HomeMy WebLinkAboutMiscellaneous - 37 BRENTWOOD CIRCLE 4/30/2018 (2)bate. .......
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Of ,ti
°p TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
This certifies that .. .�,,t-../.' ....°� ..................
has permission -for, gas installation ... l�.S.. E'< <. ��....... .
in the buildings of . r. f !........................
at .. �.�-. `� C . t. { , North Andover, Mass.
Fee..?. .. , Lic. No../U7 q!... .... ........
,ETAS INSPECTOR ��
Check -# 3 3 > U
7325
MASSACHUSETTS UNHORMAPPUCATONFORPERMUTODO GAS RUING
(Type or print) Date � — /0 . 7M
NORTH ANDOVER, MASSACHUSETTS
Building Locations ►J c Permit #
Amount $ J
Owner's Name t'
New ❑ Renovation a ReplacementEr
Plans Submitted ❑ 1T1
Name of Licensed Plumber or Gas Fitt 6 yl i e-2— _/
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
j5�mlco.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No'
If you have checked es pleas cate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirem
Check one -
Signature of Owner or Owner's Agent O t 0
I hereby certify that all of the details and formation I have submitt d (or t ed) ' abov a cati n are true and accurate to the
best of my knowledge and that all plumbin tions p rfo e ed this application will be in
compliance with all pertinent provisions of the Massachusetts Stat e d�Chapter eneral Laws.
I City/T0—V7I
(OFFICE USE ONLY)
Si ature o Licensed Pf mber Or Gas Fitter
Plumber
Gas Fitt r ice a um er
aster
Journeyman
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SUB -BASEM ENT_U
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RASEM ENT
1ST. F L 0 0 R
2ND. FLOOR
3'R D. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
_
B.T -H . F L O O R
Name of Licensed Plumber or Gas Fitt 6 yl i e-2— _/
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
j5�mlco.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No'
If you have checked es pleas cate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirem
Check one -
Signature of Owner or Owner's Agent O t 0
I hereby certify that all of the details and formation I have submitt d (or t ed) ' abov a cati n are true and accurate to the
best of my knowledge and that all plumbin tions p rfo e ed this application will be in
compliance with all pertinent provisions of the Massachusetts Stat e d�Chapter eneral Laws.
I City/T0—V7I
(OFFICE USE ONLY)
Si ature o Licensed Pf mber Or Gas Fitter
Plumber
Gas Fitt r ice a um er
aster
Journeyman
y..
The Commonwealth of 1Mfassachusetts
Department o findustrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www -mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Lemb1
Name (Business/Organization/Individual): A7
Address: G t> .4--
City/State/Zip: �.1, I, r- Phone #: Q / ���
Are you an employer? Check the appropriate box:
L ❑ I am a employer with T
44. ❑ I am a general contractor and I
employees (full and/orpart-time).*
2, ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet #
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We
are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp,
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
c9mp, insurance required.]
Type of project (required):
6. 0 New construction
7. 0 Remodeling
8. 0 Demolition
9. 0 Building addition
10. ❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
t
" `-n3' aPplicant that checks box y1 must also fill cut the section below sh^v. rhe Workers,t _
Homeowners who submit this affidavit indicating they are doing all work and then hire outside ontra ors must su moit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I an employer that is providing workers' compensation
inffoo rmation insurance for my employees Below is the policy and job site
4r
Insurance Company Name: l y pro
Policy # or Self -ins. Lic.
��/j /O Expiration Date:
Job Site Addr-ess- 1. l (Z01 r f �
City/State/Zip:
Attach a copy of the workers' compensation policy de ation page (showing the policy number and expiration date).
Failur sec overage as required under Section A of GL c. 15 can lead to the imposition of criminal penalties of a
fin up to $1,500. and/or one-Eio
prisonment, well as c" ' penaltt s in the form of a STOP WORK ORDER and a fine
of p to $250.00 a d y against thor. Be adv ed that opy of thus s tement may be forwarded to the Office of
[n esthgations of the IA for 'oaQP ., ,;�
I do
the
of
the inf�lrmation provi d above is true and correct.
Official use only. Dorot write in this are to be completed by cityor town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
T r
Information an d 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 pe arson 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 �o 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 apartazents 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."
I
MGL chapter 152, §25C(6) also states that "every state or local licensing'agency shall withhold the iss6ance'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 coxmpliance 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
v
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) bf
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 LLOor LLP do s have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of ltndusttial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or ioCn ar'2 that. the appl'scauCn for the pet; lt'oI license is being reque3sed, not the De'Jar nnent of
.Tndustrial Accidents. Should you have any questions regarding the taw or if your 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 permittlicense 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 "aIl 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 Ince to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Depar(ment's address, telephone and fax number.
The Commonwealth ofMassachvsetts
Department of'Industrial Accidents
Office of Investiagatroas
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900.ext406 or 1-877-MAS.SAFE
Fax # 617-727-7749
Revised 5-26-05 wvru,_mass-_govfdia
i
Location
09
No. iC Date
�ORTM TOWN OF NORTH ANDOVER
JL
•. • O
Certificate of Occupancy $
9
Buildin /Frame Permit Fee $ 161
�sa._....ab
Foundation Permit Fee
Other Permit Fee
TOTAL
Check # /, �1(36
146L0
f Building Inspector
✓ it
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:.V
SIGNATURE: t
Building CommissioneE2 for of Buildings Date
SECTION i- SITE INFORMATION
1.1 Property Address:
--7 &aru
1.2 Assessors Map and Parcel
(Q3
Map Number
Number:
3 .�
Parcel Number
n ^
1.3 Zoning Information:
Zoning Districi Proposed Use
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft -
Front Yard Side Yard
Rear Yard
Required Provide R red Provided
Required
Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Q-
Public Private ❑ . , Zone Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSEU/AUTHORIZED AGENT
2.1 Owner of Reeprd
Name (Prin) Addressfor Serv'
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
.Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Con truction upervisor:'
Licen e Number
;;e
J^S�
g14
Expi tion D e
Telephone
93.2 R istered Home Improvement Contractor Not Applicable ❑
C ny Name
Reg stra on Number
Ad&essT�
Expi ion Date
Signature Telephone
Ma
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to piovide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Description of Proposed Work check all 'cable
New Construction ❑
Existing Building
Repair(s) ❑
Alterations(s)
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify^ N
I 1, io.
Brief Descriptiop of Proposed Work:
t
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
CorApleted by permit applicant
y r QFFICIAL U ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical(b)
Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X (b)
J
(/
4 Mechanical (HVAC)//!
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized A gent of subject property
Hereby authorize to ac on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 0 as Owner/Authorised Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, t the best of my knowledge
and belief
Prim e ^Li�
s
S e of Owne ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST2ND 3Ku
SPAN
DIMENSIONS OF SILLS
DWENSIONS 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
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am a homeowner performing all work myself.
�1 am a sole proprietor and have no one working in any capacity
I —S-36
QI am an employer providing workers' compensation for my employees working on this job.
Company name: _
Address
City' Phone #
�_s
vPhone*: "_( i
IL s
Insurance Co.
DU- Poli # _L /(U
Pailure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500,00
andtor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me:
understand that a copy of this statement maybe forwarded to -the Office of Investigations of the DIA for coverage verification.
/do herby certify ungferihelns and pena5t14 of perjury that the information provided above is true and correct
Signature
Print
Official use only do not write in this area to be completed by city or town official'
❑Check if immediate response is required Building Dept
Contact person:_ Phone
FORM WORKMAN'S COMPENSATION
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E] Licensing Board
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTI'UG
(Print or Type)
\ NORTH ANDOVER Mass. Date,,_ �7 r%
t`3uilding Location�'�Z �Q�'Permit # 2—
Owners
Owners Name
New '^ Renovation IE Replacement II Plans Submitted D
Ply: o=c
(Print or Type)
Installing Company Name
Address Z/ d %
r
Check one: Certificate
�Q Corp.
Partner.
Firm/Co.
Business Telephone:j�
Name of Licensed _Plumber or_Cas Fitter
Insurance Coverage: lndica:e ;h` :vpe of insurance coverage by checking the
aporooriate-.box:
LiabiIity__insurance._po(icy. Ot^er type of indemnity � Qand
L -
= s_:._:.._ ....:__
Insurance Waiver: -I, the urdersicneJ, have been made aware.that -the licensee or
this ap.piication.does not have anv one o: the above .three insurance._coverages.
Signature of owner/agent or property Owner = -Agent
a
I hc:cay ec:tify that all at the details and Wormation I bare submitted (cr entutd) in above xopiieation ate trtte and acctuate to the best of my
k -10 -ledge and that x11 ptumbin; work and InstAd4tioes -.=forase.d undue ' terr..it i::Led [o: thiz sppilcxt:en will =mpEianoa with to pestln=t
ptarisiocts of Ilse Massaa4us4tts State cat Gad6 usd t3aptcr I4. of t;a Ce:tCz1 LAWS.
3v TY?_= LICZNS-:7, V,
Ti.ie ! Gasfitter Signature of Licensec
Ci`;r/Tcwn- ! gaster Plumber or Gasfitter
Journeyman / �L
APPROVED (OFFtcE USE ONLY] Li Pn e Number
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4TH FLOOR -.I__. -•I
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5TH FLOOR
6TH FLOOR
7TH FLOOR
aTHFLOOrT
(Print or Type)
Installing Company Name
Address Z/ d %
r
Check one: Certificate
�Q Corp.
Partner.
Firm/Co.
Business Telephone:j�
Name of Licensed _Plumber or_Cas Fitter
Insurance Coverage: lndica:e ;h` :vpe of insurance coverage by checking the
aporooriate-.box:
LiabiIity__insurance._po(icy. Ot^er type of indemnity � Qand
L -
= s_:._:.._ ....:__
Insurance Waiver: -I, the urdersicneJ, have been made aware.that -the licensee or
this ap.piication.does not have anv one o: the above .three insurance._coverages.
Signature of owner/agent or property Owner = -Agent
a
I hc:cay ec:tify that all at the details and Wormation I bare submitted (cr entutd) in above xopiieation ate trtte and acctuate to the best of my
k -10 -ledge and that x11 ptumbin; work and InstAd4tioes -.=forase.d undue ' terr..it i::Led [o: thiz sppilcxt:en will =mpEianoa with to pestln=t
ptarisiocts of Ilse Massaa4us4tts State cat Gad6 usd t3aptcr I4. of t;a Ce:tCz1 LAWS.
3v TY?_= LICZNS-:7, V,
Ti.ie ! Gasfitter Signature of Licensec
Ci`;r/Tcwn- ! gaster Plumber or Gasfitter
Journeyman / �L
APPROVED (OFFtcE USE ONLY] Li Pn e Number
MDate
2542-
F ppRT1y TOWN SOF NORTH ANDOVER
F? PERMIT FOR GAS INSTALLATI
:
9
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�ySSACeMUSEt
LL *fi
.—i
This certifies that...
has permission for gasinstallaton h
in the buildings of ej!G.31
/c��
at ..�.%../� ........ 5� �.. f. !'t. , ,North Andover, Mass.
Fee y/x .: Lic. No
C.Gat GAS INSPECTOR. :r
WHITE:, Applicant ,' CANARY: Building Dept. PINK: treasurer GOLD: File
N° 3015 Date........�y�.z% a�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
j(�This certifies that ........l ..t.�, . �°.........R..C.?.....................
has permission to perform ...........................................
wiring in the building of .......... .............................................
°t. c)'dC /7.North Andover, i
r Fee.,�"......� Lic. Nol .,.J /.!......... ..........-In . c,..,f. F::.: ..
ELECTRICAL INSPECTOR
Check # � f � �V
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
,r
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: ��� 0 �,� g� To the Inspector of Wires:
By this application the undersigned gives notice o his or er intention to perform the electrical work described below.
Location (Street &Number)
Owner or Tenant S — I Telephone No.
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Fixtures
r3
No. of Lighting Outlets
No. of Lighting Fixtures
No. of Receptacle Outlets Iq
No. of Switches
1' No, of Ranges
No. of Waste Disposers
F
No. of Dishwashers
No. of Dryers
No. of Water KW
Heaters
No. Hydromassage Bathtubs
OTHER:
Yes No (Check Appropriate Box)
Utility Authorization No.
Overhead Undgrd No. of Meters
Overhead Undgrd F] No. of Meters
IE
Completion of the following
No. of Ceil: Susp. (Paddle) Fans
No. of Hot Tubs
table may be waived by the Inspector of Wires.
No. of Total
Transformers KVA
Generators KVA
Swimming Pool Above In
rnd. rnd.
o. o Emergency tg mg
BatteryUnits
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Gas Burners
No. of Air Cond. Tonsl
No. of Alerting Devices
Heat Pump Number Tons KW
Totals: �� """ " "' -
Space/Area Heating KW
No. of elf -Contained
Detection/Alertina, Devices
Local Municipal Other
Connection
Heating Appliances Key
Security Systems:
No. of Devices or Equivalent
No. of No. of
Signs Ballasts
No. of Motors Total HP
Data Wiring:
No. of Devices or Equivalent
Telecommunications Wiring:
No. of Devices or Equivalent
uuumonai aerau y desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 0 BOND F] OTHER F] (Specify:)
Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date)
Work to Start: Inspections to be requested in accordance with. MEC Rule 10, and upon completion.
I cert, under the ins and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: tZ ��
Licensee: Signature 4Z t LIC. NO.:
(If applicable, enter -exem in the lice umber LIC. NO.:
Address:�\ Bus. Tel. No.:
OWNER'S INSURANCE WAI ER: I am aware that the Licensee does not have the liability inlsut. Tance overage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 -owner E] owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $