HomeMy WebLinkAboutMiscellaneous - 356 REA STREET 4/30/2018IIS
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Date ... .V�... -' i........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... .................. ................................
has permission to perform,
wiring in thebuilding of ... .....................................
at,?SX� .............................. North Andover, Mass.
Lic. ..............
...........
AE IC INSPE R Ili 11 -
Check # -
.e
Commonwealth of Massachusetts Official Use Only
p Department of Fire Services Permit No.
—
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked"
[Rev. 1/07] Qeave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52 p WORK
RK
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: "- a
City or Town of: NORTH ANDOVER To the
By this application the undersigned gives notice of his or her intention to perform the el� trical woector ofrk es nbed below.
Location (Street & Number) — � /e�
Owner or Tenant D n
Owner's Address Telephone No.
Is this permit in conjunction with a building permit? Yes
Purpose of Building � NO EJ (Check Appropriate Box)
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: -
/�
-c.. d- t ,-vo 4
Com letion of the follomdn table maybe waived bv the inspector of, Wires.
No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total
No. of Luminaire OutletsTransformers KVA
No. of Hot Tubs Generators KVA
No. of Luminaires Swimming pool Above In- o. o mergency ig
End. [Dmd. Batte Units g
- No. of Receptacle Outlets No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Switches 3 No. of Gas Burners No. of Detection and
No. of N
Ranges TotInitiatin Devices
g o. of Air Cond. a!
Tons No. of Alerting Devices
No. of Waste Disposers Heat Pump Number Tons KW _ No. of Self -Contained
Totals: M`""""-. "- "'�� Deteetion/Alertin Devices
No. of Dishwashers
Space/Area Heating KW Local ❑ Municipal
No. of Dryers Heating A Connection ❑ Other
g ppliances KW Security Systems: *
' No. of Water No. of No. of Devices or E u'valent
Heaters KW No. of Data Wiring:
Si s Ballasts .
No. Hydromassage Bathtubs No. of Motors No. of Devices or Equivalent
Total HP Telecommunications Wiring:
OTHER: No. of Devices or Equivalent r
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start (When required by municipal policy.)
S'.? - O Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAG : '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 ❑ (S ec'
I certify, under the ains and enaldes o p )
p fP�7ur1', that the information on this pplicadon is true and complete -
FIRM N � -C-c� l£� c c
Licensee: d LIC. NO.: E -5,125-5-
• 0 Signa
(If applicable, enter mpt " in t e license u be ine.) LIC. NO.: G-:,1ez�
Address: / �� v�/ c�l �` ce /12Gn /� 07 Bus. Tel. No.: "I
r7GS-t/ry3
*Per M.G.L c. 147, s. 57-61, security work req es Dty Alt. Tel. Nolo ? .P 9 t' v� 6
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ehave ,the liability Lic. No.
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner coverage owner's agent.
Owner/Agent
Signature
Telephone No.
P PERMIT FEE. $ �`
'7A 6-
7 17- 6��,,049
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The Common wealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Nfashington Street
Boston, MA 02111
{ b www. mass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
P-Plicant Infortrtrtatinn
Nanie (Business/Organizafion/Individual):_ ?1
Address: /
City/,State/Zip:_
Phone
H
Are you an employer? Check.the appropriate box:
I. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.k I am a.sole proprietor or partner_
listed on the attached sheet. I
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. ❑ 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No -workers' comp,
c. 152, § 1(4),and we have no
insurance required.] t
.employees. [No workers'
comp, insurance required..]
*Any applicant that checks bob # 1 must also fill out the section below showing their workets' nom satin
Type of project (required):
6. ❑ New construction
7. gRemodeling
8. ❑ Demolition
9. ❑ Building addition
10- 11 Electrical repairs or additions
1 I .❑ Plumbing repairs or additions
12.❑ Roof -repairs
13.❑ .Othtr
omeowneth who submit this affidavit indicating they are doing all
;Contractors first check this box must work and then hire outside c nit a nctors must submit new affidavit indicating such.
attached an additional sheet showing• the name of the sub-connactms and their workers' comp. policy information.
i ant an employer that is prp"MI,7g:workers' compensation Insurance for mY employees: Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
------------
Job Site Address:
City/state/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date),
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
! do here cerci d mains a pen perjury that the information provided above is true and correct
4�'a3
Official use only. Do not write in this area, to be completed by city or town—
official
11 City or Town:
Permit/License #
Issuing Authority (circie one):
r
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector
5. Plumbing inspector
6iM.1�
!� Contact Person:
Phone *.-
Information and Instructions o
Massachusetts General Laws chapter 152 requires all emp foyers 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, Y
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 includirig 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 evidenceAr compliance with the insurance 'coverage required"
Additionally, MGL chapter I52, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public woric 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). and phone numbers) 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 requiredto 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 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 numberlisted 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 pernit/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 bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-8.77-MA.SSAFE
Fax 41617-727-7744
Revised 5-26-05
www.mass.gov(dia
Date. ........0/ . .
NORTH
pf .ao 1tip
TOWN OF NORTH ,ADOVER
40
: PERMIT FOR GAS INSTALLATION
This certifies tha-t---.�......... ...- .... .
has permission for gas installation-
�..... a
Ga_
in the buildings ofd..U�-?�-... ......................... .
at . '3� ��... !. ................... , North Andover, Mass.
Fee -?. �..... Lic. No. CR .. _. .. .
71-31-6
��� C/ --GAS INS E1GtOR
Check # /U16
6790
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: Zi'J. MA. Date:_ Permit#
BuildingLocation: ,
/f -plc Owners Name:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No
1•'IVTI tllrw
INSURANCE COVERAGE:
I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes T–N-V❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2--� 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box ❑ 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Ty a of License:
Plumber
Title I 0 Gas Fitter
journeyman
LP Installer
Srgnature of Li6erised Plumber/Gas Fitter
License Number:
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WCerfificate#
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Installing Company Name: .� ,�,
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Address: /,(J City/Town - �� `— State:Z "
Corporation
Business Tel: ��� ��fG Fax: ew>l
❑ Partnership
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❑Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes T–N-V❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2--� 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box ❑ 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Ty a of License:
Plumber
Title I 0 Gas Fitter
journeyman
LP Installer
Srgnature of Li6erised Plumber/Gas Fitter
License Number:
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2 Silver Ledge Road, Newbury, MA 01951
Office: 978-462-4331 • Cell: 978-973-2366 • Fax: 978-462-5528 • email: jfix@comcast.net
May 26, 2009
Inspector of Buildings — Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: Residential construction for Williamson residence, 356 Rea St., North Andover, MA
Dear Building Inspector:
Today I visited the Williamson residence at 356 Rea St. in North Andover to observe the
construction of the renovation. During my site visit I observed that the steel beam and
supporting columns appeared to have been constructed in general accordance with the
design drawings, dated 5/6/09, prepared and stamped by me.
If you have any questions, please feel free to contact me.
Sincerely,
Joseph P. Fix, P.E.
<1
2 Silver Ledge Road, Newbury, MA 01951
Office: 978-462-4331 • Cell: 978-973-2366 • Fax: 978-462-5528 • email: jfix@comcast.net
May 26, 2009
Inspector of Buildings — Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: Residential construction for Williamson residenc(356DReaSt., orth Andover, MA
Dear Building Inspector:
Today I visited the Williamson residence at 356 Rea St. in North Andover to observe the
construction of the renovation. During my site visit I observed that the steel beam and
supporting columns appeared to have been constructed in general accordance with the
design drawings, dated 5/6/09, prepared and stamped by me.
If you have any questions, please feel free to contact me.
Sincerely,
Joseph P. Fix, P.E.
Date. /..`A7.Gf 1-
j �.
Of
"OR
°T :1�c I`..____,TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
This certifies that S� .. !�� ....1<
has permission to perform ....�'!� .ca�..e.?�.�:-- .............. .
plumbing in the buildings of ..............
at ....?'G...' !!* ... . �v ... North Andover, Mass.
Fee. A/7 Lic. No..e).'...... ......
PLUMBING INSPECTOR
Check #
6670
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location -I q (a le a
Date J O �
Permit #-L"716
Amount V2
Type of Occupancy
New11 Renovation Replacement Plans Submitted Yes No 11 11
FIXTURES
(Print or type) I44 Check one: Certificate
Installing Company Name t Corp.
Address jt4[]ZC .
� �V
BusinessTelephone 0.
Name of Licensed Plumber.
Insurance Coverage: Indicate the t e of insurance coverage by checking the appropriate box:
Liability,i rance policy Other type of indemnity D Bond
/ '
the undersigned, have been made aware that the licensee of this application does not have any one of the above
i
I hereby certify that all�he details and information I
best of my knowledge and that all plumbing work and
compliance with all pertinent provisions of the Mass
[y:
VED (OFFICE USE ONLY
11 Agent 11
(or entered) in above application are tnie and accurate to the
ormed der Permit Issued for this application will be in
oinode ander 142 of the General Laws.
License
Master oumeyman 1-3
r
6172
Date...r,..��..
I�:���a^•�'eryppL TOWN OF NORTH ANDOVER
mow p PERMIT FOR WIRING
y This certifies that ................................. r ......................................
has permission to perform,. ..'`�.............�
..............................................
wirn3 the building ....:.�.9......:»^'..-................................................
/
at..........V`....(�...............:�-e`....... ��.................... , North Andover, Mass.
01-r/
Fee ���l_......... Lic. NA..l..ZW
................
'..:....t........✓:..��` `:�..........—
V ELECTRICAL INSPECTOR I
Check # ��
N
The Commonwealth of Massachusetts /ae Oelr
Department of Public Safety Nrelt
occu"ney L F" Onxk"
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12003/90 (l.a.. blank)
APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK
All %*& b be periormed b accordance with the Mawtsachusetu Ekctrkal Code, 527 CMR 12:00
(PLEASE PRINT IN INR OR TYPE ALL INFORMATION) Date_ le-ld y�aJP
City or Towa of 10OA 11 IIA"Ve4eX To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 17j 4., A.-.4 -r,7—
Owner
f
Owner or Tenant l�� LGi9 of / O nJ
Owner's Address
Is this permit in conjunction with a building permit: Yes B No ❑ (Check Appropriate Box)
Purpose of Building d4u� �Llr�J G Utility Authorization No.
Existing Service Amps / Ofd / ��y Volts Overhead 8__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 �GG// �iC!✓%%wG %-[/jfi�:�/
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers KyA
No. of Lighting Fixtures /�-
Swimming Pool Above In-
grnd. [Dgrnd. ❑
Generators KVA
No. of Receptacle Outlets 14J
No, of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets 6
No. of Gas Burners
PFIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Sel( Contained
Detection/Sounding Devices
Local ❑ Municipal []Other
Connection
No. of Ranges /
Total
No. of Air Cond. 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
Signsf BallastsLow
Voltage
nt
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
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 a- NO I have submitted valid proof of same to this office. YES pr NO
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE LK BOND ❑ OTHER C] (Please Specify) e711 C
Estimated Value of Electrical Work S _Zf-001 ac; xpirationate
Work to Start 1010' ,Klo/_ Inspection Date Requested: Rough A"I // C79`100eFinal
Signed under the penalties of perjury:
FIRM NAME V4' .fZv,,6/
N0. /�, / /- /G /
Licensee �/��
SignatureLIC. N0.
Address / Lli/ ,Idd ,176 Jj i.3%-�r..� /lif. Od/ Bus. Tel. No. l4ei
Alt. Tel. No ?*,7
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts GeneralwsTa ,man that my signature on this permit
application waives this requirement. Owner Agent (Please check one) d
Telephone No.
Signature of Owner or gent
0
c
The Commonwealth of Massachusetts-
Department
assachusetts Department of Public Safety N nit %o,
ocwwncy i Fr oneW+_3t5_.'
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 1/90 (t"&" !.land)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be pniw ted b aceord"Cll with the Maswchuselts Ekctrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORHATION) Date %�� of ff%'✓
City or Town of /')-1111ZY To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 14 J i
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes a- No ❑ (Check Appropriate Box)
Purpose of Building /� %t' �l/°`/ C Utility Authorization NO.
Existing Service yiej`3 Amps / ,la Volts Overhead 8--*6ndgrd ❑ No, of Meters_
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical WorktGL°/
No.
of Lighting Outlets
No. of Hot Tubs
No. of Transformers K A
No.
of Lighting Fixtures
/,]r
Swimming Pool Above In-
rnd. ❑ grnd. ❑
Generators KVA
No.
of Receptacle Outlets
j u
No. of Oil Burners
No. ofyEmer!:ncy Lighting
BatUni
No.
of Switch Outlets
No. of Gas Burners
iFIRE ALARMS No, of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No.of
fSal( Contained
Detection/Sounding
Local ❑ Municipal ❑ Other
Connection
No. of Ranges /
Total
No. of Air Cond. tons
No. of Disposals /
No, of Heat Total Total
PumpsTons KW
No. of Dishwashers %
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No.
of Water Heaters
KW
�. of o. o
Si ns Ballasts
Low Voltage
Wirinit
No.
Hydro Massage Tubs
No. of Motors Total HP
OTHER:
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 Q' NO I have submitted valid proof of same to this office. YES Q' NO
If you have checked YES, please indicate the type of coverage by checking the appropriate box./
INSURANCE D-BBOND ❑ C]OTHER (Please Specify) /a'/ e C
Estimated Value of Electrical
Work to Start
Work $ j.
(Expiration ate
Inspection Date Requested: Rough ��% // C77!/Final
Signed under the penalties of perjury:
FIRM NAME
I.I.C. NO. "� / ✓'!C'
Licensee ✓ /J SiWaature � 7 JLIC. NO.
Address / y/ .'� vii J4�✓ .ij �.3v —Z,t /1,e��d/tel Bus. Tel. No. �ci C ` j.
Alt. Tel. No -,i%
OWNER'S INSURANCE WAIVER: I m aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General wa, and t at my signature on this permit
application waives this requirement. Owner Agent (Please check one) c•
i Telephone No. PERMIT FEE•S`,e___)
/ Signature of Owner or gent
s
j
Location Avg .1 l
No. e2,Vl' Date
MGRTp TOWN OF NORTH ANDOVER
JI,
Certificate of Occupancy $
rev t� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #�, f v
!866'6
Building Inspector
G'
a -I 211rvX%iV&i11V1,q
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Map Number Paroel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zonin District Proposed Use Lai Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
_Required Provide Required Provided Required Provided
3c) DC7 3d I 'I
1.7 WaterSopp M G.L.C.40. S 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT Historic District: Yes _ No
2.1 Owner of Record
80.4 3S6
Name (Print) _ Address for Service:
2.2 Owner of Record:
,&?G� Llara� sow 3._C�.9 s%
Name Print - Address for Service:
SECT rvoN 3 -CONSTRUCTION SERVICES
3.1 LiWised Construction Supervisor:
e
Licensed Construction Supervisor: V
9Adre
d`�
tgnature Telephone
3.2
Improvement
--j i -Ne -n
Not Applicable ❑
61R/h'/<o
License Number
8
Expiration Date
Not Applicable ❑
Registration Number
7-7-67
Expiration Date
TOWN OF NORTH ANDOVER
.
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT W45
RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERNU NUMBER:
DATE ISSUED:L7
7
r��
SIGNATURE:7//7,
—
B 'n Co"issionerflqsMr of Buildings Date
a -I 211rvX%iV&i11V1,q
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Map Number Paroel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zonin District Proposed Use Lai Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
_Required Provide Required Provided Required Provided
3c) DC7 3d I 'I
1.7 WaterSopp M G.L.C.40. S 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT Historic District: Yes _ No
2.1 Owner of Record
80.4 3S6
Name (Print) _ Address for Service:
2.2 Owner of Record:
,&?G� Llara� sow 3._C�.9 s%
Name Print - Address for Service:
SECT rvoN 3 -CONSTRUCTION SERVICES
3.1 LiWised Construction Supervisor:
e
Licensed Construction Supervisor: V
9Adre
d`�
tgnature Telephone
3.2
Improvement
--j i -Ne -n
Not Applicable ❑
61R/h'/<o
License Number
8
Expiration Date
Not Applicable ❑
Registration Number
7-7-67
Expiration Date
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 buildina permit.
Signed affidavit Attached Yes ....... No ....... ❑
SECTION 5 Description of ProDosed Work (check all aoolicable )
New Construction ❑ 1 Existing Building V9 I Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑
Accessory Bldg. ❑ Demolition ❑ 1 Other K Specify Afie 2oceec_
Brief Description of Proposed Work:
A
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
23-646 DO
(a) Building Permit Fee
Multi lier
2 Electrical
/0040
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
Q
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT ORed,,
CONTRACTOR APPLIES FOR BUILDING PERMIT
edI, �e ,,1114/7S as Owner/Authorized Agent of subject property
Hereby authorize Ar -len �A e-'= // ft /eG. /N�'U /ZP to act on
My b half ' all mattersrelative to work au riz by this b V ding permit application.
/v - i9 -0.S
Si ature of Owner Date
SECTION 7b OWN
ER/A
UTHORIZED AGENT DECLARATION
I, 9161 Gtr/(/1,1i'7 Sdti/ 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
i't
ge,
Print Nauae
of Owner/.
10-19-6s
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRVMERS iST 2 ND 3EM
SPAN
DIlv1ENSIONS OF SILLS
DM ENSIONS OF POSTS
DR\, ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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CITY OF BOSTON
BOARD OF EXAMINERS
MAYOR
Lic. No B 18679
ISILLI E►tApGEOF
WOR CIDER PROVISIONS OF THE ACES
OF, b H R AMENDED.'
�, I + 6/13105 6I13/06
Class ! Due ycuea
E00 -Dale
BOARD OFMEXAMINERS
DAIA {•
T F SCOTT DARLING m
PATRICK TRACY
�rtC TDOOILili00t[IJCQLL/L a�a/!�(.CLdd�ICIQI.i[d `i
Board of Building Regulations and S*gndards
HOME IMPROVEMENT CONTRACTOR
Registration: 113679
007" 5. I
h,d
Type: 'Private Corporation
MAGEE INC
PETER MAGEE
95 CHESTNUT ST
WILMINGTON, MA 018&7
Administrator
_ - i a�,�iaaoac%uaella �
)ING REGULATIONS
BION SUPERVISOR j
21816
Tr. no: 275.0
Rngar
PETER R MAGEg4
95 CHESTNUT ST
WILMINGTON, MA 01887 Commiaslorier
1
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
-
'. ; s Boston MA 02111
' i'' S www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: S 7—
City/State/Zip:
Are you an employer? Check the appropriate box:
. [9 I am a employer with _3— 4. ❑ 1 am a general contractor and 1
employees (full and/or part-time).*
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F-1 Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also till 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.
Contractors 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:s�•ysv/2/,'ye
Policy # or Self -ins. Lic. #: VC 1 1Expiration Date:
Job Site Address:,( d��Q Stz , ,U, A1y41ot/e2 City/State/Zip: i(/ ,•%y�t/��
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 hereby certify u!!1kj the pain penalties of perjury that the information provided above is true and correct.
Ph
Date /G /Y—
Official use only. Do not write in this area, to be completed by city or town qffllcial.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. .
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An 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 till 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 tilled 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
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
at: 31! F4 S is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
:; 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
'V 7( �� 14:��
d17-387-3706) (Location of Facilit
4
Sig ature ermit Applicant
Fire Department Sign off:
Dumpster Permit
Date
WIZ
I'1U1I1. 101 24U LUUI lu JrU u:jl U.JJU I ,. J, _i✓ 1.1111- — , , — 11. , —1
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID C
DATE (MMroDIYWY)
MAOPID 1
05/16/05
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
DATE MMIDDIYY
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Thomas Gregory Associates Inc.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
601 Edgewater Drive 3235
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
01/01/05
Wakefield MA 01880
Phone: 781-914-1000 P'ax:181-246-2601
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURERA: "''Western World Insurance Co.
INSURER B: Citation Insurance Co.
Magee Incorporated DBA
Magee Builders
95 Chestnut Street
Wilmington MA 01887
INSURER C: Granite State Insurance Co.
INSURER D:
INSURER E: ,
COVERAGES
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 TO 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
S
TYPE OF INSURANCE
POLICY NUMBER
DATE
DATE MMIDDIYY
LIMITS
A
AUTHORIZED RESENTA
GENERAL LIABILITY
g COMMERCIAL GENERAL LIABILITY
CLAIMS MADE Fx-� OCCUR
NPP925106
01/01/05
01/01/06
EACH OCCURRENCE $ 100000
PREMISES (Ea occurence) $ 50000
MED EXP (Any one person) $ 5000
PERSONAL & ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
GEHL AGGREGATE LIMIT APPLIES PER:
POLICY PEa D LOC
PRODUCTS • COMP/OP AGG $ 1.000000
B
AUTOMOBILE
$
X
}{
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS(Per
04MMJNY2338
12/17/04
12/17/05
COMBINED SINGLE LIMIT
(Ea accident) $
BODILY INJURY
(Per person) $ 250000
BODILY INJURY
awdert) $ 500000
PROPERTY DAMAGE $ 250000
(Per accident)
GARAGE LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
AUTO ONLY. AGG $
EXCESSAIMBRELLA LIABILITY
OCCUR F] CLAIMS MADE
DEDUCTIBLE
RETENTION $
EACH OCCURRENCE $
AGGREGATE $
$
$
$
C
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
If yes. describe under
SPECIAL PROVISIONS below
WC6928234
01/01/05
01/01/06
X TORY LIMITS ER
E.L. EACH ACCIDENT $100000
E L DISEASE - EA EMPI.OYEE $ 100000
-"-
E L DISEASE - POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
0000000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
To Whom i t Map concern
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED RESENTA
ACORD 25 (2001108) ,j(,y,,,,.A O ACORD CORPORATION 1988
This fax was sent with GFI FAXmaker fax server. For more information, visit: hfp://www.gfi.com
Location 3 S(,
No. Qn-�;—
V
Date 1 1 _ la -OZ -
TOWN
a-Oa
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # �Si99&I 03
160u5 AA(CQ,,
Building Inspector
a
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
T�t15 fbr Qlf�iCtAI _ SC tilnI
BUILDING PERMIT NUMBER:r7DATE ISSUED:
SIGNATURE:
Building Commissioner/In t of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
35-(,o &0
1.2 Assessors Map and Parcel Number:
038 005y-
Map Number Parcel Number
N0r l O J P_C,
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot _Area (s Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required v'� ReClUired
Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54j 11.5. Flood Zone Information:
Public ❑ Private ❑.. , Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record
RSCS ; y) 1 i r4 WtS 0 ►rl e2 (D Q A Si -
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address r
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
'R)G�4
Not Applicable ❑
13 7/f —3
Company N me
Z /0��c L
Registration Number
Address
A"'� C9 Y ' `'
Expiratioif Date
Signature Telephone
00
M
Z
O
v
rn
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 ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
0 " 0 V -e
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
�� O
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
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/AUTHORIZED AGENT DECLARATION
I, .31 -Gz' Lo.-� 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
5/'11 A'1A
1am
Prie 0 Z
Signature of Owner/A ent Date
NO. OF STORIES SIZE -
BASEMENT OR SLAB
SIZE OF FLOOR UMBERS 1sr2 No3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I 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: / `Gt QOFP/ S
Address 2 % f /9rK 54
Company name:
Address
City: Phone #7
Insurance Co. Policy #
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_wtell_as_civil.Renattiesinsheinrmiofa_S_T_OP WORK..ORDFRand..a.fine,of._(.$1D.0-00)-a-daye .against.mI
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify gWer the pains
Y
penalfies�pf perjury that the information provided above is true and correct _
SIU//� c(/_ Date 1� `Z —e
)2—
Print
Print name phone #
Official use only do not write in this area to be completed by city or town official'
City or Town PermMcensinq
Building Dept
E]Check if immediate response is required E] Licensing Board
p Selectman's Office
Contact person: Phone #: o Health Department
❑ Other
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4062
Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that..F 5.,Y
............................................ ... ........................
has permission to perform ......... &-Z�J.!�X
wiring in the building/hof .... .................................
at ...... .......... it-.................. North Andover, s.
Fee .... Lic. No/y,;U( ............ . ...... . ............ ..........
tcmicAL INSPE R
Check # 75��
Commonwealth of Massachusetts Official Use O l
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 C 12.00
(PLEASE PRINT IN INK OR"givesno
IN. ORMATION) Date:_ a
City or Town of:e_— To the Inspector of Wires.-
By
ires:
By this application the undersighis other intention to perform the electrical work described below.
Location (Street &
Owner or Tenant
Owner's Address
Telephone No. LJ"/X d,5er'—
Is this permit in conjunction with a building permit? Yes ❑ No LY (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
{ Location and Nature of Proposed Electrical Work:
a
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
Installation of Securi
No. of Meters
No. of Meters
wstem ti ,M
Com letion of the followin table ma be waived hi, the Ins ector o Wires
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In -"N
rnd. rnd. ❑
-0—.0t mergencyiging
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No.__oT Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alertin Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑Other
Connection
No. of Dryers
Heating Appliances K`,4,
Security Systems:
No. of Devices or Equivalent
No. o Water KW
Heaters
No. o No. o
Si ns 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 as required by the Inspector of Wires.
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:)
Estimated Value of lectri al Work: - (When required by municipal policy.) (Expiration Date)
Work to Start:Wnpen
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under TValties ofperjury, that the information on this application is true and complete.
Licensee: John S. Bassett Signature LIC. NO.: 1533C
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 603 594 SQ28
Address: Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Lid see 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 a ent.
Owner/Agent
Signature Telephone No.PERMIT FEE: $ ,
aAz��'(�,�,Ze�,` v BUILDNORTIi
�jI 1 1 BUILDING PERMIT ��ct`yeD bv°�O
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
"
Permit No#: / "/ Date Received RAo ED 4y
q—z; CHU55C
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION �5-� < 5f—
Print
PROPERTY OWNER✓
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
pROne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
A+ (Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone: e?
Address: 3rd A(k+ sr-
Contractor
rContractor Name:kfAj6 „��1>ehone: 2 1� Z<'
Email:
Address: V-� A«= �,6 kAWE g" wtsf- Olf 32—
Supervisor's Construction License: -40 k5 I"S— Exp. Date: AQ •Z(.
Home Improvement License:. 19-3 X7 i Exp. Date: !9` 2��7
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
�.
Total Project Cost: $ FEE: $
Check No.: /` ��,�� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Well ❑
Private (septic tank, etc. ❑
Certified Plot Plan ❑ Stamped Plans ❑
Tanning/Massage/Body Art ❑
Tobacco Sales ❑
Permanent Dumpster on Site ❑
Swimming Pools ❑
Food Packaging/Sales ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Manning Board Decision:
t
Conservation Decision:
Com
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIREID,EPARaTMEN1T TempDurnpster onsitei �yesa__`
Located 384 Osgood Street
= a --
LoeatedtaY t
F.i;re,DepOft inent si
gnaturo/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on. Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, rust or service drop requires approval of
Electrical Inspector Yes No
®ANGER ZONE LITERATURE: lies No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Pennit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
�. Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
* Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
M ust be submitted with the building application
Doc: Building Permit Revised 2014
Location
No. 1
Check # if ' ,:
Date �a
,'/?`!h
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ '
Building Inspector
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DISPUTES
THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN
ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS
CONTRACT, PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE
ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY
OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS
REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO
SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A
Pella Windows & Doors
Contractor
�tJ 1
Homeowner
NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE
AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT
INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE
ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT
SEPARATELY SIGNED BY THE PARTIES.
NOTICE OF CANCELLATION
Date of transaction: 4/7/16
You may cancel this transaction, without any penalty or obligation, within three business
days from the above date.
If you cancel, any property traded in, any payments made by you under the agreement,
and any negotiable instrument executed by you will be returned within ten business days
following receipt by the seller of your cancellation notice, and any security interest
arising out of the transaction will be cancelled.
If you cancel, you must make available to the seller at your residence, in substantially as
good condition as when received, any goods delivered to you under this agreement; or
you may if you wish, comply with the instructions of the seller regarding the return
shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up
within twenty days of the date of your notice of cancellation, you may retain or dispose
of the goods without any further obligation. If you fail to make the goods available to the
seller, or if you agree to return the goods to the seller and fail to do so, then you remain
liable for performance of all obligations under the contract.
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation
notice or any other written notice, or send a telegram to
Pella Windows and Doors, at 45 Fondi Rd., Haverhill, MA 01832
not later than midnight of
transaction above).
4/11/16
I hereby cancel this transaction.
(Date) (Buyer's signature)
(three business days from the date of
The Commonwealth o Massachuseas
Departiitent of f •Industrial Accidents
- Office of •Investigations
1 Congress Street, Suite .100
Boston, MA 02114-2017
i4%w. inassogovIdia
Workers' CompensationInsurance Affidavit: Builders/Contractors/Electricians/PlumbersApp icalrnt Ignformatiorn Please Print LeLyibly
Name (Business/Organization/Individual):
Address:
Ci
Phone M
Are you an employer? Check the appropriate box:
R'I am a employer with -- — 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
. ❑ .I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.]
These sub -contractors have
employees and have workers'
comp. insurance.$
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance reouired_1
Type of project (required):
6. ❑ New construction
7. [&Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
1 l.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
t
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Tconn•actors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp, policy number.
I am an employer that is providing workers' compensation: insurance for iicy employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:_40C)0 L4 0 10 4 Expiration Date: % 1
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and Penalties of Perillry that the information provided above is true and correct
Siunature: _ �—
Of
ficial use only. Do not write in this area, to he completed by city or town offocial
City or Town:
Issuing Authority (circle one):
1. Board of health 2. Buildin De art t
6. Other
g p men
Permit/License #
City/Town Clerk 4. Electrical Inspector y. Plumbing Inspector
CERTIFICATE OF LIABILITY INSURANCE NO12015
THIS CERTIFICATE 0 ISSUED AS A MATTER OF INFORfIflAT10N ONLY AND CONFERS 90 RIGHTS UPON THE CERT-- P
IFICATE HOl�EI;;. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TFIE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETiN�EN THE AGE AF INSURER ($), HE IO ICES
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER
IINPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(iesl must he endorsed. IF SUBROGATION 18 WANED, subject to
the terms and conditions of the policy; certain Policies may require an endorsement. A slateenent on Ih)s certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Fad C. Church, Inc Z
ponlhyA CodeO CIC, RPLU
41 WeOmanSheel N
LOWA MA 01051 Pg7g 3227231
(600) 225-1065 FACH No : (910) 454-1865
AOaRESS_ 1bh0@IradMhurrh com
INSURED
New England Window A DaorLLC
45 Fondl Road
Havefilk MA 01032-1302
CiGzeaslnsraance CampanyhFAmadm
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSU::1)70—THE INSURED
REVISION
ABO FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 BYPAID CLAIMS.
uTR TYPE OF INSURANCE ADD SUBR POLICY EFF POUCY EXP
GENERAL LIABILITY POLICY NUMBER MMIDO rrlDp UMTS
% COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g 1,000,000
DAMAGE TO RENTED
CLAIMS -MADE ID OCCUR PREMISES Es accunence S 100,000
A ' R . COOD01 ZBNOIS1407 7/1/2015711p�116 MEDEXP(An onepamon g 10,000
PERSONAL 5 ADV INJURY R 1.000,000
LIMIT APPLIES PER
AUTOMOBILE LIABILITY
13
ANY AUTO
ALL OWNED
SCHEDULED
AUTOS
AUTOS
HIREDAUTOS
AUTOS��
UMBRELLA LIAR
OCCUR
EXCESS LIAR
-!C.-
!C ..._
AND EMPLOYERS LIABpJty
B OFFiNY cERIMmsERPEARCWDEm CUTIVEa NI
(Mandatory In NH)
400040101 I 7/112015 I 7112016
DESCRIPTION OF OPERADONS[LOCATIONS IUERICLES(AtiachACOR0101,AddGonalRemalts Schedal%almore 5Pacei rgWred(
TE
$ 2,000,000
$ 2,000.000
E
BODILY INJURY (Perperson) $
BODILY INJURY(Perauidenl) $
8
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE 1MLIL IRF mrr RveOL-n ,M1
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