Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 363 WOOD LANE 4/30/2018
N 0 QQ m ., IS � 0 I� v z m O N O t.� N w S O J � i � � o z b i I e Date.................................................. NOR7N 03 TOWN OF NORTH ANDOVER * * PERMIT FOR GAS INSTALLATION 88AC/1U8� _ This certifies that .��.`..e— tr c ...............................................�....................... has permission for gas installation ..... - ...!! - .... 4 ... )P.�y in the buildings of ..... . �n..y i�.�?a/�........................................................................... at .... b= .... ��R.,.:?�+�....... ......................... North Andover, Mass. 00 Fee. .. Lic. No....��.3 ..... ................................................................ � f GAS INSPECTOR Check # Ij (0� 0222 TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 3/24/2014 PERMIT # L/ JOBSITE ADDRESS L363 Wood Lane OWNER'S NAME I Kristen Koukias OWNER ADDRESS Same 94— OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIALQ NEW:E] RENOVATION: El REPLACEMENT: APPLIANCES -1 FLOORS BOILER BOOSTER CONVERSION BURNER DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNJVENTED ROOM HEATER WATER HEATER OTHER PLANSSUBMITTED: YES® NO(j BSM 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [3 NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE # 8736 N RE MP ED MGF ® JPEI JGF ® LPGI ® CORPORATION E1# 3285C PART SHIP ®# LLC ®# COMPANY NAME: RH White Construction Co ADDRESSI 41 Central St CITY Auburn STATE MA ZIP 01501 TEL (508) 832-3295 FAX 508-926-4347 CELL 508Y832 4614 EMAIL JMarino@RHWhite.com 0\\t W F O z z 0 F U W C�. a� d z w o❑ a Z z o y� w � ~ w o o aLLI w � v' v) W N a w a w Cx o W U) a 0 a a oCA a a co w W LL on w o z z 0 H U w a z 0 x um��fZ co LO 'CD. JX � ..�*'�'. ;it:;�.ir• � ;i:, `.",: 'iji:: b Hyl 1°�jf.�r�: Q • Win Lu LL > b Q� ¢ H o of Q = Ce Z . . w . w�n . E W al '.rf), i. i m 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 A <F® CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polioy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certiflcate does not conferrights to the certificate holder in Ileu of such endorsement(s). lnilli4 09 MBsedehueetts, Inc. C/o 26 co -Awry Blvd. P. 0. Box 305191 Nagbville, TN 37230-3191 R. K. White Conct:ruction Company, Inc. 41 Cener*A Street P. 0. Box 257 AubUrn, MA 01501 iNSUHhK(3)AFFOfiDINGCOVERAGE I NAICa INSURERA!The Charter Oak rizo Insurance Company I 25615-001 INSURERS: TraV019> 2 property Casualty CCM>ipany of Am 23674-003 INSURER C:NatiOnal Union Fire Snsuraneo Company Of 19445-001 INSURER D: Travelers Indam ty Company 25658-001 INSURER F; v,.r. F, WM1r., wUMULa c AVA0 roou KEV15IVN NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 18SUCD 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, LIM17S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NSR TYPrOrINSURANCE DD SUB pQLIGI NUMBER POLICYEFF POLICYEXP LTL vuvnLIMITS A GENERAL LIABILITY VTC2000 977X9948-13 9/1/2013 9/1/2014 EAACCHOCCURRENCE T_ 2 000100 $ COMMFRCIAL GENERAL LIABILE ITY PREg �Ee oceuiencr.S 3 0 D .QQ � CLAIMS -MADE OCCUR MEDEXP(Anyone arson 10100C PERSONAL&ADVINJURY s 2 nnn nnn GEN'L PER; D I WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY YYYYYY��/��/ NNNNNN D ANYPROPRIETOR(PARTNF_PIEXECUTIVE NIA OFPICERMEMEER EXCLUDED? Mandatonnrr In NH) iyee,deadrlbeundnr U�esUKnl I iuN Uf OPERATIONS below Evidence of Inmurance PRODUCTS 977K955A-13 9/1/2013 19/1/2014 2,000,000 BODILY I NJURY(Per person) IS 130DILY INJURY(Peracaldent) $ 888766140 19/1/2013 19/1/2014 VTRK11B 920SA185-13 X9/1/207.3 19/l/2014 9/1/2014 A7 VTC2KUB 92031A-13 19/1/2013 E.L. Acord DIAEASE-EA EMPLOYE. DISEASE- POLICY LIMIT morespeca 11000,oa0 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZEDREPREBENTATNE COAI:4197604 Tp1:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION, All rights reserved. ACORD 25 (2010!05) The ACORD name and logo are registered marks of ACORD AUTOMOBILE LIABILITY X ANY AUTO NED AUT08ULED AUITOS X HIREDAUTOS X AUT08AUTOSNON-OWNED X Com Dad X Co11 nee Anoo C UMBRELLA LIAR X OCCUR X EXCESSI CLAIMS -MADE DED I $ RETENTIONS lo,001 D I WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY YYYYYY��/��/ NNNNNN D ANYPROPRIETOR(PARTNF_PIEXECUTIVE NIA OFPICERMEMEER EXCLUDED? Mandatonnrr In NH) iyee,deadrlbeundnr U�esUKnl I iuN Uf OPERATIONS below Evidence of Inmurance PRODUCTS 977K955A-13 9/1/2013 19/1/2014 2,000,000 BODILY I NJURY(Per person) IS 130DILY INJURY(Peracaldent) $ 888766140 19/1/2013 19/1/2014 VTRK11B 920SA185-13 X9/1/207.3 19/l/2014 9/1/2014 A7 VTC2KUB 92031A-13 19/1/2013 E.L. Acord DIAEASE-EA EMPLOYE. DISEASE- POLICY LIMIT morespeca 11000,oa0 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZEDREPREBENTATNE COAI:4197604 Tp1:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION, All rights reserved. ACORD 25 (2010!05) The ACORD name and logo are registered marks of ACORD Date ...10h l !4 .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......................... ;S j lAk-4 ............. F� .................................................... hart permission for gas installation 5.. X1 2.........I ............................. inthe buildings of ........................................................................................... a ....................... LA) ........................................... Npfth Andover, Mass. Fees . ..... Lic. No. � Y ..... .... .......................... GABS SPECTOR Check # 9576 Date ..%U1'F/1 T.. 10 7 9,6 "SRT" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'yam •o;:;.e:"•'"t�°j Thiscertifies that .......:)............................................................................ has permission to perform...rr':.�.�����............................................ dumbing in the buildings of............................................................................................. at . ,:�...WmIko.................................................aortAndover, Mass. Fee..l rw... Lic. No./.!?`�.. ..................................................P' NBING''�INSPECTOR Check # INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES K NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY k OTHER TYPE OF INDEMNITY Df BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i ompliance with all �ntprovlslonofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ �An ly s �'c r+r/t6/lf I LICENSE # o z SIGNATURE IMPN— JP p CORPORATION _J # PARTNERSHIP r --"#® LLC I COMPANY NAMEADDRESS CITYn r rr i Slb�/ �, STATE . VLA ZIP TEL 1 6o-2 FAX j CELL 16v� �Zy7EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY co -L Ai'lave IMA DATE /o - ( PERMIT# JOBSITE ADDRESS 6 3 0000 LA A16 ( OWNER'S NAME /cd�lca�S ADDRESS fa , tiL TEL �7 y 4 4i� FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL NEW: D RENOVATION: ® REPLACEMENT:, PLANS SUBMITTED: YES 0 NOD FIXTURES I FLOOR--> BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB —1 _____j —_f _f CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ I _., i _._ ._ M1 _ DEDICATED GASIOIUSAND SYSTEM ---I—Y —j .--j f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM j E DEDICATED WATER RECYCLE SYSTEM I._.___._..1 ---j __( f __._ I _I �I .i .uj I DISHWASHER { .._... f ._w. f I ._._J=f INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES K NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY k OTHER TYPE OF INDEMNITY Df BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i ompliance with all �ntprovlslonofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ �An ly s �'c r+r/t6/lf I LICENSE # o z SIGNATURE IMPN— JP p CORPORATION _J # PARTNERSHIP r --"#® LLC I COMPANY NAMEADDRESS CITYn r rr i Slb�/ �, STATE . VLA ZIP TEL 1 6o-2 FAX j CELL 16v� �Zy7EMAIL FM - INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES K NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY k OTHER TYPE OF INDEMNITY Df BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i ompliance with all �ntprovlslonofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ �An ly s �'c r+r/t6/lf I LICENSE # o z SIGNATURE IMPN— JP p CORPORATION _J # PARTNERSHIP r --"#® LLC I COMPANY NAMEADDRESS CITYn r rr i Slb�/ �, STATE . VLA ZIP TEL 1 6o-2 FAX j CELL 16v� �Zy7EMAIL W F O F U W P-1 A W ' o El z N ❑ QOD p W O Q w W O a W Ocnuj aa.a a 0 o w� a � U LL (L a Cf) ui z w W F O Z O F U a C7 a a p� 0 x The Commonwealth ofMassachusetts Department ofIndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2b, Name (Business/Organization/Individual): u 4.,- a' Fl, fly /J- Address: t Address: GllCyl ,� 01 City/State/Zip: I S1`OLc j Ne Phone #: 6 o? Yi yG Y Z Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. [ 1 am a sole proprietor or partner- have Hired the sub -contractors listed on the attached sheet. t �• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. F1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13. Other 'f` comp. insurance required.] *Any applicant that checks box #I 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic. 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 requiredunder 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby cert1 oder thepains a penalties ofperjury that the information provided above is true and correct Signature: Date: Phone #: O :7 F 2 L/G �12 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone M. _ 1 Information and Instruction. -s 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 -contractors) 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been. officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Mossachusetts Department of Industrial .Accidents Office of Investigations 6.00 Wasbington Street Boston, MA 02111 TeX, # 617-727,4900 owt 406 or 1-877-.MASSAFE Revised 5-26-05 Fax # 61.7"727-7749 www.mass.gov/dia LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _.� —v.._ I _ _ _ _ _ I _ TES UNI HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - - - - - INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E3 OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _l AGENT SIGNATURE OF OWNER OR AGENT 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 complia ce with all Pert. ent rovisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� 2 PLUMBER-GASFITTER NAME VAlm ct_.- _�hT�> s LICENSE # p SI NATURE MP P MGF Ej JP El JGF LPGI *CORPORATION Ej# © PARTNERSHIP [J#= LLC E]# COMPANY NAME: �S _ _ ADDRESS CITY )STATE ZIP 6: L;TEL111,19-7 36'Z FAX--- - CELL EMAIL�_-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNERADDRESS TYPE OR PRINT CLEARLY CITY d MA DATE % 09,- l y y� PERMIT # JOBSITE ADDRESS 361 W 0100 UA1VOWNER'S NAME s•Z--eA/1 AA/ 4pV14hr __96 W000 I-A&F, TELred? GOrGZ Sr&JFAX OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALW NEW: RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES Z FLOORS— BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER -- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER_- FIREPLACE FRYOLATOR FURNACE GENERATOR r-_ 1.- -,i _.—.,1 a a hY -! —_ _ i r _ ��- 1. _I GRILLE INFRARED HEATERt- LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _.� —v.._ I _ _ _ _ _ I _ TES UNI HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - - - - - INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E3 OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _l AGENT SIGNATURE OF OWNER OR AGENT 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 complia ce with all Pert. ent rovisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� 2 PLUMBER-GASFITTER NAME VAlm ct_.- _�hT�> s LICENSE # p SI NATURE MP P MGF Ej JP El JGF LPGI *CORPORATION Ej# © PARTNERSHIP [J#= LLC E]# COMPANY NAME: �S _ _ ADDRESS CITY )STATE ZIP 6: L;TEL111,19-7 36'Z FAX--- - CELL EMAIL�_-- O zz z w z O W �El >- O � W w O H w o- z qt � CO w =CO w w co �+ w CO d P4 cn O a U J CL a E w x w I -- Un H O z 0 H u a un x • a The Commonwealth of M'assachuseiis - -' Department offyidustriglAceld nts Office of Invesfigafions 600 Washington Street .Boston, MA. 02111 www.rnass gov/clia Workers' Compensation Insurance Affidavit: Suateiers/Contractors/Electr iclans/.Pliiinbers Applicant Xnformation Please Print Legibly Name (Busynessforgani'zation/fndividual): Address: % /\1,1C4 O/C -r City/State/Zip. J 14� j• < LL -t/ N* Phone #: CPO 7 F z 6 Ci 2 Are you an employer? Check the appropriate box: Type of project (required): 1. [( I am a employer with 4. 0 I am a general contractor and' 6. E] New c6nstruction employees (full and/or part time).* have hired the sub -contractors listed on the attached sheet. 7• F1 Remodeling 2.liQ'I am a sole prroprietor or partner ship and'have no employees These sub -contractors have 8. E]Demolition working for me in any capacity. workers' comp, insurance. g, E] Building addition (No workers' comp. insurance 5. ❑ We are a corporation and its 10.[j Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised.their right of exemption perMGL 1l.[] Plumbing repairs or additions myself. [No workers' comp. c. 152, §I(4), andwehaveno [No workers' 12,[] Roofrepairs insurancerequired.] i employees. I -her comp. insurance required.] 'Any applicant that checks box4f must also fill out the section below showiagtheir vrorkers' compensationpoHcy information. 'Homeowners who submittMs affidavit indicating they 9• dying all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that cheektbis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that isproviding workers' compensation insurance forrny employees. BeImp is thepoliey imd job site infarmation. Insurance Company Name: Policy ## or 8 elf -ins. Lir. Expiration Date lob Site Address; Ciiy%State/Zip: Attach a copy of, the workers' compensatlon-pollcy declaration page (showing the policy number and expiration date). Failme to secure coverage as required.under Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/ox 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do Hereby Gertz under the pains and penai'ties of perjury that the information provided above is true and eorrect. sig -nature: L- -- Date: z n '711 Phone 0. 6d,,7 --7f2- yc y2 official use oRy..Do not write in this area, to be completed by city or town ofcial. City or Town. 7Permit/License # Issuing Authority (circle one): 1. Board of Health 2.130ding Department 3. Cityffown Clerk 4. Electrical Inspector S. 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 id the service of another under any contract of hire; express or implied, oral orwritten." An ernploydis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foxegoirig engaged in a j oint enterprise, and including the legal repxesentatives of w deceased employer, or the receiver or- trustee 6f an individual, partnership, as§ociation or other legal entity, employing ennploy' as. 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 lie -ening 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, MOL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract fbr the performance ofpublic work until acceptable evidence Of compliance with the insurance requirements of this chapterhave been presented to the contracting authority." Applicants Please fill out the workers' coinpensaiion affidavit completely, by checlang the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphonenumber(s) alongwiththeir ceitifcate(s) o£ insurance. Limited Liability Companies (LLC) or Limited Liability Partuerships (LLP) with no' employees other than the members or partners, are not required to carry workers' compensation insurance. if au LLC or LLP does have employees, apolicy is required. Be advised thattbis affdavit maybe submitted to the Department of 7ndusfxial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit: '.the affidavit should be xetaxn ed to the city or sown that the application fox thepexmit or license is being requested, nod the Department of Industrial Accidents. Shouldyou 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 andprinted legibly. The Department has provided a space atthe bottom of the affidavit for you to fiH 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, as applicant that must submit multiple pemsit/license applications in, any given year, need only submit one affidavit indicating current policy Information (if necessary) and under "lob Site Address" the applicant should write "all Iecaiions in (city or towir):' A copy ofthe affidavit that has been officially stamped or marked by the city or townmay be provided to the applicant as proof that a valid affidavit -is on file for future permits or licenses. Anew afixdavit must be filled out each Year. Where a home ovmer or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves ate.) said person is NOTrequired to complete this affidavit. The Office ofinvestigations would Moto 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. Tho Commonr�aTt ol'l� ssael?vSPtls De,padmu,Tat of Industrial Acoidonts Office Qi AVIPSUga-am 600 Wak gtw S17reQ.t .Baw1on,, 02111 ` , # 617.72.7 900 o 4Q6 ox 1-877�M S�l� Revised 5-26-05 FaX # 617-727-7749, www-mms,govIcha r • ,aORTIi pf ,..o ,e1h0 O A 'o,,r�o ,SSACMUSEt Date .� .'.. �..... �... �....... TOWN OF NORTH ANDOVER PERMIT FOR- WIRING This certifies that J. .a Vin!. ........-/LA.....r................................ has permission to perform ... b..0 -L...... .1! 1.!' . �.'........................... 11 wiring in the building of..,'�....... kms.............. at ........ :Gt.)ra.#.lr....Z..✓........................ . . North Andover, Mass. Fee ..tfT::77...... Lic. No. ELECTRICAL INSPE O •� Check # p rr 8278 Date ../�....��../, .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 41.. has permission to perform ............................... wiring in the building of...., ✓ . "9�......., 'fit,,. .........lJ.......d Uc ..............:................ . North Andover, Mass. ........./y 2. -�Fee J .......... Lic. NW .�-'Q.. ...,,U _ LEC'rR AL INSPECTOR Check* 9 � 7c 11 A � Commonwealth of Massachusetts Official Use Only — Permit No. zce Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code �)), 27jC� 12� (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: Y City or Town of. NORTH ANDOVER To the Inspector 6f 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 sh Owner's Address 5c,� Is this permit in conjunction Purpose of Building �l>2 - Existing Service Z ow Afnps / Z-)/ ZYb Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. Ys F No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ff Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. EJ o. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners % No. of Detection nndInitiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number Tons I.KW No. of Self -Contained 0) Detection/AlertingDevi ce CCt^� No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritNo. o De iIIe s or Equivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNo. of Devices or E u valent OTHER: JAttach additional detail if desired, or as required by the Inspector of Wires. `lt Estimated Value of Elec ical Work: (� 0�., �,b (When required by municipal policy.) Work to Start: /61rj / y 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 cove age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 'certify, under the pains and penalties of pe%�, that the information on this application is true and complete. FIRM NAME:. rc % In I LIC. NO.: l 7Z3Fl4 Licensee: 1Va„01J, Wr C. Signature/,/64/ 1 LIC. NO.: Z %S/YZ-- (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No. :QZY-3'7 Z-/,/, `t Address: Alt. Tel. No.17L- io t - Z/ � -7 *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic 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: $ Signature Telephone No. J� ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 4 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;Ian 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Inspectors Comments: Failed 0 Re- Inspection Required ($.) ❑ Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed D Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass❑' Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comment toll a Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department of IndifstritilAccidiks Office of Investigations 14 600 Washinglon Street Boston, MA 02111 UT www.massgovIdia WQrkexs' Compensation Insurance Affidavit: Builders/Contractors/ER Anniieanf Information Name Address: `7 i 3 W C.. ISG City/Slate/Zip: f I�Y'�9� �l t phone #: Are you an employer? Check the appropriate box: Type of project (required): F 1. I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/ox pari time).* have hired the sub -contractors 7• � emodeling 4 2111 am a sole propxietor or partner listed on the attached sheet x These sub -contractors have 8. ❑ Demolition ship and'haveno.employees working for me in any capacity. workers' comp. insurance. 9. Building addition [NO wort Ors' comp. insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL . 11.❑plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), andwehaveno UP Roofrepairs insurancere ed. ] employees. [No workers' 13.[:] Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensationpolicy information. i -Homeowners who submit this affidavit indicating they g're doing all work and then hire outside contractors muse submit anew 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 fop my employees -8 e1OW is the policy andjob site information. /d Insurance CompmyName:. /�1SG12'i /��c ✓o l v 1)dJ17 (,� r Policy # or Self fns. Lic. #: 1/�� ✓� y� Expiration Date: 31 ZO 1 S Job Site Address: -363 1*tJ00-'!?/ / e%t j% ,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 requ*edunder Section 25A ofMGL c.152 can lead to the imposition, of criminal penalties of a fine up to $1,500.00 and/ox ane -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 ofthe DIA. for insurance coverage verification. X do Hereby cert under the pains ar�d penalties�of perjury that the inforaation provided aboue fs true and correct. 1-- A//! _ _ Date: �Gl ?fl -' �6 z Official use only. Do not write in this area, to be completed by city or town off City or Town: Permit0cense 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Inspector S. plumbing Inspector 6. Other Contact Person• Phone Information and Instrnctions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employecs. Pursuant to this statute, an employee is defined as "...everyperson in the service of another under any contract ofhire,• 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 Tore going engaged in a joint enterprise, and including the legal representatives of a: deceased employer, or the xedeivex oxtrustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore than three apartments andwho 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 orbuilding appurtenant thereto shallnot because of such employment be deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local Jim -using 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 0 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supplysub-confractor(s) name(s), addresses) andphonenumber(s) along with theircertificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members ox partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicyisrequired. Ba advised that Us affidavit may be submitted to the Department of Tndusfrial 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 chat 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 Toym Officials Please be sure that the affidavit is complete andpxinted 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 "fob Site Address" the applicant should wxite "all locations in (city or town): ' A copy of the affidavit that has b een officially stamped or marked by the city or town- may be provided to the applicant as proof that a valid affidavit -id on file for future permits or licenses..A. new affidavit must be fdtgd out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture U.e. a dog license orpermit to burn leaves etc.) said person is NOTrequired to complete this affidavit. The Office Of Investigations would like to thank you in advance for your cooperation and should you have any questkus, Please do nothesitaieto give us a call. The Department's address, telephone and fax number: Thc) Commoitwealthofyassacl?use s Depar(ment ofIndmWal.A,celde to of ace of Investipaoft 600 Washtg Qa Ste, -a BW04, MA 021 It T01 # 61`x -7-2-'x_4.900 PA 406 or X-87MWqM Revised 5-26-05 Fax ' '�.�xtass,govfct�a HKCL. 773 WASHINGTON `HAVER`H I LL ----- . --"# %,ol•-sdssacnusetts Official Use Only Y Department of Fire services 9 J Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked V. 1/071 r" �D r APPLICATION FOR PERMIT TO PERFORM ELE (leave blank All work to be performed ;n accordance the Massachusetts Code CTRICAL WORK (PLEASE PRINT INDX OR TTPE ALL INFO (MEC), 527 CMR 12.00 City or Town o£ NORTH ANDOVER ONS. Date' BY this application the undersigned gives notice of his or her To the Inspector of Wires: Location (Street & Number 3 6 intention to perform the electrical work described below. C� oo �.'A 'N e- Owner or Tenant �. Owner's Address Telephone No. IS this permit in coniunction with a building permit? Purpose of Building_ • ��,,� �„� M i I PO�1 Yes N0 F](Check Appropriate Box) Existing Service Utility Authorization No. AmPs _Volts Overhead❑ Undgrd ❑ No. of Meters New Service Amps / Volts . Number of Feeders and Ampacity Overhead 0 Undgard ❑ No. of Meters Location and Nature of Proposed Electrical work: of Recessed Luminaires No, of Luminaire Outlets No. of Luminaires No, of Receptacle Outlets .40. of SviZtches No. of Ranges No, of Waste Disposers No. of Dishwashers of Dryers Heaters KW No. Hydromassage Bathtubs OTHER: vel � Rav Co letion o the followin No. of CeL-,5utsp. (Paddle)'Fam 1T0. of Hot Tubs iwimming Po0-1 Above d. ❑ � d, ❑ bio. of OR Bua-ners . io. of Gas BuLmers 3a. of Air Cond, otal leat um To P umber Tons Totals: - - pace/Area Hea�g KW ] testing APpHances KW n. of n. of Si s Ballasts ] o. of Mors Total HP table may be waived by the Inspector o No. of otal Transformers KVA Generators KVA n. o mergeney g Batte Unita F]REALARMS No. of Zones o,o etectl and I.Ld isi� Devices vo, of Alerting Devices o. of -Contained )etection/Alerfi ¢ Devices local❑ Municipal Connection ❑ Othe•. security Systems; No. of Devices or Egnrvale_ nt rata Wig: No. of Devices or E &alent elecommunicaiions No. of Devices or Eau�P.,r Estimated Value of Electrical Work: Attach additional detail if desired, or as (When required by municipal policy,) required by the Inspector of Wires. Work to Start Inspections to be requested in accordance with NEC Rn1e 10, and upon.co letio IIVSURANCE CO—V-E-R�A-GGESU-nless waived b the o mp n. the Iicensee provides proof of habili Y ' no pennk for the performance of electrical work undersigned certifies that such coverageTy insurance including completed �Y sue .unless is in force, and operation" coverage or its substantial equivalent The CHECK ONE: INSURANCE exhibited proof of same to the permit issuing of6ce. . I certify, under the ��Bs ❑ OTHER ❑ (Specif3"•) Pains and penalties of�rerjury, that the information on this .application is true and complete. FIRM NAME: to vJ �`y R SZ Licensee: N 0 R I r S' LIC. (I.faPPicable, enter esempt ' in the license afore Address: 10 �� er line.) LIC. NO.: -7 �,A cz� v0 t � �/(� ® � y Bus. TeL Na. � - _ o� *Per M.G L c. 147, S. 57-61, security work requires Department ofPubIic Safety S License; Alt Tel. Na: OWNER'S INSURANCE w AIZ'ER: I am aware that the Licensee does not have the habih �c No, required by law. By my signature below, I hereby waive this re t1 insurance coverage n— o�- Owner/Agent quuement I am the (check one) [] owner Sipature ❑ owners agent Telephone No. PERMIT FEE: $ Policy # or Self -ins. Lic. ----------- Job Site Address.- Expiratim Datc: ------------ Attach a COPY of theworkerst --------- city/statezip. . cmPeuwtion Policy declar-Ation pap Failm,-- to Be (Showing the policy number and expiration date).cur"'Overage as required Lmdw Secti fine- up to $1,500:00 an on 25A of MGL a. I52 can lead to the imposition of d'Or One -Yew imprisonrnen� as wellMiminal Penalfies of a of UP to S250-00 I day against the ViOlUtDr. Be advised that as civil penalties inline fom�of Is' SMP WORK ORDER an� a fine . a COPY Of ties statement may be forwarded inv=;ti . gations of t6e' DIA for inSIOMM coverage verifimcn. rwarded th the Office of 3 h$7- penalties VfP e7ary t the information jo . nvided aho., is &W and Corr= f Data' Official ase only. Do not write in tll, 0ZI; .. &.be co City or Toww. PermiuLicense 9 Issuing Authority (cirde one): I. Board of Health 2. fiilffi-g Departgoot I CIWTown Cj 6. Other erk A. -Eiect I rical inspector 5- Plembing Inspet., Contact Person: Phone #. The COMMOJ2 weaft ofMmachuset& Q Depwtnwnt Of Lndnstria(Accidmts Off 0j'IftVeSfi,-a&ftS V r 600 If.-'ashinjoiz Street Boston, MA 19.2.111- www-nW=,&ov1dia Workers' Compensation Insurance Cant Information ARicl&,Vit.Builders/contractorsme Name(Bmi Please Print Lm-'blv Alt- A, Addrcss: e, �.A LL) ......... . City/.state/Zip: L11\- PA phone 4-.. Are You an employer? Cheep the appm.priate,bo= C)- I ama employer Type with .unpipyeas. (fun and/Wp�j�--time). V I=, sole 4. 1 my, -of P IL gm=j� Cant2ater and f rOjed (required): . have 6. Now c hired the sEd:.oantracton construction ' PrOPrictOr or pwtner- ship and have no employees listed on'thr. attached sheet 7.❑Rem01 7b=m sub -contractors have 0 1 ling working for me in any capacity, wcxkers' ODMP•inns an= workers' camp. insurance. Demolition S. El we are IL Corporation 9- ❑ Building addition required[No 3. 1 am a homeowner doing . all work MW i is Offio-, have their I repairs rePRor additions .MYWE. [No-work=19 cm p T&of exemption M MOL 1 Plumbing repairs or additions -M I LS'Z § 1(4),' and we have no 12.[] Poof * -amploy'-s' [No workers' repairs *Any srMjimm gw t mm also fm Wn %Meo-= who a= c 4 . -hMit this affWavit indicating OOMP. h1surance required.) 13-0.0th= section - Oht, i g their warted, b6*..wdj - they am d PaHey infoma6on. C4nftIWM that vh k this box m= ' doing 211 tk and than him-ouft sm &1ditional sheet showing ide -ntm4"m mW submit a new affidavit fildim* nich. dMir I am an erf 4vra tha.ispr work=, camp. POIL-Y Mrw.. in compensadma I forpladon. Be'" InsLmmee company Name: ir-the-1;054 and job site Policy # or Self -ins. Lic. ----------- Job Site Address.- Expiratim Datc: ------------ Attach a COPY of theworkerst --------- city/statezip. . cmPeuwtion Policy declar-Ation pap Failm,-- to Be (Showing the policy number and expiration date).cur"'Overage as required Lmdw Secti fine- up to $1,500:00 an on 25A of MGL a. I52 can lead to the imposition of d'Or One -Yew imprisonrnen� as wellMiminal Penalfies of a of UP to S250-00 I day against the ViOlUtDr. Be advised that as civil penalties inline fom�of Is' SMP WORK ORDER an� a fine . a COPY Of ties statement may be forwarded inv=;ti . gations of t6e' DIA for inSIOMM coverage verifimcn. rwarded th the Office of 3 h$7- penalties VfP e7ary t the information jo . nvided aho., is &W and Corr= f Data' Official ase only. Do not write in tll, 0ZI; .. &.be co City or Toww. PermiuLicense 9 Issuing Authority (cirde one): I. Board of Health 2. fiilffi-g Departgoot I CIWTown Cj 6. Other erk A. -Eiect I rical inspector 5- Plembing Inspet., Contact Person: Phone #. Information aL ind Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation. for thou employees. Pursuantto this statute, an enTlayee is defined as "...every person in the service of another under any contract ofhire, express or impiied,.omi or written" An employer is defined as "an individual, partnership, &Rsv=Ldiatdon, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enberprise, and includi"g the legal represcnteiivcs of a deceased employer, or the rcceiber or tniatee of an individual; partnership, association► or other legal entity, employing empioyees. 14owevctho owner• of a dwelling house having not more than -thr= apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or work on such dwelling house or on the grounds or building appurtenarst thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every slate o.r- local licensing agency shall withhold the issuance or reoewal 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, MOL chapter 152, §25C(7) states "Neither the commonwealtit nor any of its•political subdivisions shall enter into any contract for the performance of public work until -acceptable evidence, of compliance with the insumce requirements of this chapter have been presented to the contracting authority." Applicants Pica se fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sW5-contractor(s) name(s), addo�ess(es) aund phone numbe(s) along with trair ceraficaie(s)' of insurance Limited Liability Companies (LLC) c r Limited Liabilfty Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' ccarnpensation insurance. If an LLC. or LLP does have employees, a policy is required. Be advised that this africtavit.may be submitted to the Depwtnent of Industrial Accidents for confirmatim of insurance coverage- Also'.lie sure to sign and date the affidavit. The affidavit should be returned w the city, or town that the application for the pit or license is being requested, not"the Department of Industrial Accidents, Should you have any questions regarding the law or if you .are regairsed to obtain a workers'. oornpeRnsation policy, plem-call the Dopsrtment at tine number. listed below. Self-insured companies should entertheir sell-itzsrnance.ncanac aumb= on fie appropriem line. City or Town Offdmis Please be sure that the affidavit is complete and printed icgibly. The Department has provided a space at the bottom of the affidavit for you to fill out in rite event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit%iicetiae number which v►,ilI be used as a reference number. in addition, an applicant thatmust submit multiple permit/lice= applications in any given year, need only submit one affidavit indicating-eurront policy information (if necessary) and under "Job Site Addrew" the applicant should write "all locations in (city or town)." A copy ofibe affidavit that his 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 futtaz -permits or licenses. A new affidavit must be filled out ech year. Where a home owner or citizen is obtaining a license or permit not related to any business commercial venture (i.e..a dog license or permit to bum leaves etc.) said person. is NOT required tb-.compiete 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 Dmpansnent's address, telephone and fax number. The COInIIl nwcalth of Ivfassachusetta UGparf =fit of Indust ial Accidents Office- Of-%ave�aafions 600 Washington Stmt Boston, MA 62111 TeL 4 617-7274900 ext 406 or 1-977-hWSAFE Revised 5-26-05 Fax 4 617-727-774 www.masa.gov/dia { 4152 //?..... Date?a a ................... �10RTM 3r�; .� ��-j•��oc TOWN OF NORTH ANDOVER p toW PERMIT FOR WIRING This certifies that- .......L.......... ....................................................................... has permission to perform ...... --' ............................................................................... wiring in the buildingof ...:::{:......!... ..... ................................................... '- at.. .. .-................................... ::. -' -.............. , North Andover, Mass. ` Fee.��... ........ Lic. No .............. "�'................... �........_......................... ELECTRICAL i SPECTOR ell Check # � y Sf..>> TUE COMMONWEALTHOFMASSACHUSEnS ffice Use only DEPARTtI WroFPUBL1cs FETy Permit No.4 L/" BOARDOFFMPREVEMONREGUTATIONS527CAMI2..Oo Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date /O ZZ-6'7— Town 2•yZTown of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 3 3 wi t7y d Lyj . Owner or Tenant S l�•s. ti Owner's Address Is this permit in conjunction with a building permit: Yes El No (Check Appropriate Box) Purpose of Building —.Dui e 11, w 6, Utility Authorization No. _ Existing Service Amp �/ Volts Overhead ED Underground �' No. of Meters New Service Amps / Volts Overhead ED Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No_ of Lighting Fixtures 1 No. of Receptacle Outlets / No. of Switch Outlets �No. of Ranges No. of Dispceals No. of Dishwashers No. of Dryers No. of Hot Tubs Swimming Pool Above ground No. of Oil Burners No. of Gas Burners No. of Air Cond./ Total Tons_ No. of Hea[ Total Pumps Tons Space Area Heating Heating Devices No. oi�Vater Heaters KW No. of No. Hydro Massage Tubs OTHER- No. of No. of Motors Total HP DDr rto xJ P. V0 066e, No. of Transformers Total KVA Below Generators KVA ,round No. of Emergency Lighting Battery Units 3 FIRE ALARMS _J Total No. of Detection and KW Initiating Devices KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW Local M Municipal Connections No. of Zones --------� Other Dc f• I ttsurutoeCo�ag� At�tttothetegtmen>etysofMC�arialLsws haveaa�aYLiala7ityhmuatrepblicymclttdmgComP]� Co�ageorifslagtuvakr� YES NO hawsubryWcdvaBdploofofswrlodrOffim YFSr—rp gycuhavedudiedYES, pkm #rtypeofmraageby VSUp,INCE BOND MEEK C] y) t E�SalionDa� �' �otkto SlattE9hrn*d Vahleofflecixal Wotk $ l& gnedunda ofperjuty. It >e IDateRet ted Rao / D - 2 3- b 2 F>rnl RMNAME Vo R M q ,J d R LicenSeNo. 7 6,SG fi cfflsff-1 Sigtam — Liomscm REi rssTelNo. q 71- 6 S 7. J o3 7 -dtm f b Z BoA -,!$ A.) Si L4 t.✓. M9 Alt Tel. No. JJNFIZ S WSURANCE WATVII2 Iam awarethattheLioai9edoes nothave theitmuanMOMMageorits substmfialequivalgas tt #udbyMassw1rtmgts CknualIam dthatmysig mh mhspwiutapphcMonwatr� tbsm4mmrnL lease check one) Owner Agent _ Telephone No. PERMIT FEE Signature o caner or gen �= t Location No. �� DateOZ- "pRT" TOWN OF NORTH ANDOVER p16. q - w Mw « y + ; , Certificate of Occupancy $ Ip Building/Frame Permit Fee $ �y s�cHus y Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ::PRO Check # 15879 G /J�---Building Inspect A SECTION i- SITE INFORMATION TOWN OF NORTH ANDOVER 1.1 P,roperty Address: BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 77 _ MT ,. $T� r. " , _ J , a RRA....,... ,,... w. _..... ., a. x...,:....v.i :.,, - "":°..4, sT....w ."'°F BUILDING PERMIT NUMBER: ! DATE ISSUED: q� j 1,3 Zoning Information: R"q ZoningDistrict 1 r osed Use C SIGNATURE: 1.6 BUILDING SETBACKS ft Building Commissioner for of Buildings Date SECTION i- SITE INFORMATION 1.1 P,roperty Address: 1.2 Assessors Map and Parcel Number: � � � i'] 4r: Map Number Parcel Number 1,3 Zoning Information: R"q ZoningDistrict 1 r osed Use 1.4 Property Dimensions: i S cob (O C) Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 30" oc Hoer-�Sti `ip I �� Zvi o2 � 3 Z5 S(D i- 1.7 Water SupplyM.G.L.C.40. 54) Public 0 Private 0 Zone 1.5. ,Flood Zone Information: 1.8 Sewerage Disposal System: Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record L Name (Print) Address for Service: Signatur Telephone 2.2 Owner of Record: 1. Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.I Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone v rn O z M 90 O ic r v rn r r atv z ^ 0 SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all a licabte New Construction 11 Existing Building 0 Repair(s) 0 Alterations (s) 11 Addition Accessory Bldg. 0 Demolition ❑ Other 0 Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATF.D CONSTRUrTTnN CMTS I Item o11ar) to be Estimated Cost (D Completed by permit applicant �� 1 "I'Vil 'i'IaE ` ;'_Nr , x _ 1. Building r� (� a (� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 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 BUII..DING 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 pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 Owner /Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR 12vMERS 1 ST 2ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IiEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: CkOaw-pv kla/vci (Location of Facility) ` Signature of Permit Applicant Ct Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I .363 Wood Lan Andover.No rU-I Scale: 1t, �+" t Da.' ,e No e as i' 23, 10,76 t. ZOT Ih'= 1. i ID. c, Z -Or 17 Aj IOT X5 o, h ry rra F.v, ow. 1V31 -?39-!30W �40 - vViDE� _�QLI� rRF��.a ;T, i✓ c �? G? ?�.AN�4 �ti � i propeerV is located as shorn on plan_ and complies t, -1-h the Bu4ldlng and Zoning Laws of the lawn of North ,vcb : -11 E. CYC CIJ,-IL , CD II 03 0 o n1 n - CD a rn � o � O ®® Ft7t: �o d Cl) CO I C-7 C� CZ3 Q o � � ^� ch O d co O � ®®® ®® C,o tv O ti Q 0 FM14 I a` 6 z w a �i o u°. Cn a � O z z LN c O U w z c O w u w W °�° � c p � w w � ° w w Q k, m o Z cn Q w o cn I O'' C� 0 C L O O O Z Q. O y D = IO Q) C ca Q CO y G> �ff co m CL ~_ +�•+ �3 O 00 L Cc O 0- 2L 2L tm Q ca C cc O +�••� C a� c Z L) O O. V C CL r _h 6 W C) LLJ U) Ir w CCW w U) . c� c s C H � C r.+ O a= A � 4! c ® E- •�c o a N p M E S ri :op a;_. E krw m m a C I -N Co L y 3 = m�C� .0 L C C Amo = cm CD = o crm Qf p = m O � O O m cm Q � H m W +•• N m r Z O CO � o = W N dui Z V V cma� a' p: a H m� I O'' C� 0 C L O O O Z Q. O y D = IO Q) C ca Q CO y G> �ff co m CL ~_ +�•+ �3 O 00 L Cc O 0- 2L 2L tm Q ca C cc O +�••� C a� c Z L) O O. V C CL r _h 6 W C) LLJ U) Ir w CCW w U) . i I 3 U)0Q� LAA7 e) Location —P—oo No. 3 cf' Date ----- I ��—Z --.- TOWN OF NORTH ANDOVER F 01;4 .. _ o ' Certificate of Occupancy $ +,'%•"�# BuildinglFrame Permit Fee $ . "SACMUSE�$ Foundation Permit Fee I Other Permit Fee TOTAL Check # 14110 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER:a DATE ISSUED: V 1 16 SIGNATURE:A,N*C Building Commissioner/1for of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Y– Jo S LUZA cP rc ( G 0 6 4AA e , n, , 1 /I _ _ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required =Provided ReTured Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ILS Name (Print) Address for Service: %� Q l/— Signattde Telephone f 2.2 Owner of Record: 7� Name Print Address for Service: A SignatuLel Telephone SECTIM 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 9 (tom M 00 e M rn SECTION 4 - WORKERS COMPENSATION (1VLG.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 applicable) New Construction ❑ Existing Building V Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �' �Jv�, � c�►"",�,;�� ()✓C`�l V �C� WIC ��� SCJ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL IISE QTIhy - 1. Building7 31 C3(?C� —�� _ ( a BuildingPermit Fee ) Multi li r 2 Electrical (b) Estimated Total Cost of Construction 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 v I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behal , in l t r lative to work authorized by this building'permif application. J'7 G Sign.76z6 of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 'f and belief Print Name Signature of Owner/A Pent Date 91-1 11MIM0111 NO. OF STORIES SIZE BASEMENT OR SLAB 77 SIZE OF FLOOR TINMERS 1 ST2 ND3M SPAN DIMENSIONS OF SILLS DITv1ENSIONS OF POSTS DMIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIv NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. r APPLICANT iC� kCiy1y- E� f��.� PHONE ASSESSORS MAP NUMBER C5�—LOT NUMBER / SUBDIVISION NUMBER STREEI�C S STREET NUMBER ............................................................ .............. OFFICIAL USE ONLY 1�.�Ci�............... RECOMMENDATIONS OF TOWN AGENTS lonesome Mumma ..■.mmm.....s.................................... . seem qq.... ...... l h 4 DATE APPROVED t 0 U� CO&SERVATICIN ADMINLSTRATOR Q / DATE REJECTED COMMENTS tw> wi t ^ �(- i TOWN PLANNER COMMENT'S FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH COMMENTS PUBLIC WORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT COMMENTS DATE APPROVED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED RECEIVED BY BUILDING INSPECTOR DA P L U T P L A v r 363 Wood Lane North Andover, Mass4chusetts Datta.: November 23, '1976 r°P' �cLc l� LDT /6 ,a X30 �/-- GR�H�cr•e�N 17 a m # o N 107 L. Or /S .o ti MO.. FA Ow. �+ 46.0 IL MIOD�40 WiDE� _1�LlL► I hereby certify that the b„i i ding on t1h11 property ie lolmted as shown on plan_ and complies with the $u. fling and Zoning Laws of the Town of F CHARLES E. CYR r ;r CIVIL ENGII'MER, y, ISE, MASS f Si t'l 17° ro m m m m VJ m 0 m = 'v C � d CO) ('7 n Z vn Cl) O '0 a. r �� d _• y o C-) CD o p CD o M CD CCD o c ov w C O co) I CD EL O H o I CG CD � v CO) O 1CD z 74 o CD G CD c =r tm 2 O -• o 0 Q to ` "0 y am O m n C=) yeiaC m Z Erm H o Ma -' c T =rcLr-►a m m O m N 0 imm m D > > o 0 C -� O 0 H 0 . CD N Wa 0.,�.. C ? N 7R i r 0. pO 5. �m 0. .•..: n y x f 0 O Dl y f� m'�N ?� i N 21CD O Oko 0 co O � O ^ W z .00 . 0 C 0 . :C :O m r. G Ir ! i :c o m CD e'+ • •� N �W 0 :r Oq m o CD AA ` 0 �V 0 d o d a (� 0 Ci o r � Q �` O C cp C/)n ; a n O C7 ll%��il Ill O C 07/28/2000 08:24 3604599305 THOMPSONS V Lk It ..0 a • . a�•,. N �- n Mi CU L4, Vx 0 �.. r t : iL re a•T 07/28/2000 08:24 3604599305 THOMPSONS K.IA I _ Fkc Vj -AlliL:. I � � do = O = o 1I-X� W w+ m ■ d CD rCM v'� me E N :�3.`9L ® � N r.. 9 _ tr c G � N m av � m 2: :NmCD .00 c 'n USCP •aZ O. .: a �5 o. m !\ h a ` V`z3 O CD CL, O N m Z LL. CD CIO = r•+ w- HZ W •C Z °C •E c, � CO o O y m=� z �cy• o.wcoo CL b CL w°' U G w a O U G 4 oG O w w w2' U) p w c w E o � do = O = o 1I-X� W w+ m ■ d CD rCM v'� me E N :�3.`9L ® � N r.. 9 _ tr c G � N m av � m 2: :NmCD .00 c 'n USCP •aZ O. .: a �5 o. m !\ h a ` V`z3 O CD CL, O N m Z LL. CD CIO = r•+ w- HZ W •C Z °C •E c, � CO o O y m=� z �cy• o.wcoo CL :CC. Cc ' �• v' y� N � L C: clb �/J O U f O co 0 ts Z 0 C. O y C C O cm ,. COD p� co COD MO MMC w+ Wo wW i r C. _ }. t C� CD 3� 0 � ; 0 !� O a CL C Q C = C ccC v J .O .c co 0 CL V H e0 C C C _cc C. 0 •airgon4s UuAdn000 of joua perm ei oue n000;o a;eogp,raO ,(Apealj ae) 00'gZ$ - eej uoiMcIsu!-aa voiloadsui jo; paiinbei sjie;S tiejodwal -a.rnloni;s 6uiAdn000 o; joud paiinbei Aouedn000 jo aleopia0 -alaldwoo Bwpei6 jouapg ,sj!els jepaO uado ap!s6uole paimbei sl!ejpjen0 ;sod llemou/ lem o; pawn;ai sl!eJpueH :HSINIJ -aseq i!els le ped -ouo0 'ugy umop s6uilool Ja!d -sl!ej pue s;sod Ile bel -6u!oejq lejalel/m s;sod 9xg asn 'apeJ6 anoge ,g JOAO jaluao uo „S aoeds xew jalsnle8 '46iq n 9£ 'uiw si!eb '6uigseg ap!nwd 'asnoy of 6el :paj!nbei l!wjad alejedaS :SN030 }ins *lsngwoo @o p!los „g 'slu!of ueolo '6u!6jed y;oowS gs!u!3 - aagwe40 ajows - 6u!lood le suo!loadsul -pannbai l!wjad alejedaS :S30V1d3U=l 96ejols jol pasn 11 mels japun apooajld -sluan a6pu paiinbei pue jWos '„luau jadoid„ - sooeds o!lle luaA -joop jo Mopwm ssai6a t ZxOZ 'u!w paimbai swoojpa8 algeuado aq pet's 6u!zel6 pa.nnbai to V, -, -eaje joog jo %9 o; lenbe ly6!l lernleN :aneH isnV4 wood algei!geH tian3 jo einpegoS mopui/N Sanols g sooeldaig aouejeolo .0. jo awes; poom d/S opooand '4!.40s ul ;ou) ao!aapxe of lonp lelaw aneq of sue; isnegxa 41ee •(yZ)(gl •uww) •ss000e coeds imej0 (anoge woapeaq £/M 0£xZZ 'ww) -ssamv O!Ad sweaq japun 'sdeNu!els - saouejealo woapeaq joaUO -Ola swea8/SJapeOH jo; lroddns 6uueaq p!IoS -sessnil s,lAl/sweOS jol pannbai -suoilelnoleo p9pia0 •spue le Buloejq lejalel -slalood uo!lepunol ui saps le aoeds ne „ y suo!lepunol le 6uueaq aleld loots jo jopq p!los - slt!O Meas II!s/M (ld l) 9XZ-Z saleld II!S *sl!eu je6ueq /nn paileu (lin; - sJa6ue4 ;slob •7poddns leay pue sino golem - sjeBuuls eels -aleld of ai; „sd!10 aueownH. asn pue suolloauuoo jadoid ap!noid s.ral}ej;oa leipayleO -suol;oauum jadad ap!nad - d!H'g 96p!8 .sllem le 6uueaq yOlem - SJO14BJ ftalleA pue d!H •s;no jal;ei le 6uueaq lin; ep!noid of a6pu az!S -suoiped 6uueaq jaluao pue sjeuaoo ooejgpu!M -sra6uu;s .rte;s le sfleM 'ola 'oala ';eat' 'Bulgwnld Jo; su011e4au8d lslof joog uaaNaq s9leld/slr!6 JOAO - joolgand :3Vjya j r, -uoipauuoo lagno pue moopel!g ouge;/auo;s/ad!d - uiejp uoilepuno j 6u400idwed sde.ils jo slloq jogouy paiinbei se aegab :NOIldONno=i suwnloo joualui jol s6u!lool duffs snonuguoO AeWo>i IrxZ llnd snonuiluo0 :SJNIl0OJ leu!d 'uo!lelnsul 'awej3 'uollepuno3 '6u!lood ' u01leneox3 (wnw!u!w) :SNOIlO3dSNl suoipadsu! ou JO OiO MOO) ilVgH3d (INV 'SS38aod 'SH38vynN 101 ltd 1S0d M0138 SIN311 01 0311WI1 lON-1SI1A.03H0/S31ON ONimin8 lV83N30 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I ct o Buildings Date SECTION 1- SITE INFORMATION 1.1 operty Address: i L /1 -' J � . CrMap CL InInf form 1.2 Assessors Map and Parcel Number: -7( ember Parcel Number attionn: 1.3 Zoning R-4_ 't2, 2 t _,_ 1" t a. l Zoning District Use 1.4 Property Dimensions: i 6 Vo a ( 160 Lot Areas Prmrta g. ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Provided 3n 4D I S IS 1 2z I -A -Required 30 rl1 1.7 Water Supply M.G.LC.40. § 54) 1.5. Flood Zolie Information: Public 0 Private ❑ Zone Aft Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSIFIIPA ZED A ENT 2.1 Owner of Record Vc T A�s Natne (Print) Address for Service �� 2 k - �� ���- a Signature Tele one 2.2 Owner of Record: 4 Name Print Address for Service- ervice:I / Signature Si nature JT Telephone SECTION 3 - CONSTRU IO R CES 3.1 Licensed Construction Su icor: Licensed Construction Supervis Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone I �111 N. SECTION 4 - WORKERS COMPENSATION MG.L. C 152 S 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 licable New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief 6nption of Proposed Work: ._ c� 3 Ho r t/L.P.✓ t SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be ti?EICTALIJSE ONLY: Completed by permit applicant; 1. Building �p dd (a) Building Permit Fee &56 �C Multiplier 2 Electrical (b) Estimated Total Cost of �) O Construction 3 Plumbing Building Permit fee (a) X (@) / �! 4 Mechanical (HVAC)--� 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ,,. SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN t OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as OwnerJahorized Agcnt of subject property Hereby authorize ':' to act on My behalf. in all matters relative to work authorized by tIft building permit application. Signature of Owner Date I, SECTION 7b OWNER/AIVTHOR17AD AGENT DECLARATION t I, C as Owner/Author'zed Agent of subject per proty /M Hereby deo are that the statements and information on the foregoing application are true and accurate, 'to the best of my knowledge and belief j G Print Name I ie Signature of Owner/A ient Date NO. OF STORIES SIZE + BASEMENT OR SLAB SIZE OF FLOOR TiIvIBERS 1 s 2 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 • FORM U - LOT RELEASE FORM 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. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT J -��"� �1Lt��-�a� PHONE LOCATION: Assessor's Map Number-� PARCEL SUBDIVISION � �A ` LOT (S) ` STREET �7C' LQ,yu ST. NUMBER 6(03 & lMe2CQca�w �a—> *****************************************OFFICIAL USE ONLY*********************************** REC CONS COMM AGENTS: ATION AcImINISTRATOR DATE APPROVE=D 2Gb J DATE REJECTED TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMM DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 im Date: :dov ember .23, 1976 d E ZOT /6 LOT 17 J. e)o te 1- ¢2.D� 40.0 MO.0 - --- N3/'39=3O-W O(40 � W/DE) -W~� /RFFEo 0 /✓FRG? ,�AN4S�7i I heretV certify that the j:o 1 cling on t11 -4 s Propertq is located n ted so showon pier and complies +h the Bt;r2djng and Zoning Laws of the 'Town of 3 North Andover: CHARLES E. CYR rte. CIVIL ENGDEM LgWKENCE, MASS. North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: e -IQ M A- �s 61-r-,". CRUS ► . � Location of Facility) �/O, L --- Signature of Permit Applicant v[ Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector BUILT -fir LAST construction 23i North End Bol" l invard Salisbury, MA OU951 (978) 46'2-302 William J . Ferris, contractor ESTIMATE T--: Stefan Koukais Date: August iia, 2001 Re: RPeonstruiction of Second Floor of Residence at 393 Wood Lane luorth Andover, -M-A S' Ol E OF SLR 1ICA"10 Built to Last Construction will be responsible for the following c Demolition and Removal of Debris of Existing Attic o Framing of Structure Installation of Windows and Exterior `Vood Frame Doors ® Application of Roofing, Paper, Bitliuthanc, and Hashing o C n-nstruction ofEave, Rake, and Soffitt Trim • Application of 1 vvek e Labor and Materials for A ll of the Nbov- Price includes $3,000 window allowance. PROJECT ESTIMATE law ) IN S-> A 1--ov) 77 d V rt1 Q a3a a � � � a � o i d 1 n � d O� O z \ O -- O O O <- F-I v U L� O � LO 10102/2001 15:44 60394*09 CF FSL.I�:� UPPLYAd MAScherk C(MPLIANCE REPOAT Massachuyetta Energy Code MAScheck Software Vexslon 2.01 Release 3 TITLE: 13111. FERRIS CITY: North Andover STATE: Maissachuaetts t1Aq: 6322 CONSTROCTION TYPE: I or 2 Family, Detached HEAVING SYSTEM TYPZ: Other, 1Non-Eleactrtc Resistance) DATE: 10-2-2001 VATF OF VUWS; 10/02/01 PROJECT INFORMATION: NORT1i ANDOVER ADDITION COMFLIANCE! passes Maximum UA I2"1 Your Home 119 F4GE 91iO4 I I ! ['6= LC 0 1 k I 4 I I Chockedby%Date I I,-- I Arioa or Qavity Cont. Glaz;ng/Boar Perimeter R -Value R-Val'ie, CS -v 31ue i1A Y_..__.. ----..____--__.._..-___.______ -^T CEI1I14GS864 30.4 3.0 30 WALLS: stood Fran+, 16" O.C. 720 19,0 0.0 43 GLA2ING; Windows or Doors 144 C.32G 46 COMPLIANCE sTATZMT;- The proposed buLldi,ng design deecribed here as consistent with the building plans, spacificati.ons, and other calcalettons submitted with the permit application. Tire pxopaaed huilding has )eon designed to n+eet ti,e requ.iremerts of t')e Maee3A0 h'tlaetta Energy Cad* The hesatinq load for this hvlildinq, and th* Cooling load iI aroprop :iate, has bean determined using the appl.Cdble Sta:ldard Design COndirlon R fturva In the Code: The X7AC equipment zelec7�ad to beet ax' col the bu.i111ng shall be no grouter than ':25* of the dsnign load as speoi.fied. in Seotioria 780CMR 1310 dnd J4.4. Builder/Designer t'a'ke..._.. �. V�.ouV.kis Loa , Qat 5s�� 113/02/2E(dl 15.44 6033947608 CP BLD3 5uppLvw TITLE: BILI, FEARIE DQ4Check INSPECTION CHECKLIST Hassachusects Energy Code MScheck Software Veraion 2.01 Release 3 DATE: 10-2-2001 Bldg . Dept. Use I FAGE 02/00,4 CEILINGS: 1. R-30 Comments/Location WALLS: 1. wood Frame, 16" O.C., R-.9 Com*nt.s/Looatlon ..... _ _. - —�... I WINDOW3 AND GLASS DOORS: I 1. U -value: 0.32 ror windows without labeled U -values, describe features 1 k Panes Frame Type Thermay Bxeak7 t 7 Y is ( j No I I AIA LEAKAGES I Joints, penetrations, and all )that such opening$ in the bxllding I envelope that; are sources of alr leakage must to sealed. Shen I installed in the building eaveLope, Sreceased Lighting fixtirea ! shall meet ons of the followin; requirements: I 1. 'type IC fated, manufactured with no penetrations betw9Sn the I .inside of the recessed fix;,ure and ceiling cavity ,and sealed or I gasketed to prevent air .leakage into the unconditioned space. I 2. Type IC rated, in accordan.e with Stardaxd ASTM 9 783, with no 1 mora than 2.0 cfn (0.944 Lea{ air movement from the th I conditioned space to the ceiling cavity. The lighting fixture shall have been tested at 75 PA ox 1.57 ,lbs/ft2 Pr*$tu:e I difference and shall be la:Deled. VAPOR RETARDER: Required on the warn, -in -winter side of all non -vented fram )d ceilings, walls, and floor*. MA1'ZArJ L$ IDWITIFICATION: Materi;a►ls and equipment must b9 identified so that complia ice con be determined. Manutacturer m.AnuaslB for all installed baa :: ng anti cooling equipment and ServLce crater heating equipment Must be provided. Insulation R -values and glazing U -values mus" b,+ clearly marked on the building plana of specifications - 0 DUCT INSULATION: Ducts Shall be inpalated per T.sble J4.4.7.1. 4."0 15:44 N 6033947608 CF BLDG SuPPLYU FAGS 031 04- C, DUCT CONSTRUCTION: All accessible joints, serine, and connection9 of supply a.ni return ductwork JOcated outsides conditi6ned Apace, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastio and fibrous backing tape ,installed arc>rding :o the manufa.rturer's installation inatructi.onrs. Mesh taps may bs omitted where gaps are lees than 1/8 inoh. Duct tape it n>t permitted. The: KVAG system must provide a means for balAn:Ing air and water system&. TE HPVRATURE CONTROLS: Thermostats are required for eich Zeparate XVAC system. A manual or automatic mear►e to partially rastriQt or shut off the heating And/or, cooling input to each x3no or floor shall be Nrovid)d. HVAC SQUIPMLNT SIZING: Rated output capacity Qt the ,hsatinq/cooli.nq system is not gcaat$r than 125% of the daaign load as bpeeified in Sectione 760CM 1310 and ,74.4. SWIMMING POOLS: All heated swimming pools must nave an on/off heater switci and require a co7er unless over: 20k of the hea.tiag energy Is E:am nor-depletable sources. Pool ;3umpA require a tire clock. HVAC PIPING INSULATION: RVAC piping conveying tjui.da ri.�ovo 120 F or chilled fluids below 55 V roust be insulated t:) the feliowirg levels tin.): --NOTZS TO FIELD !Building Departmen . Ube PIPE SIZE,$ 4a,) I HEATING SYSTEMS: TEMP (T) 2" RUNOUTS D-1" 1,25-!0' 2.5-4" 1 'bow pr6 ssure/temp. 201-25] 1.0 1.5 1.5 2.0 1 Low temperature 120-20) 0.5 1.0 1.0 i.5 I $team cvndervete any 1.0 1.0 1.5 2.0 I COOLING 3Y5'1US: I chilled water cr 40-55 0.5 0.5 0.73 1.0 ! relfripwrant below 10 1.0 1.0 i's 1.5 1 1 CI'RCUT ATIVG HOT WATER SYSTE S t E 1 I rns2.ilatib cixculatirg hat avatar pSpe' to the following Lays_s (in.): i PIPE SILEB (in.) j NON-CIR1XLA11NG I CIRCULATING MAINS & RUNOOTS f HEATED MATER 'DEME (F); RUNO T S 0-1," 1 0-1.25" )_5-2.)" 2.0+" ! 170-100 0.> I 1.0 1.S 2.0 I 140-•160 0.5 I 0.5 1.0 1.5 ! 100-1.'*3,0 01i I 0.5 0.$ 1.0 --NOTZS TO FIELD !Building Departmen . Ube O'!lLJ1' Board of Buildin1 ulations ° One Ashburton P ®ce�m 1301 Boston, M 108-1e18 I.kynse: CONSTRUCTION SUPERVISOR LICENSE ®bthrft: 03MYli 00 Number. Cs =674 : 031Z9,*M RMblebti/ To: 00 WnIJAM I FERRIS 231 A N END BLVD , 9AUSSMY, MA 01"2 . a Tr. rw. . 17790 IiM� � df +'wew! W awM� d rd ws �IIMMoai K�L /// -7-2,--v,� p , /K,, 0 FM4 9 4 w W u �2 v u a c�' Z A CCl p ti w a C U w � O W a a c i� a O W W a u ci) w' . ¢ o a w w W W v ca cn °J o co c o � CD c . C O C � l� y 0 2ct m c Z l0 A Jkm ' o _ sH (16 8: E c V: G' v O y.r u Qf li m C ' m m N CC, N N t03 9� cm �p C 1: c mJ C Wo rh N m m 2 o c • cm:nc7� m 0 ac ' ,_ v c L o a dl 9i acs Co V y O �.. L; i.�•5Z O A ` .� Of Q � O C H � V .N„ m = •O caZ oc E 0= N OO cm _W ` � CD J F.- c $n � m 2 O w w P-4 bi EN s CO o� c H O 0 32 M d �E on m L � i C t O� CLI O L CL CMQ C O= C O =�p J 'O CL 0 a) CO2 Z 5 0 CL V y C c C� C _cc �. CO) C W 0 U) LIJ U) ccw W W U) NORTq H A SSACMUS� Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... ............. 1�. has permission to perform ... 14— �! x .............. plumbing in the buildings of . . at 3 LA— Fee. .... Lic. No./?..'.:.. . Check # / 31 r 5536 .t!.c).,. et .................. ........... North Andover, Mass. PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS - Date BuildingLocation �j�?j ��-t� // �� Owners Name `cj K 1 A S Permit # S's �►6 Amount Type of Occupancy V\o M New Renovation ❑ Replacement ® Plans Submitted Yes No FIXTURES (Print'ortype) . A Installing Company Name r/V I ✓-�il—�I % ,�U �LfJ //I fe-17 Address 2 � IU/AWS 'A VL Check one: 11 Corp. rlPartner Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity Bond ❑ Certificate Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner n Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus Sta Plu iEM(4j,44 Chap 142 of the General Laws. � , � I By Sign" amore o ens umoei_ -- Type of Plumbing License % Title -;-7-4 2 / City/Town icense INUMDer Master ® Journeyman APPROVED (OFFICE USE ONLY