HomeMy WebLinkAboutMiscellaneous - 365 BLUE RIDGE ROAD 4/30/2018Date .....'7'..:. :...../.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..................................-...............
......... x ....................................................
has permission to perform .............%? 7
...............................................................
wiring in the building of ..............
............................................................
at ...............................................................��r�orth Andover, Mass.
Fee.....7, Lic. No.. 7. = ............... 12t ...........0....
ELECTRICAL INSPECTOR
..
Checkit 9 ��
Commonwealth of Massachusetts Official Use Only
Permit No. 2^'
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank
�h
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: /�7/ -„ 7 J — / y
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) J C J-- /:?/Ue 6L, 0 r-
`\ Owner or Tenant ID a( r_ ee►- Al Telephone No.
Owner's Address '360— � (v 2 C
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building & /-- 0 Utility Authorization No.
- Existing Service ` 0 Amps 2 )_-(c Volts Overhead ❑ Undgrd D No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
A
Location and Nature of Proposed Electrical Work: k,,bR P�i2 Lrit^'t «L r ,� p�, eT, r
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets 3
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
No. of EmergencyLighting
rnd, grnd.
Battery Units
No. of Receptacle Outlets 2
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of SwitchesNo.
�a
of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total '
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
""
J.KW
."'.""..."'"
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER: crk� �- ,PWW r-�-
00 Attach additional detail if desired, or as require by the Inspector of 97 s.
Estimated Value of Electrical Work: /&00 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, tinder the pains and penalties of perjury, that the information on this application is true and complete.
FERM NAME: LIC. NO.:
Licensee: W&-L� Signature LTC. NO.: i Cf -7
(If applicable, enter "ex t" in th lice aer line. Bus. Tel No -
Address: cJ V 04 4Y Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, se urity work requires Department of Public Safety "S" License: Lic. No. 3
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.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPEC ION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSP TION:
Pass
Failed'❑
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature: a f /e
1, Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth ofMassachusetts
Department of IndustrialAccidents
Ofjrce of Investigations
600 Washington. Street
Boston, MA. 02111
VV www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Address:
�� �r
City/Stale/Zip: � CVtdJ,�.wtt,�. ')VKQ �� Phone #•, � 2 � 31—
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 1
6. ❑ New construction
employees (full and/or part-time).*
2G<
have hired the sub -contractors
listed on the attached sheet. t
'Z• E] Remodeling
am a sole proprietor or partner-
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance,
g, El Building addition
[No workers' comp. insurance
5. El We are a corporation and its
ME] Electrical repairs or additions
required.]
3. ❑ 1 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), and we have no
12.❑Roofrepairs
required.]
insurance . re uired
employees. [No workers'
1311 Other
comp. insurance required.)
Mny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they tie 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 anc7 job site
information.
Insurance Company N
Policy # or Self -ins. Lie. M ExpirationDate:
Job Site Address: ��G �� t/-� V <<^�C' f - GFX City/State/Zip:�Ca,"'Ci
Attach a copy of the workers' compensation polley declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL 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 DIA for insurance coverage verification.
Ido hereby petftunder the paiq_�enaltles ofperjury that the inform ation pro vided above is true andcorrect.
-25
S 2k- /A`35—
Official
`35
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. CitylTown 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 ofpublic 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 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 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'
compensationpolicy, 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 whichwill 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 orpermit 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:
Tho Commonwealth of Massachusetts
Departmout of Jndustdal .Accldauts
oBice ofIuestigati ms
604 Wasbhtgtau Street
Boston? MA Q.2X l l
TO, 0 617-727-4900 ort 406 or 1,-877�MASSA.k`F,
Revised 5-26-05 Fax# 617-727-7749
VAM.mace an-uhilA
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This certifies that ...(.7
has permission to perform
Date. /o/).A r. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�.. ... / .........
.......................
plumbing in the buildings of ..../.-/ —6 .....................
at ...3 ep j -.31.L. r. P. A.� y :Y ........... North Andover, Mass.
.% .�'"�Lic. No... 1. 7.
Fee. t...J. . , . .` .... .
PLUMBING INSPECTOR
Check # �r
7867
N,
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Typ�444
) l
d� Mass. Datc!5;4, 200S Permit # 7
Building Locatio Owner's NameV1r
f
Owner Tel# C V/J .Type of Occupancy 7
New ❑ Renovation ❑ Replacement ❑ PlanSubmitted: Yes ❑ No ❑
FIXTURES
Installing Company Name w `-% r-1—)" Check one: Certificate
AddressR4
\ v *—Orporation 4 o❑►PPartnership
Business Telephone # i 3 q V" tp &37 ❑ Firm/Co.
Name of Licensed Plumber FC,
INSURANCE COVERAGE:
I have a curren liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes, No ❑
If you have ec domes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner 11 Agent ❑
Signature of Owner or Owner's Agent
i nercuy cerury mat an or me aetans ana mrormatton t nave 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 the pe tssu for this application 01 1b),e in c ce with all pertinent provisions of
City/Town
APPROVED (OFFICE USE ONLY)
J Chapter 142 of (�
Signature of used Plumber
Type of License: Master /\/ Journeyman ❑
License Number
R��_"-,;
i
Date ..... . � I.Z. 5..:. .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
4 -D./ Tf�44 cThis certifies that ......................... .............. ...........................
....
.
has permission to perform ST��i �'{%�- ��
wiring in the building of ................... i-' m—b................................................
at ........... Y, 6�dL-G<. .. l Gr ...? 1/ ........ , No Andover, Mass.
Fee . �� ...... A� Lic. No....S.33G S` �jls�r?........ � � ..
ELECTRICAL INSPECTOR /
Check #
P 0 1 1
C-nU- a1"U4Ci& o/ V� ad,=�w4ff; Ot�icia�l�Usc Only
<.J4aarfJ)1.4Ri o f }irs �4rvicad Permit T`+'o.
Occupancy and Fee Checked
BOARD,OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank)
'J
APPLICATIION FOR PERMIT TO PERFORM ELECTRICAL WORK .
All work to be performed in accordance with the Massachusz u Electrical Code (MEC) 5271 MR 12. 0
(PLEASEIN
PRT IV INK OR TYPE ALL INFORiiMTYOP� Date: / a U /Q
City or Town of: M0F+h AN2�60ee__ To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) �J Los L--�l1 e (2�
Owner or Tenant
of tC(r)r)e— k—�o0&�
Owner's Address
Is this permit in conjunction with a building perrixit?
Purpose of Building
Telephone No.? 7,F=
Yes D No L" 1 (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps / Volts Overhead Undgrd ❑ No. of Meters_
r—'
New Service Amps / Volts Overhead D :. Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed EIectrical Work:y��-a l� �1�C-t cr, o eGttr t : p r t_arr'l
Comoletion afire fb,7owinQ table may be waived by the lnwector of Wires.
No. of Recessed Luminaires
jWves
No. of Ceil: SusQ..(PvidIe) ;'ans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs i
Generators KVA.
No. of Luminaires
Swimming Pool..Above In-
brnd. ❑ zrnd. ❑
o. o Emergency ib.ftfng
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Cas Burners
INo. ofetection an. n.dating Devices
No. of Ranges
a
No. of Air Cond. Total
Tons
No. of Alerting Devices
eat Pump
I Number
ons 7RWWo.
o Se - onWne
No. of Waste Disposers
Totals:
---
Detecdon/Aler-ting Devices
No. of Dishwashers
S ace/Area Heating KW
P b
Local N unicipat 11 Other
onnec ' n
No. of Dryers
Heating Appliances KW
qcv6tvezr Equivalent
i o. oi Water KW
. Heaters
o. o o. of
Signs Ballastc
Data Wiring:
No. of Devices cr Euivnl:nt
No. Hydromassage Bathtubs
No. of Motors Total HP
e ecommunications firing: '
No. of Devices'or Equivalent
OTHER: / 4 -7.. a3 lid 9 I
Attach addutor,a! dctar! f desrrcd oras required by the ierpector o
Estimated Value of Electrical Work: 7• • (When required by, municipal policy.)
Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit foe the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑. OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and.complet
FIRM NAME: P��r SeCurt-Tq ScrV(Ces LIG NO..
Signatures �_ LIC. NO.:
Licensee:,(-{ � _ �
ilaPPlicable, entero e Pt 1L licensk &C _) f /_ ��t5 {%H Oot4? Bus. Tel. No.:
Address: /7� AIL Tel. No.: D G / 9
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety -S- License: Lic. No. s �_ /5
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
towner's gent.,
Owner/Aent PERIYIIT FEE ,
Signature" Telephone No.�
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Date J 3-- 9',3.
tt WN OF NORTH ANDOVER
BUILDING DEPARTMENT
•BuALg/Fr�te"Pe93it Fee $ 16 1 1 O
F Ati��tt J n�,e
ation .Permit Fee�-
Other Permit Fee% .t� $ /3 i+ D
Building Inspector
I
Location
NO. Date
TOWN OF NORTH ANDOVER
-/ fear I \W,
' 9 Certificate of Occupancy $
} Building/Frame Permit Fee $
A^°Foundation Permit Fee $
��--' `^•C 'Other Permit Fee $
�. Sewer Connection Fee $
y - Wt�r�Connection Fee $
$ TOTAL $
- AQ
Building Inspr
Div. r
Location
No. r
Date
TOWN OF NORTH ANDOVER
�'`" ' 1-11,CerMf1cate_of-Occupancy $
trildfr g/Frame Permit Fee $
Foundation Permit Fee $
Other Permit $
QoConnection nnection Fee $
A Water Connection Fee $
TOTAL $ • C / '
Building Inspector
' Div. Public Works
IFAR+)f IT -NO-! � ,') APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. �� ��/ � �� �� PAGE 1
I
MAP 4-40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK 'PAGE
ZONE
SUB DIV. LOT NO.
LOCATION .
OWNER'S NAME
/►_.�
PURPOSE OF BUILDING C�/� A' y
NO. OF STORIES [�/!Y SIZE G/fx !'
ea U V - Bao .,ca
OWNER'S ADDRESS
JR4 Corr
-.a
ASEMENT R SLAJ4
ARCHITECT'S NAMEe5w/
BUILDER'S NAME
DISTANCE TO NEAREST BUILDING-j�^
it
SIZE OF FLOOR TIMBERS IST 7 u t Q 2ND
O�"'� �L•�
SPAN / -[ h
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS f* fol
DISTANCE FROM LOT LINES -SIDES
REAR
�O�
GIRDERS
�V
AREA OF LOT t'� �ry�/f�..�
FRONTAGE _
OPV
7 /6& ,*
HEIGHT OF FOUNDATION d THICKNESS loot
IS BUILDING NEW
ti X
SIZE OF FOOTING ' X. .041
IS BUILDING ADDITION
MATERIAL OF CHIMNEY A
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
�••7
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Y�
G`1
IS BUILDING CONNECTED TO TOWN WATER yes
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER y
IS BUILDING CONNECTED TO NATURAL GAS LINE f� ,
INSTRUCTIONS
I
SEE BOTH SIDES ampawar
�.w a
PAGE 1 FILL OUT SECTIONS 1 - 3 • �A '' 'd (J
PAGE 2 FILL OUT SECTIONS 1 - 12 DUE FRAME PERMIT
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY P4'[LDING INSPECTOR
DATE FILED
SIGNATURE OF OWNER OR /WTHORTZED At5 /T
FEE �7 /y�o9� 0
OWNER TEL. # S" �•
PERMIT GRANTED CONTR. TEL. #
C, CONTR. LIC. #� T
19 -7�-
t Y
1
P- 11,1 -DING DEPARTI✓`-r''-
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST 9pu, o O
EST. -BLDG. COST PER SQ.
BOG/I
EST. BLDG. COST PER ROOM1S`�e
1 �
SEPTIC PERMIT NO. f . 7
_fir
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUI iNG INSPECTOR
1 OCCUPANCY
SINGLE FAMILY
GABLE I HIP
GAMBRELMANSARD
STORIES
BATH (3 FIX.)
TOILET RM. (2 FIX.)
MULTI. FAMILY
FLAT H SHED
OFFICES
_
APARTMENTS
ASPHALT SHINGLES
LAVATORY
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
a 1 2 13
PINE
HARDW D—
PLASTER
CONCRETE
CONCRETE BL K.
BRICK OR STONE
PIERS
_ DRY WALL
UNFIN.
7 NO. OF ROOMS
B'M'T 2nd _
1st 13rd
3 BASEMENT
AREA FULL
FIN. B M'T AREA
1/1 1/2 1/.
FIN. ATTIC AREA
_
N_O B M'T
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
_
4 WALLS I
9 FLOORS
CLAPBOARDS
B
1
2J
�—
_
3
I_
_
_
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
HARDIV D
COMAAON
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STRS. d
FLOOR
BRICK ON FRAME
I_
WIRING
5 ROOF
II 10 PLUMBING
GABLE I HIP
GAMBRELMANSARD
BATH (3 FIX.)
TOILET RM. (2 FIX.)
_
FLAT H SHED
6 FRAMING
I WATER CLOSET
ASPHALT SHINGLES
LAVATORY
TAR 8 GRAVEL 1 II STALL SHOWER I I
As ,
BUILDING RECORD ,
12
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
I
0
TILE FLOORHi D
TILE DADO
1
11 HEATING
PIPELESS FURNACE ;
FORCED HOT AIR FURN.
STEAM f
HOT W'T'R OR VAPOR
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
GAS
OIL
ELECTRIC
NO HEATING
6 FRAMING
WOOD JOIST
TIMBER BMS. 6 COLS.
STEEL BMS. d COLS.
WOOD RAFTERS
_
_
7 NO. OF ROOMS
B'M'T 2nd _
1st 13rd
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 local or state law,
regulations or requirements.
************** *Applicant fills out this section*****************
APPLICANT: Phone O
LOCATION: Assessor's MapN mber Parcel
Subdivision 74C Lot(s)
Street eft —aj�,j
_ St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
f� 61��M
Conservation Administrator
Comments
Town Planner
Comments
Food In'spdbtor-Health
Septic Inspector -Health
Comments-7-6&)AJ 6 /) Y' ,S&Z- ,i
Date Approved 6
A5
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections (-)(C '1-J l.t 1 3- 1S-�-2j
- driveway permit
Fire Deartment
J
�RRec�eiv d by Building Inspector
n W r{ r Date
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11 a 5
I IJ I
Ems'!LDING DEPARTHAEN!7
COMMONWEALTH
OF
MASSACHUSETTS
EXPIRATION DATE
06/30/1993 .1696
RESTRICTIONS
NO NE
SS S 001-46-0822
PHOTO (BLASTING OPR ONLY)
OTHERt ; hgHt tHUAIB PRINT
20OM-2.87.814291
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DEPARTMENT OF PUBLIC SAFETY
1010 COMMONWEALTH AVE.
BOSTON, MASS. 02416
LICENSE
CONSTR. SUPERVISOR
5 EFFECTIVE DATE LIC -NO.
106/3011991 0085M
GARY A KELLOMAY AA EE
NRRNTAANDOVERENALO1a45P
FEE:
10000
HEIGHT:
DOB:
04I03/19S4
THIS OOCUMENi MUST BE
CARRIED ON THE PERSON OF
THE HOLDER WHEN ENGAG-
ED IN THIS OCCUPATION.
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ENCLOSE CHECK OR MONEY ORDER
FOR REQUIRED FEE,
MADE PAYABLE TO
"CO SIGMEN OF P BLI ETV"
F
(DOAS
EASE : 10AIRf#6 YMREASE
fECTI�E oE�1o,► �Jo
NOTIOETACH LICENSU STV9
4 SIGN NAME IN FULL -ABOVE SIGNATURE LINE
RESTRICTIONS
01 OTHER
07 SPECIAL LIMITED
it HGHJRE:SURE ANO LOW PRESSURE
03 AUTOMATIC PUSH SUTTON
1S PGH4'PF.SSURE AND ROTARY
0A FREIGHT
20 LOW-PRESSURE AND ROTARY
OS HRT
It ASSISTANT
00 SCOTCH
II OUARRY
-
07 VET,
" TUNNEL
d STRAIGHT
gA MARINE (SHOER WATER)
42
96 RSSFOCH AND DEVELOPMENT
10 RANGE
10 ANGE
ft BLACK POWDER ONLY
I1 POT
27 SERMOGRAPW
I} NgHMESSURE
IS ELECTRIC
13 LOW*AFSSURE
M CRANES
1+ROTARY
SO tNOVELS
IS POWER (LORI pill
It SACKHOES
$2 011A0 LINES
11 POWER (HEAVY OIL)
1/ RANGE AND POT.
L CLAM. 6404.4.
so
24 CAILIWAY
F )
35
TQONT END LOADER
36
CATCH BASIN, SEWER CLEANING MACHIN,,
37
F%TEN%W)N LKTS
38
SIGN HANQFA
"
LOCOMCT7VE St(F PROAEL
AO
POLICE WWII SO(JAO
Al
TAFEICH
42
rORTABLE (COMPANY)
41
ENnmEFRFO{COMPANY)
PRE-ENOINf.EREO (COMPANY)
45
NY DROSTATIC (COMPANY)
46
PORTARLE (INDIVIDUAL,)
41
ENDINfERED (INDIVIDUAL)
48
PRE41SIGINEEREO (INDIVIDUAL)
49
MY DROStATLC (INDIVIDUAL)
so
51
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STREET
CITY OR TOWN
4 { •T E ZIPCO E
PRINT CHANGE OF ADDRESS AND NOTIFY THE
COMMISSIONER OF PUBLIC SAFETY•IN WRITING.
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Date ... ..` . G G . �..... .
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NORTH
TOWN OF NORTIJ4NDOVER
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-� PERMIT FOR GAS INSTALLATION
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This certifies that . .".........................
has permission for gas installation ... P� -4 �.............
in the buildings of .. ��. f .� T TT .. ..................... • •
at G ? !.t� -r. ............. . North Andover, Mass.
Fee.7 .'... Lic. No.. `.... �!. r
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MASSACIAUSETTS UNIFORM APPLICATION F R PERMIT TO ISO GASFITTiIVG
j "---- (Print orType)
- �'y�//
.�it<��c� � Mass. Date 9 lei � �7 Permit # Com/ 61"C
Building Location LU _ 1 Ab—Owner's Name L�fi'Ls%
Type of Occupancy RE
G
New a Renovation p Replacement Q-� Plans Submitted: YesC No O
lns-Eailing Company Name ` a, ;jtri� / �-�� Check one:
Address
- B—Corporation
0 Partnership
Business Telephone E`,D j'
`� O F1rm/Co.
Name of Llcensed Plumber or Gas Fitter > r.14-11 I -LII-, A
Certificate #
e
INSURANCE COVERAGE:
i have acurrent llfiy insurance policy or ifs substantial equivalent which meets the requirements of MGL, Ch. 142.
Yes n No ❑
If you have checked des, please Indicate the type coverage by checking the appropriate box.
A Ilabllfty Insurance policy 1S Other type of Indemnity 0 Bond O
O`YNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the iv;ass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Sionalure of puner or Owner's Agent Owner❑ Agent ❑
I hereby cerR,, that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knoydedge and that all plurnbing work and installations performed under the permit issued for this application will be In compliance with Ili
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Geneial taws.
By a
T e of Ucense:
Title Plumber Srg�jflure of License lum e�'r or Gas Fitter—
aslilter
�
City/Town aster tJcense Number 9
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SUB—BSMT.
BASEMENT
1
IST FLOOR
21{D FLOOR
3RD FLOOR
t
STH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
BTHFLOOR
lns-Eailing Company Name ` a, ;jtri� / �-�� Check one:
Address
- B—Corporation
0 Partnership
Business Telephone E`,D j'
`� O F1rm/Co.
Name of Llcensed Plumber or Gas Fitter > r.14-11 I -LII-, A
Certificate #
e
INSURANCE COVERAGE:
i have acurrent llfiy insurance policy or ifs substantial equivalent which meets the requirements of MGL, Ch. 142.
Yes n No ❑
If you have checked des, please Indicate the type coverage by checking the appropriate box.
A Ilabllfty Insurance policy 1S Other type of Indemnity 0 Bond O
O`YNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the iv;ass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Sionalure of puner or Owner's Agent Owner❑ Agent ❑
I hereby cerR,, that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knoydedge and that all plurnbing work and installations performed under the permit issued for this application will be In compliance with Ili
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Geneial taws.
By a
T e of Ucense:
Title Plumber Srg�jflure of License lum e�'r or Gas Fitter—
aslilter
�
City/Town aster tJcense Number 9
O,t�
/J'f iK7Yf n—T01TTc Journeyman