. Owner/Agent a^ Signatur�'' ?" Telephone No. r ? 14 '' PERMIT FEE: $ S � F' FC,4� of -c 3- 2ci—off Date ... ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................................................. has permission to perform .77:7�� .................................................... wiring in the building of .................................................... at,� ...... .... ... . I orth Andover, Mas Fee ..645 .... . ..... Lic. No,.-�.� PVA . .............. ...... � INSPECTOR - �ro AEc,rRIC�A�L INSPE R Check # 8967 f Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. —'� , j UV BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [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 WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant ' �. O -i ►� Telephone No. Owner's Address �� hi /t C`A t -u Is this permit in conjunction with a building permit? Purpose of Building Ezisting Service Amps / Volts New Service Amps / Volts Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires ti No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water Heaters KW No. Hydromassage Bathtubs Yes N:�— No U (Check Appropriate Boz) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool ;;ftd e - grn No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Heat Pump Number Tons l Totals: Space/Area Heating KW Appliances KW No. of s Ballasts win table may be waived b the Ins ectoi No. of Total Transformers KVA Generators KVA o. o mergency Jig g Batte Units IF1RE ALARMS JNo. of Zones Wires. �No. of Alerting Devices 11 teenon/Alerfine Devices :al ❑Municipal Connection ❑ Other urity Systems: * No. of Devices or Equivalent :a Wiring: No. of Devices ar Vnnivalont No. of Motors Total Hp (Telecommunications No. of Devices or 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: 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.� i CHECK ONE: INSURANCE '&D ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this a plication is true and complete. FIRM NAME: _J a c L t . �s g1 LIC. NO.. � Licensee: Signat (If applicable, enter "exempt " in the license number line.) 6 LIC. NO.: Address: +�� t? Bus. TeL No.: 8` 07 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" L� eee: Alt Licl. 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: $ e G Qac, �p i 9 � � 5���' IACO-4• „�, 17 P 2 k, r IVU I pail `1 The Commonwealth of Massachusetts Department of .Industrial Accidents Office of Investigations 600 NZashington Street Boston, MA 02111 e : www_rnass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plumbers Applicant Information Please Print Legibly Name (Business/orgmiration/Individual); `�� ' •� / 1 Address: -4 nn 1 .f r? City/State/Zip:`.S��L— Phone #:��"�3 �U Are you an employer? Check.the appropriate box: 1. ❑ I am a employer with 4. ❑ i am a general contractor and I ,�rrtployees (full and/or part-time).* have bred the sub -contractors 2: f I am.a.sole proprietor or partner- Iisted on the attached sheet t ship and have no employees These sub -contractors have working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.) 3• ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself, [No -workers' comp, c. 1.52, § I(4),'and we have no insurance required.] t employees. [No workem' «dam., ....::..-....i.-• -`--'-- ` comp. insurance required..] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ PIumbing repairs or additions 12.❑ Roof repairs 13.❑.Other Tl,, - -- - ..M --v nil our meco e son below showing their workets' compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors diet check this box must attached an additional sheer showing the name of the sub -contractors and their workers' comp. policy infomradon. I am an employer that is. providing: workers' compensation insurancefor my information. eMpLoyees; Below it the policy and job site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Bate: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebycera fy under the poi" penalties of er'ury that the information provided above is true and correct. iC.MllllllllKe 7A - ficial 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): 1. Board of Health Z Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of theforegoing 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 -contractors) name(s), address(es) acrd 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 cavy 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, notthe 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 tare 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 bum leaves etc.) said person is NOT required to complete this affidavit " The Office of Investigations would tike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Sfiaeet Boston, h4A 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-77451 www.mass.gov/dia . a Date ... 1...i-.�.��................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that...... i ....... .........................................................`.... ..©.................................. has permission to perform ...........................P..................................'................................ wiring in the building of ............. at .............3" , "` '^`... , No Andover, Mass. Fee ... �a�`� .......... Lic. No. ao.a . /�- .............................................................................. ELECTRICAL INSPECTOR Check # _V Commonwealth of Massachusetts Official ""Use Only Permit No. Department of Fire Services rJ Occupancy and Fee Checked 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 (VEC) 527 CMR 12.00 (PLEASE PRINTWINK OR TYPE ALL INFORMATION) Date: /9' �// r_ 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) 3.- 01j 7 Ar en W\ Owner or Tenant --,3q yn j C Pr r\- Telephone No. `1 /6 flj;� Owner's Address d N Is this permit in'conjurLetion with a building permit? Yes R7 No ❑ (Check Appropriate Box) Purpose of Building e- 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: �►,1 v�tv►y c� ,, Vj fPJ Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- rnd. rnd. TV-Elo. o mergency Lighting Batter 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 Initiating Devices No. of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW No. of Self -Contained etection/AlertinLy Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Key SecN .o Systems:* s or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Atiach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of 1 ctric Work: (When required by municipal policy.) Work to Start: �% f 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 cover e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) X certify, under the p ns and penalties of per/�ury, that the information on this application is true and complete. FIRM NAME:. {� s �, I1PA36 onLIC. NO.: �2 10(424 Licensee: '10S l Shh %.,gyp Signature LTC. NO.: �O (If applicable, infer",g,empt" 'n the li se na tuber li e. Bus. Tel. No. •�%�i %�% 4%a(i3 Address: y /r ! ' yp_ ��yt ei— iy%� %3 d 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 PERMIT FEE: $ jlj�c Signature Telephone No. N 3 .s% S- ❑ 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 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com M. The Commonwealth of Massa-Musetts F Department of IndustrialAceldents I Congress Street, Suite 100 Boston, MA o2114_2017 9� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contxactors/Electricians/Plum ers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Name (Business/Organization/lndividual): Address: %%%� City/State/Zip: � ;/� � Off_ C•� S , Olcf3U Phone #: Axe yo a employer? Check the appropriate box: 1. am a employer with mployees (fitll and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.Q i am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and T have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. L] 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.] 63 Type of project (required): 7. ❑ Ne*'C6"nstr1 dtion 8. E] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12T[] Plumbing repairs or additions 11E] Roof repairs 14. n Other cks bbac Al must also fill. out the section below showing their workers' compensation policy information: Any applicant that che t Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit anew. affidavit indicating such this box must ached additional sheet showing the name of the sub -contractors and state whether or not those entities ha tContractors that check ve employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer tliat is providing workers, compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #:. Expiration Date; City/State/Zip: - Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). nal olation by a RAO up to Failure to secure coverage as teas well as civil ivil penalties in the form of25A is a aSTOPrWORK ORDER and a fine of up to $200-00 50.00 a and/or one-year imprisonment, of this statement may be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy coverage venucauou. I do hereby cer un r the i s ndpenaldes of perjury that the information provided ab ve true`and correct. Date: Si aiure: Phone #: 6 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 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: ti C_ 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 receivetbr, trusted 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local Iicensing 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 intp 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 certificates) 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. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial -Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatiori 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia v � COMMONWEALTH OF MASSACHUSETTS'. BOARD OF E L E OTR I C,1 A No l';l;',,ES-.THE FOLLOWING: 1-11"ENSE AS r, ClIG JOURNEYKAWELECTRICIAN lr�!)'E;'H A SANFILI-Pflo M —WOOD' CT APLE uj ST E. -R MA- GJ930-2213 P2.. 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W :.P W OD V CA P. .-4 m N D N D N D iD �] m I N ❑ tD i rrhh I N < 3 n N Q I N I �I � I i D 4� I nDi W I o �N N 3 +• N � D Q v A ' t 0 n O O m z m -Dim 0 D OX X. cn� m O 71 A OD m GrK W Cl)nz n = =0 m m< v W zco z Z'DD m m z m r cn m m_ u W z m m �' m mA zO X Z n O W mm n A m m X r_ _ W //''''�� 0 l;u n D ---1 m Z �] n .rr7o2mm $m r i ii m D 0 n n resm A O m I __..______ � 0 c r cn rai OA V Z r I I l O z C 'D < `c .Z) c� Z -1 w; A "FO m ---- _ ---- O m n C z �O x DD Oz Z m y II z m� cocn m� ° co c z y n OEi D� 9°o�Om- =6 �zju r O$ MO O O 3 i m 0 O m V) rn O mm 3 3 m C� A A z3 D cn Vf 0 m m nK /II\ 05�W oz m�Fn ZmN� ci Nonm �(m>�vAz <m mo G)z �m ">cD X c -i Pz�r z0� m WO 0O D A0 m N n p D 0 Z Z Z XZ zm m nn p =Z m 0 c -i ? O m A < Z Oc r O c x_ D m i m z < �m X 0z ni X z Gz �CC 4U)D r m Z ii G7 O p zz co zm co M D m� my mOX z m� zm m O � z O Z11 m m Cl) A n A O z 5 in O DI D o j.. A 0 � D A enT O sm �o o o? N m X O X A n O m� � o0 C m m C `qR I N g n m N p7 O I wp w ' I pY' O gB" � D Qca X n 3 O Z c U1 i ,{{i I�1 OO O X m y# Go ou m W # m O1 0) V -4 W D N D N D iD �] m I N ❑ tD i rrhh I N Q I N I �I � I i D 4� I nDi W I o �N N rD p � N � D Q v A ' I L-urnmunweann Of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked .yU-"� [Rev. l/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMRWORK- All 12 00 (PLEASE PMT ININKORTYPE ALL EWOR1l�gT10N) Date: - City or Town of. NORTH ANDOVER By this application the undersigned To the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant �a�(� 4 Owner's Address Telephone No. 4 Old PAr[4„ t2 VN Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps __/ Volts Number of Feeders and.Ampacity Location and Nature of Yes b�j_ No U (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd No. of Meters Overhead ❑ Undgrd No. of Meters Date ... f . z. *.'..q ........ �a0RTM o�t...o o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING E lr' r This certifies that ...... ..'��- �- -- -o .. ................................................. has permission to perform .. Tr.. �1........................................................ wiring in the building of at......`�....��-`�.-.....!�i.. ;....orth Andover Mas .. Fee . I Lic. No.�4I f ............... CTRICAL INSPECTOR L' Check # c��5� win table may be waived by No. of Transformers the Inspecto Total KVA Generators KVA o. o mergency ❑ BatterUnits ig g FIRE ALARMS No. of Zones No. of Alerting Devices elf.-Containe Detection/Alertin Devices Local ❑ Municipal Connection ❑Other Security Systems: * No. of Devices or E uivalent Data Wiring: No. of Devices or E uivaient eI communications Wiring: No. of Devices or Eouivalent if desired, or as required by the Inspector of Wires. Iicipal policy.) 896.71 MEC Rule 10, and upon completion. M....., e Icensee prove es proof of liabiliformance of electrical work may issue unless ty 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 OND ❑ OTHER ❑ (Specify:) I certify, under then pais and penalties of perjury, that the information on this a FIRM NAME: plication is true and complete u C L Licensee: ILL I LIC. NO.: 3 Oq ^� Signat (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: e9yh (SL)�� C Bus. TeL No.: _ �` t; 7 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: �� L cl. 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. $ t Date:j. ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................... . ....................... ....... ..................... has permission to perform ... n .......................................................................... wiring in the building of ........... ��r: .................................................................. North Andover, Mass. .................................................................. Fee ... ..... Lic. No . ............. ........ .................................... .... ............ ELEcTRicALINSPECTOR Check # G4 0; 0 v _ Commonwealth of Massachusetts Oficial Use Only Permit No./�IL Department of Fire Services Occupancy and Fee Checked ep, r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 (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: 3 -' ;-- U City or Town of: JLC r �k Xjo ycA To the Inspector of Wires: By this application the undersigned gives notice of his or hernia ration to perform the electrical work described below. Location (Street & Number) 3 00 f ✓(� i `3e Owner or Tenant oc" � 3c,-4 6(bw(fL Telephone No. Owner's Address 3 Eb 41 11 Is this permit in conjunction with a building permit? Yes Q�No ❑ (Check Appropriate Box) Purpose of Building �\y\ssti k- Utility Authorization No. r Existing Service �' Amps Volts Overhead ❑ Undgrd No. of Meters C New Service &�'60 Amps / Volts Overhead ❑ Undgrd No. of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of lhefi)lloiving table may be waived by the Inspector of P'ires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans TransTotal Trsformers � KVA No. of Luminaire Outlets No. No. of Hot Tubs Generators 0 KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergency Lighting Units No. of Receptacle Outlets No. of Oil Burners -Battery FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of No. In Detection and InDetection Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: attach additional detail if desired, or cis required by the /nspectoi of 1,7res. Estimated Value of Electrical Work: ISc�o 'pD (When required by municipal policy.) Work to Start: Q C Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VERAGE: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and pettaNies of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (// applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes not have the liability insurance coverage normally required by law. B my signature bel w, I hereby waive this requirement. I am the (check one) ❑ owner ❑owner's agent. Owner/Agent x(•?�(�� PERMIT FEE: $ Signature , J� � !�'� Telephone No. C 471 Date ......... f NORT" , 3j;.<„``° '• ."�o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that .......�.............. has permission to perform ,!Yj ..... wiring in the building ........................................... at:...............................I.................,,........................... ,North Andover, Mass. +Feevr .............. Lic. No: v ELECTRICAL INSPECTOR v U Check # Commonwealth of Massachusetts t/r1"/i:'I use Only ITO Permit No. Department of Fire Services Occupancy and Fee Checked �S BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9,'05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Mork to be performed in accordance NNith the Massachusetts Electrical Code (MFC). 527 CANIR 12.00 (PLEASE PRINT IN INK 0R TYPE ALL /NF0Ij44-ITION) Date: /— 20 — o City or Town of: � / To the ln,ypeclor o/Wire,v: By this application the undersigned gives notice of hisAr her intention to erform the electrical work described below. Location (Street & Number) .? S t��1�"✓L- Owner or Tenant Telephone No.7 Owner's Address y Is this permit in conjunction with a building permit? Yes F]No � (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 20a Amps /, V Q Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd ® No. of Meters % Undgrd ❑ No. of Meters D/, /Grl r. �e,,� r C,,,,,nlvtion of the lnllotrinQ table may he waived by the Inspector of 11'ires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIn- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Cas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices 11 1 No. of Waste Dis osers p Heat Pump Totals: Number. Tons KW No. of Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ MunicipalE]E] Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional delad {I desired, oras required nv me urspecror of ,r a c.N. Estimated Value of Electrical Work: 700 (When required by municipal policy.) Work to Start: /— ZO — D G 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 pe mit issil tg office. CHECK ONE: INSUR;\NCE [ 130ND ❑ OTHER ❑ (Specify:) I cert?fy, under the pains and penalties of perjury, that the infori al ion on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (t/'applicable, enter -exempt" in the license number line.) Bus. Tel. No.:/j 7 Address: Alt. Tel. No.: *Security System Contractor License required for this work-, if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes 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/AgentPERMIT FEE: S �� Signature Telephone No. Location �`� Old "' l?#,l J' No. 02 Date �oRTN TOWN OF NORTH ANDOVER O�t.° y,ti0 � 9 Certificate of Occupancy $ 7 Building/Frame Permit Fee $ J�cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ✓ J� 153,—Building Inspector 4 it SECTION 1- SITE INFORMATION TOWN OF NORTH ANDOVER 1.1 Property BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .? 4't�..li Py'wA$"xc�C„'+•y.... ^Wytt 'G§i .y.. 'k'.;;..yg:: 'ffiv+8 ,..'.. ..., K `i—iS" BUILDING PERMIT NUMBER: DATE ISSUED: n -i9 -oma a SIGNATURE: Building Commissi erilfor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property 1.2 Assessors Map and Parcel Number: Address: 3 1�1 ;— —(9 I / po ve ( Map Number Parcel T4umber 1.3 Zoning Information: 1.4 Property Dimensions: i tkc, p C2 Zoning District Pr osed Use Lot Areas Fronts ft 1.6 BUII.DING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8Sewerage Disposal System: Public Private ❑ Zone Outsrde Flood Zone Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record } t vW Name (Pnn Address for Service Signa re Telephone 2.2 Owner of Record: kj S - wr (� d g 3y 01� �m �� ^ �l�(Joyr( t Address for Service: �DL- Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address N • Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone IN ^i Ll L r r SECTION 4 - WORKERS COMPENSATION (M. G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afl in the denial of the issuance of the building rmit. Signed affidavit Attached Yes .......'Ek No ....... 0 SECTION 5 Description of Pro osed Work check all applicable) New Construction D 1 Existing Building Repair(s) Alterations(s) Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: �e <MDve (Mcuo r\, 1e Si.d Mrd rtp �(d Vt✓�-�� I SFCTTnN 6 - F.STIMATF.D CONSTRUCTION COSTS I 0 1 result Item Estimated Cost (Dollar) to be Com leted b permit a hcant X SIFFIC)FALU3E�ON b`'� ..: r' ..,, 1. Building d (a) BuildingPermit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (.) X (b) / �- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 p no Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent 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/AUTH(�ORIZED AGENT DECLARATION I, �� yh e !> ao �-"h ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief (( Print Name Signature of er/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE •• 4 1 W w ori o w° cn ° z °U cisa ; ti C2 U w o �" a°G w a o v w w2' v cm w a C2 w z � .. w o cn Q o cn LIJ z c 0 m C O C; c O N ' 0 is O 0 CS CLc �R C,3 ; O c _O O � CDc 0 awl LCL H E c m ' v o cp mi a cc O € m �e�m O O 3:y Z m O zoo Rzt: _�CA co co O m Ap cm CLU 'D mo ate= m Vcm hZ O O. c = o ~ 0 t «. c � •H dt W C Z W .E C=i .a v � QO = 44 m C3 A CO2 CL ` � O �- F. sawm z 00 0 z 0 U to a� CD L Z CD C. O h G C CD _ I Com_ y Q -0 CD A C> m m CD � H � CL CD L ca cc C3 ii CMQ Ce C C C Q �v a� c Z CD �..� ca � C _ C . C c _ CL 0 LU0 U) U) w w Ir V) Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 °(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print �1 DATE `�©� JOB LOCATION 00 Number "HOMEOWNER '94yvk,c � , G v CJS N Street Address I/j S. 9 q79'- 7q4 -)voLt Map / lot ame riome rnone Work Rhone PRESENT MAILING ADDRESS Vh Voin,-A,)J.ove( MA r-) r Q►._ t— City Town Tip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does . not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who awns a parcel of land on which helshe resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use andlor farm structures. A person who constructs more than one home in a two-year period shall not be 'consi-dered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, bylaws, rules and regulations, • The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL ems` I j6l ,, s 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 property licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Sig ature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Location--"` No. Date TOWN OF NORTH ANDOVER o * ; ; Certificate of Occupancy $ Building/Frame Permit Fee $ s�cNusE Foundation Permit Fee $ Other Permit Fee $ TOTAL i Check # 15371 Building Inspecvr` • TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1.2 Assessors Map and Parcel Number: BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/In for of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0 3 0 0 I 0AJ Map Number Parcel Number 1.3 Zoning Information: Property Dimensions: . '1.4 (' y(/ � L K yj o w 7 j Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Recyired Provided Regiured Provided v 30 3 � 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone 1.8 Sewerage Disposal System: Public Private ❑ Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ✓��--...�w 3r O l 0( 0 Cd . N (Prin Address for Service Signature Telephone 2.2 Owner of Record: Gn ye rUwtn �� O�Gta /;'►'� r`� Name Print Address for Service: ` / - q 7g ' 7 qtt - Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Ml Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone n C / ■ ■ C 0 SECTION 4 - WORKERS COMPENSATION (M.G.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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a licable New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: I AcAa �r ✓v� �ti G ✓a. t L �� �` e t- 4 tv ku n L ✓\ N (iG r 0 F W v,J e G'J f C iCC it cJe 1 vi O der �'kW er, 1Fk SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant 1,)� f OFICiAL1iSE ONLY, 1. Building l % C7o0 , D 0 (a) Building Permit Fee Multiplier 2 Electrical 3 (�00 00 (b) Estimated Total Cost of Construction 3 Plumbing f,5- f)o • 00 Building permit fee (a) X (b) Q / 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 RCITO <00_ Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT I, as Owner/Authorized Agent 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/AUTHORIZED AGENT DECLARATION I, 5Gr as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief yyw Print Name 3 Si ature of er/A Yent Date �U NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUIL DING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U .- LOT RELEASE FORM Fit, %gym 1 Ic C -4,V - 3-I INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. -^-AIJNLIGANT FILLS OUT THIS SECTION*************** ******* 0 j 11 V r APPLICANT CJ (4,/j lbwV? LOCATION: Assessor's Map Number SUBDIVISION c( rx., Vn STREET" �� ✓+'\ RECQInf�l gMpAT10 OF TOWN AGENTS: ATION COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMME DATE APPROVdD DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTFn DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT _ /% FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO 3 a Z PHONE '97r- -744._ ),00Lf PARCEL( LOT (S) ST. NUMBER- ,S� USE DATE_ Revised 9\97 jm The Commonwealth of Massachusetts Department of Industrial Accidents Office or Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit -- Please Print Name: G 1(`n� P �w In - Location: S fG r int us a homeowner performing all work myself. -1 r . % qtr, �-OOL 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Company name: Address City:. Phone # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1.500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($10o. oo) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DtA for coverage verification. ! do herby certify under ti pains and Signature of perjury that the information prOvided above is hue and correct Date 3- (- )° Print name _ Gwl i P J ?Ju l^ Phone # Official use only do not write in this area to be completed by city or town official, (]Check if immediate response is required Building Dept Contact person: Phone RM WORKMAN'S COMPENSATION '?p - N )9) - E] Building Dept E] Licensing Board El Selectman's Office' F� Health Department 0 Other Town of North Andover Building Department 27 Charles Street North Andover, MA. 01846 D. Robert Nicetta Building Commissioner (978) 688-9545 ,(978) 688-9542 Fax Please print DATE_ 108 LOCATION S Number HOMEOWNER 'RESENT MAILING HOMEOWNER LICENSE EXEMPTION ��.t ,m �.e G,rcl. �Gt ✓ � U i 6k I JG1 � Street Address Home Phone '3 s- o W Map / lot 70-6�s-4� Work City Town State Zip The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an Individualfior hire who does . not possess a license, provided that the owner ads as supervisor. (State Budding Code Section 108.3:5.1) .DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land an which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dweiring, attached or detached sirudures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be'considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by4aws, rules and regulations, The undersigned "homeowner•' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she wig compty with said procedures and requirements. HOMEOWNER'S SIGNATURE_ APPROVAL OF BUILDING OFFICIAL 41 MECcheck Compliance Report Massachusetts Energy Code MECcheck Software Version 3.2 Release la TITLE: D & J Brown 00M CITY: Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detaches HEATING SYSTEM TYPE: Other (Non -Electric Resistance; DATE: 02/28/02 DATE OF PLANS: 2-14-02 PROJECT INFORMATION: addition and renovation COMPANY INFORMATION: Colp Custom Builders COMPLIANCE: Passes Permit Number Checked By/Date Maximum UA = 124 Your Home = 122 .1.6%o Better Than,Code Gross Glazing Area or Cavity Cont. or Door Perimeter R -Value R -Value U -Factor UA Ceiling 2: Flat Ceiling or Scissor Truss 626 44.0 0.0 17 Wall 1: Wood Frame, 16" o. c. 636 19.0 0.0 29 Window 2: Vinyl Frame, Double Pane with Low E 80 0.330 26 Door 2: Glass 80 0.330 , 26 Floor 1: All -Wood JO1sttTruss, Over Unconditioned Space 626 25.0 0.0 24 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans; specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in MECcheck Version 3.2 Release la. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design to specified in Sections 780CMR 1310 and J4.4. l Builder/Designer Date 2 -2 B ' z North Andover Building Department Tel: 978-688-954.5 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 c 11, S 150 A. The debris will be disposed of in: (U LA J McG-,hr,j �,jCj�e (Location of Facility) Lj Signature of Permit Applicant —-rc-� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Cl) m U) 0 m W. y CA Cl) C1 'O O CD a Z CO) CL "0. CM � c CZ =• CO) '�O O n o CD CD O 06 Cr s d CD CD o CD OD W c CD Vi Q O CDy co CD a y O 'o Z CD CDo 0 CD O -• N O Q N -1 5-5060 m m C9 m A m O y C) 06 Z �m y -I o� °..' o CA -o T m CL=r M =CA m O O m y O fwCD� m � o = o ZLa•ow q O N• A CDo /ec ^ ??h '� :�• v, m m y N, m cr CL �y y C � n ►Q " c :1t m �^ =rN :� N V) H O i. C CD CrN W O a C-) n Z CD rr o ���`� C z opo C5, bd Pte• :� 7 � I 1 � _\`n`1 CD o �r: d d d �C =m o 3 o =o C=* C�7 A = n V : _ !D Cn 0 0 ptr d rA p m n � a a R x o 0 c FRANK S. GILES, P.L.S. FEBRUARY 18, 2002 DATE FEBRUARY 18, 2002 REVISIONS: SCALE: V= 40' 0' 40' 80' i i --- d I P.O.L.= POINT ON LINE (ORANGE RIBBON) SCOTT L. GILES FRANK S. GILES SURVEYING 50 DEERMEADOW ROAD NO. ANDOVER, MA 01845 (978) 683-2645 FRANKGILES SURVEY@ATTBI. COM OLD FA_,W Gnr ROAD FLAN OF LAND LOCATION 35 OLD FARM ROAD NORTH ANDOVER, MA PREPARED FOR JAMIE BROWN C:\CLIENTS\JAMIE BROWN\PLOTPLAN.DRG JBJECT PROPERTY JAMIE BROWN VIAP 35, PARCEL 70 :ED BK. 5019. PG. 240 PLAN #8926 3 OLD FARM ROAD 'H ANDOVER. MA. 01845 • r t v t L I u h vi Lim V 9m V I 9— Lm /"l I V EK SURVEY INC. 11 MORTGAGOR AuAtj DEED REF. Mot PG. iv ADDRESS OF PRINCIPLE BUILDING PLAN REF.L 891Zo £ 35 -OW AMOK W DAT"F INSPECTION AQU, e• 1449 �1� - ie, mg 664tE:111=601 /.5a, 004 o o � HS, oov 5 { 2 ,ems MI .- Oc to A ern fWo �x NOTE: This mortgaga Inspection was prepared ��? 1 FURTHER SATE THAT IN Lly PROFEsSjONAL &ad speclly for mortgage purposes and Is not toor • �•,, OPINION the pr{nclpit strucWm/s and accsssory be refled upon ass a survey& FX *9U?tVtY occepb T �_ outbuildings, _ dp&(VV M no responstblfty for damage RUDEL Na DEL with the setback requirements of Ire lord— rallanca by anyone other than the sold mortgagees �t zoning ordinances,, and that no enchroact meas ndrtsmortgag lqu fiin nancing onetI0�cIn Vtr{haq y .ptopawed "�fOfS(C1E+� of ma)o.tlmp vrments etttwc way oams-s c1RT►Flc.�noN M p P y excpt as abawn. AEWOLFE MORTGAGE SERVICES, INC. 1p1. Property Is not _ In a Flood Vomu rd Area. This csrtif3catlon G based on the locutlon of stirvey markers d 2' PcopectY is In •a Flood Hazard Ars( . of ather7t, and doaa not represent a property suvw y. ark al [3 3• lnformat an Is Ihsuf4dent to Aat�cmtts Flood Hazard. offsats shown oro not to bn Used for the eaiabllAment of Pow Hazard doictmPa tFoaa est �°dO� Hood Mappropelty !Rtes. Insurance Rota Map Pandy Date ...5 �i r zn > TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that _.... l ...... �� .l '`""" ..................... has permission to perform ................ plumbing in the buildings of at .........�. North Andover, Mass. /���3y i Fee. .� ..... Lic. No. ....;•>_���.c...;.--,;-�,� ........ j . PLUMBIr ACTOR Check # - .-2 0 �j�' 5238 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS_ ' Date Building Location Cd tw'<M eU'qc/ Permit # , ZcvZ v Amount Owner j) %} o d 'D New Renovation Replacement Plans Submitted Yes No (Print or type) Installing Company Name She ve 4 Check one: 8--c-orp. rlPartner UFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent 1-1 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 i�nsd under Pe a or this application will be in compliance with all pertinent provisions of the Massachg C * a� )f4 of the General Laws. By: S a ure o ice�P um er Type of Plumbing License Title 1013 4 City/Town License Numner Master Journeyman {. APPROVED (OFFICE USE ONLY LJ • OFT. MST nnnnnn��nnn���nnn�nnnn�n�n ■�■�■r��■�s�������nnn�nnnn�nnn �, . � ,-� : nnn�nnnnnnn��nnnnnnnnnnn� (Print or type) Installing Company Name She ve 4 Check one: 8--c-orp. rlPartner UFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent 1-1 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 i�nsd under Pe a or this application will be in compliance with all pertinent provisions of the Massachg C * a� )f4 of the General Laws. By: S a ure o ice�P um er Type of Plumbing License Title 1013 4 City/Town License Numner Master Journeyman {. APPROVED (OFFICE USE ONLY LJ 1 3779 0 SS CHUS Date ...... ...... ......... ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING rf Thiscertifies that ....... ................................................................................ has permission to perform ......... .................................................. wiring in the building of .......... I-If,)C) (/j -L ............ QQ at ......... ......... ..... .. 4 orth Andover MassT Fee ... z Lic. No. . ............... � LECTkICAL INSF!ECMR Check # Id I--,' IOfficial Use Onn! �J Permit No. !. 7 Do -t--4 4 P4404 S460 Occupancy & Fee Checked 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 Massachusetts Electrical Code 527 CMR 12::00 (Please Print in ink or type all information) Date s-/// / `t( U To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number '3S_ OIC( Owner or Tenant �U ✓t^ e /,Gu� Ownel's Address -3f G� O "I o f ✓✓, 1 / r O G d Is this permit in conjunction with a building permit Yes C No ❑ (Check Appropriate Box) Purpose of Building_ PS \ �� CA ( [ � 1 ` Utility Authorization No. Existing Service LyQ Amps Z- 7 o Voits Overhead ❑ Undgmd r No. of Meters S New Service Amps Volts Overhead ❑ Undgmd ❑ No. of Meters Number of Fgaders and Ampacity Location and Nature of Proposed Electrical Work GAW RI U W r►yh! , _1C. n �� t: +wC Jv� i u rive t No. of Lighting Outlets No. of Hot fuse r� ,l Total No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ ,1 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Batte Units No. of Switch Outlets U No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and _ Total No. of Ranges No of Air Cond Tons Initiating Devices j Heat Total Total No. of Di al No. C/ Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating G KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of D s Heating Devices KW Local Connection No. of Water Heaters KW No. of Signs No. of Bailases Low Voltage Win ow - No. Hydro Massage Tuds <1l No. of Motors Total HP INSURANCE COVERAGE. Pursuant to #te 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) %✓, - ,.1 (Expiration Date) Estimated Value of Electrical Work$ ! S �/ V Work to Start Inspectl n Date Resquested Rough Final Signed under the Penalties of perjury: '� A FIRM NAME <1 LIC. NO. Address / OWNER'S INSURANCE WAIVER: I am avlare General Laws. And that my i/gnature on this /l/i/Ii1 f� A (Signature oPgfvner or Agent) NO. / Bus. Tel No. Alt Tel. No. that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts permit application waives this requirement Owner Agent 70(P(Please 7Ch/eck one) Telephone No_ ` `T^ ✓C -\� C/ E $T 10-