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HomeMy WebLinkAboutMiscellaneous - 370 FOREST STREET 4/30/2018 (2)e Date ..... ........�'.. �..'�-- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that w' . '....,,,,, ........� has permission to perform ...7 /':7 ................................................................. wiring in the building of f..&kJ 5�;v ....................................................... ....................... at .3.7 . . ...........T...............North Andover, Mass. Fee.. — ... Lic. No.. .....:s9 .......tLEE�L......... INSPE4TOOR Check # —t� / s Commonwealth of Massachusetts , uivDepartment of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. L (9 56-3 Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 04-26-2012 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) 370 FOREST STREET Owner or Tenant Michael Jorgensen Telephone No. 978 - Owner's Address SAME Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building RESIDENCE Existing Service Amps New Service Amps Utility Authorization No. Volts Overhead ❑ Undgrd ❑ Volts Overhead ❑ Undgrd ❑ 184335 No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7KW STANDBY EMERGENCY GENERATOR — PROPANE No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Tota Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑In- ❑ rnd. md. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection an Initiating Devices No. of Ranges No. of Air Cond. Tota Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number I Tons KW """.............. No. of Self -Contained Totals: F-*- Detection/Alertin 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. o No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydro massage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: MOVE APPROPRIATE CIRCUITS TO NEW TRANSFER SWITCH/PANEL INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licen- see provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certi- fies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) 10-01-2012 (Expiration Date) Estimated Value of Electrical Work: $4,300 (When required by municipal policy.) Work to Start: 04-26-2012 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: WILLIAM J. IANNAZZI, INC. \ -- _ LIC. NO.: 13592A Licensee: WILLIAM J. IANNAZZI Address: 191 CHANDLER ROAD ANDOVER, MA 01810 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liab By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner Owner/Agent Signature Telephone No. LIC. NO.: 13592A Bus. Tel. No.: 978-686-7300 Alt. Tel. No.: insurance coverage normally required by law. � owner's a ent. PERMIT FEE: $ QThe Commonwealth of Massachusetts IkMDepartment of Industrial Accidents Office of Investigations a 600 Washington Street Boston, MA 02111 " sM y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): WILLIAM J. IANNAZZI, INC. Address: City/State/Zip 191 CHANDLER ROAD ANDOVER, MA 01810 Phone #: 978-686-7300 Are you an employer? Check the appropriate box: 1. ❑X I am a employer with 16 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. x❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other GENERATOR *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ATLANTIC CHARTER Policy # or Self -ins. Lic. #: WCA0 0 5 2 0 7 0 3 Expiration Date: 10/01/2012 Job Site Address: 370 FOREST STREET City/State/Zip: NORTH ANDOVER, MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undehelrainsd penalties of perjury that the information provided above is true and correct 04-26-2012 978-686-7 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: Phnnr ;i- y -a4_ All, ":g- s' ,/,/ 407 -//- i Date. 'S/f! .l Z........ . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. G..... .�?�... . has permission for gas installation . %� F«''�!'. l.' ./ r�ir in the buildings of ...... t,� E'. 17 ................... at ..3�° ..., ?res / `Sr........ North/Andover,Mass. Fee ... W- a9 Lic. No.. *�%� GASINSPECTOR Check # ZD%`►% �ot4t,vv &V c9 &Tff& MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE MAY 4 2012 PERMIT # JOBSITE ADDRESSI 370 FOREST ST. OWNER'S NAME MICHAEL JORGENSEN GOWNER ADDRESS I MICHAEL JORGENSEN TE 978-989-9464 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL F1 RESIDENTIAL] PRINT CLEARLY NEW:E] RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES® NDE] APPLIANCES -1 FLOORS- BSMPF___ 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 1 GRILLE INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST 1 _ UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER OTHER I RUN UNDERGROUND GAS 1 LINE AND CONNECT A GENERATOR _ I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY fTj OTHER TYPE INDEMNITYE] 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ROBERT WHITE LICENSE #W-/.473+ SIGNATURE MP K MGF EJ JPE] JGF ® LPGI ® CORPORATION ®# PARTNERSHIP ®# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY DANVERS STATE MA ZIP 01923 ...... TEL 1-800-322 6628 FAX CELL EMAIL �� __�///Z 1 The Commonwealth of Massachusetts _ . Department of Industrial Accidents Office of Investigations � 1 Congress Street, Suite 100 "^7 Boston MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Iaferna-t6vn Tease Print Legibly Name (Business/Oreanization/Individual): EASTERN PROPANE & OIL Address: ' 131 WATER STREET City/State/Zip: DANVERS, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate boa: 1. ❑✓ I am a employer with 45 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] T c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.7 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑✓ Other GAS FITTING *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL INSURANCE COMPANY Policy # or Self -ins. Lic. #: W C7-641-435806-052 Expiration Date: 03 / 15 / 2013 Job Site Address: 1' 0 .I 2sf 5A. Ci /State/Zi ty p: in e4H c.! cn.ea1 CIPS' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penaltiesperjury that the information provided above is true and correct- 03/13/2013 orrect 03/13/2013 978-750-6500 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 Depart7nen# 3: City/Town=CIerli 4. Electrical Inspector 5. Plumbing Inspector 6. Other 'Contact Person: Phone #: Location 3 70Or2P�ST ,Si rice 7` No. 13 Date _ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # a 5 3a 17599 $ 50.60 Building Inspector DLj A TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ... :: p�i� ✓,• r. LF .I[%Ax"'k'i�X��"- ., ��i':' _ " F' r+zkkv -.n35 k ., 1.:. `� � € '� S x BUILDING PERMIT NUMBER: DATE ISSUED:13V Q SIGNATURE: Building Cotrlm"issioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number V 1.3 Zoning Information: 1.4 Property Dimensions: 0 4 X56: 5%. /111 Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required I Provide Required Provided Required Provided 73, 06 15-6. 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zone Information: Public V Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT historic District: Yes No 2.1 Owner of Record I w A3 b L) A 0 t 4 S �3A Kktk) a e �t) Address for Service: �-. 5 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: +Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construccttion Supervisor: �� �yxi t S Not Applicable ❑ ! h1 Licensed Construction S pervisor: l f I. VZ � trYltlTt�� I�VI����i�yZ -� . J 1 7 License Number dli ess Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number l>ddress Expiration Date S:� elute Telephone MV M Z O Gi ft SECTION 4 - WORKERS COMPENSATION (MGL 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 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition 1r Other ❑ Specify Brief Description of Proposed Work: r , LCA—`z, SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OF>FTCIAL USE E3NLY 'I. Building `- �- (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction�� 3 Plumbing Building Permit fee tel 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 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 Own er/A ent Date . NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS IST 2 ND 3 SPAN DINIENSIONS OF SILLS DIN ENSIONS OF POSTS DIWNSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIvWEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE d Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 Building Demolition Affidavit ATp 5-'5,04c � p10 t2 Tli ddw- T �� �O[KICnIWKM 1Sy^+ 9 �4SSgcHus���y DEPARTMENT SIGN -OFFS D.P.W./ WATER R( EWER GAS A)o P 9 - ELECTRIC Z_ i k TELEPHONE CABLE ,,. TAXES., ¢� POLI .1' 1k.r` �► (✓'R� irJ , p?r/U,� FIRE` f Qii �. EXTERMINAf R DUMPSTER- ON/ OFF STREET DIG SAFE NUMBER BLDG. INSPECTOR DATE RECD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 !Workers' Compensation Insurance Affidavit Name Please Print Location: City Phone # 71 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' Insurance. Co. _ _ _ Policv # Company name: Address City: Phone #: working on this job. Insurance Co. Policv # Failure to secure coverage as required under section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment -as -well-as -civil,penatties; in 1he form iof a.-ST.OPWORK.ORDER..and_a.fine_of.(.$1DO.OD)_artay against -me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i do hereby certifya the p d peg Signature � 17a Print name the information provided above is true and correct. Date - © 4 Official use only do not write in this area to be completed by city or town official' City or Town PermWLicensing Building Dept ❑Check if immediate response is required Licensing Board p Selectman's Once Contact person: Phone #. E] Health Department R Other Ae 'i�ia��vmA7u�real a ✓j%r ac/u ael t BOARD I- BUILDI G REGULATIONS License: CONSTRUCTION SUPERVISOR t Number: CS 051123 Birthdate: 02/27/1957 Expires: 02/27/2005 Tr. no: 8988 Restricted: 00 M SCOTT MCINNIS , 1 ALEXANDER WAY HAMILTON, MA 01936 Administrator mv - 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 c 11, S 150 A. The debris will be di�� sed of in: � (Location of Facility) Signature of Permit Applicant Date �\k NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector o u W W s.� 6 z q �ll U 0 O TIT P4 T U) Ce W W C9 W N x V:: w o x o � h x vV H s •aCOL. Cm� m44C 4"'. O 1r o c fA 0 C O m �0 a t GO cc >C2 Z C O y y `�0+ w lo ,F, C 32 �Oa s CL mom 0 �•�Z o` 2p _ m 'mwo A CR o cn 0 A q �ll U 0 O TIT P4 T U) Ce W W C9 W N V:: w o o � h O C vV H s •aCOL. Cm� m44C 4"'. O 1r o c fA 0 C O m �0 ts C. m c E t GO cc >C2 Z C O y y `�0+ m W :mo o.c, h.:m lo ,F, C 32 �Oa s CL mom 0 �•�Z o` C o Ca a c N C •C _ m 'mwo A : d r CO) m~ CD COD LY t C m Z �• O LL r C •y N W . z •E v .0 v •y C COD m Cpm 5 a 4 D _ v a`�� o .a�mF q �ll U 0 O TIT P4 T U) Ce W W C9 W N Location c./%6) No. /30/ Date OfNORTH TOWN OF NORTH ANDOVER F Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ s,+cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $x'30 Check # .17768 Building Inspector Q) N 2� N Z Ego p ~ Q � ��--,, > ~L,WC9 ^� W � o N TZ m lv Q 6 m zw�� o° W °� o m°mQ �' J Z W Z W?o Wo Z�v3 mo ti �ooJ r V� x60 W°zZ� of e�o� o W o Qo �?(n j��� cn Q W W �i ��� cn Q) O d Q � `v ° W W U) 0 C) o W��Wm °Q� WW °x W� o Z�°j"' o° ZQQ V �� o z �¢000 (Qo W°aL' °° �* SQ-°^ o0 W v Q o V~ p 0 J Z Q Z Z N Q O J O W N U N U Z?OO�Q. mm� �Z?L,Z �� �� YQCL:Z, i `'O J �(� �� "II r"� c oo pcnk O W O --J p �m a h Q- i~ W ~ p Z O W � V O oO� Z W ~ W` Hwcn o���w.� Q ZZ�Zm o� o� mZoo� Wm O O Q JO O OZ O QO Q W° C) Q- zoo o'Zz mz 2L J� J O �mN JQ- Lu�J �c�2 °kc\Lu> CLQ C�� O�J�JQ v� Q cnN z Z° Lw k aO ZkW ZO O W W I I I Imo° OOZ ? � a T Lu Jcn �m j� -- Q wa o m Lu (n Z T� IW kcnOocn� N Ni M �� *9 9991P, 'ON 3SV,? IdnOD Z- k ONV7 NO 03SVS S1 NVIG183PV � o � Lo v o co mg Z ^ OZ OW �4j z� :Z) CL LAj � QL (3) >Qzcom W:W:, o 00 150' o�Z o Co '4;K C9 W WZ Q 00 Q L o gym° o, Opti Lo T ,� za N m�� g o Z pz O� AAA. b �vj :ZQ WO �� W 2tn za �c) Y W Q C♦ y ► � Cf) 141 GARAGE No. 370zz Q �- \_°oma aZza o-dY I , w ° p V— 0 0 I N 0 � _ Z o119'± (TO L ' 43.36' CEDAR LANE) 00 E41 1 sT a' 150 NW LE �pTN) \ 60 B�Ic�vPR�PB cP� . Es 1 F OR IQ Location—,3 70 FO-12ej T S in SPT' No. J,;)� el Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ / Other Permit Fee $ TOTAL $ Check # X533 17 6 u 0 I)o Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICAtION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING MM..;_ fv w. a r •:.,`- r 5-s 3%�'*nx _ �.. �T�isss�:teon f�� �a� Usei�rt► - BUILDING PERINIIT NUMBER: � � RATE ISSUER: SIGNA'T'URE: Buildin Commissioner/Ins or of Buildin Rate 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number \\\Information: 1.3 Zoning 1.4 Property Dimensions: 'Zoning District Proposed Use Lot Area (sf) Frontage R 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Re 'red Provided 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal On Site Disposal System ❑ 2.1 Owner of Record Name (Print) Address for Service Signature � � r Telepho 2.2 Authorized Agent Name nt Address for Service: Signature Telephone 3.1 Lice sed Construction upervisor r Not Applicable 0 Ores �� ,s nIs �2 License Number Address 2 — Z 'C- C L ceased Co ructio Su niso C~ ��� �dQ Expiration Bate � Signature Telephone 3.2 Registered Nome Improvement Contractor Not Applicable 0 Company Name Registration Number Addrtess Expiration Date Signafv,re Telephone M Z v n M INO 0 M X Z Z M 0 v M r r 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 Yea .......❑ No ....... ❑ 5.1 Registered Architect: Name: Address Signature Telephone Cm ��� a -c r Not A Applicable Company Nq pp ❑ 1 Responsible m Charge of Construction , Area of Responsibility Registration Number Expiration Date Name: i Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: ` Address` Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Cm ��� a -c r Not A Applicable Company Nq pp ❑ 1 Responsible m Charge of Construction , V A New Construction ❑ Existing Building ........ ......; ,::..:: Repau(s) USE GROUP (Check as applicable) Alterations(s) 0 Addition Accessory Bldg. 0 Demolition Other ❑ Specify Brief Description of Proposed W rk: CZ ❑ ❑ U.` ❑ 2A 2B 2C I USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A4 ❑ A-2 0 A -s A-5 ❑ 0 IA IB ❑ ❑ B Business ❑ 2A 2B 2C 0 0 ❑ C Educational ❑ F Factory 0 F -I ❑ F-2 0 H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional 0 1-1 ❑ I-2 ❑ 1-3 ❑ M Mercantile ❑ 4 0 R residential R-1 ❑ R-2 0 R-3 ❑ 5A 513 ❑ ❑ S Storage ❑ S-1 0 S-2 ❑ U Utility 0 Specify: M Mixed Use0 Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: Proposed Use Group: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if Number of Floors or Stories Includ Basement levels Floor Area per Floor s Total Area (s Total Height lftl ? Independent Structural Engineering Structural Peer Review Required — Yes ❑ No ❑ SECTION IQa Owner Authorization - TO BE COLLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Hereby authorize PROPOSED Owner of the subject property My behalf, in all matters relative two work authorized by this budding permit application Signat'iire of Owner Date to act on �f a 2 lA C as Owner/Authorized �� Agent Fle er y declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penaltileF of perju C—:�c �& Print Nam Signature of Owner/Agen Date Item Estimated Cost (Dollars) to be fJx Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of P-/ Construction from (6) 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) C�1 a 1 5jj Check Number YI'31 'iii Y.L>F} } t.l ll 4j r '( GF! E� tz,r� x � �,� f �' t p f1�F ,kl �_ '+ .4? +•l � � �� �, a . t - y":l" i�'v' �i y �i} � f f :n; �J r �. NO. OF STORIES SIZE 30, cl l BASEMENT OR SLAB l� l-5 fit SIZE OF FLOOR TRvIBERS 1 sr 2ND 3RD z k l� 1 SPAN / 5- 1 /' DEMENSIONS OF SILLS 2 , Z X DEMENSIONS OF POSTS x 0' S DDAENSIONS OF GIRDERS 3 �a �' L C HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING Z- X 4 MATERIAL OF CHIMNEY �� o cA--Z— IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ,, =F",,:. r f 5,5 63��� IIS b a 0 ffI t� a t Q. tat 02 1) 3s a r7 ,t I -v FiI- FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that ali 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*********************** APPLICANTW LOCATION: Assessor's Map Number. SUBDIVISION STREET PHONE —4-S\ PARCEL LOT (S) ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: RVATION ADMI COMMENTS TOWN PLANNER COMMENTS FOOD TH TH ,TOR DATE APPROVED 8'Zz Le y DATE REJECTED DATE APPROVED _ DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS_LI,&L.0 r_��� Y► 27a 'rZ Le: �,� r'o �,,..t S P -L)4c •L S Via• � �,� � v • / "-f � s-» •fe�.�� �►. ro � � �-- � a ��-�'c �- PUBLIC WORKS RIWATER CONNECTIONS � �`� i 04/ C-C,'^"s��" DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 Jm �/aeam�miaiuucuil a �/ BOARD OF BUILDING F License: CONSTRUCTION-c Number: CS 051123 Birthdate 02127/1957 Expires: 02/27/2005 Tr. no: 8988 Restricted: 00 M SCOTT MCINNIS 1 ALEXANDER WAY. HAMILTON, MA 01936 Administrator The Commonwealth of Massachusetts Department of /ndustnal-Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity FFT I am an employer providing workers' com ensatio for my a ployees working on this job. Com an name: C fU � I S �6 A --Qt( cel? Address • 't ( q_lr' Vk-IQ L rl-& VU _ X City: A pti t f 8 a�) - El lT Phone*: q (S -.z4 6CS _ q cRo Insurance. Co. Policy # Company name: Address City: Phone #• Insurance Co. . Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment -as .well,as.civil.penaltiesin. theiorm ofa_S7 WORK ORDER..arid_a.fine.of.(.$7.-00.00)-a day.against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify rJelpe p d peta�Jes offfrj,ury th, ( the information provided above is true and correct. Print � `Jk9"Ut Official use only do not write in this area to be completed by city or town official' - /Z -0 4 ASCO City or Town Permit/Licensing Building Dept []Check if immediate response is required Licensing Board E] Selectman's Office Contact person: Phone A- n Health Department Other PEST END, INC. UNCLE f ,1 s Pont -End, Inc. 508 6888344 08-18-04 09:46 P.02 15 Pelham Street 82 Piaistow Road, Ote. 125 Mothuen, MA 01844 Plaistow, NH 03985 (978) 794, 4321 Fax (978) 699.8344 (603) 362-9644 Fax (603) 382-9525 poalendinc.com pestendinc.com Innovative Properties, Inc. Attn : Alex Caruso 237 Lantern Road Revere, Ma. 02151 August 18, 2004 Property Location :370 Forest Street No.Andover, Ma, 01845 Dear Alex, This letter is to confirm that you have retained our company to bait the above property 3 days prior to demolition. If you have any questions feel free to call our office. Sincerel�r, -'; Pest -End, Inc. GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVER BUILDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the necessary info '�onasp uested below. Permit Applicant Property address Map / Parcel -�(C8 (- ze,�FQ - � `� 3t 5 Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the Growth Management Bylaw. I also understand providing this form does not absolve me or any, party to this permit from the requirements of obtaining other permits required prior to the issuance of the building permit. Further 1 understand that my interpretation of the exemption status is subject to review by the Building Department and is only officially accepted when the building permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit ap kation and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for building permit for the enlargement, restoration or reconstruction of a dwelling in . existence as of the effective date of this bylaw, provided that no additional residential unit is created. v� T so L t r� The lot(s) was / were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and or moderate income families or individuals, where all of the conditions of 8.7.6 are met and or represents dwelling units for senior residents, where occupancy of the units is restricted to senior citizens through a properly executed and recorded deed restriction running with the land. For purposes of this section "senior" shall mean persons over the age of 55. This application is part of a development project which voluntarily agreed to a minimum 40 % permanent reduction in density (buildable lots) below the density permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the planning board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a one time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready fora building permit ( all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that year. One building permit will be issued per year per Development until such time as the development schedule accommodates issuing building permits. Applicant must submit an approved FORM U with this EXEMPTION. PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS. BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED BUILDING PERMIT 1S ALLOWED AN EXEMPTION AS CITED ABOVE. FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE CHECKING OFF OF A ABOVE EXEMPTION WHICH DOES NOT COMPLY, WHETHER DONE TO MY KNOWLEDGE OR NOT IS GROUNDS FOR REFUSAL BY THE BUILDING DEPARTMENT TO ISSUE A BUILDING PERMIT. APPLICANTS SIGNATURE DATE THIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION 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 ' (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 370 Forest Street _ North Andover_ Owner's Name: _Innovated Properties Owner's Address: _237 Lantern Road_ —Revere, Ma 02151_ Date of Inspection: 7/23/2004_ Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc. Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 475-0786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: (\ Date: 7/23/2004 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _370 Forest Street_ —North Andover_ Owner: _Innovated Properties Date of Inspection: 7/23/2004_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: X One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. X The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Septic tank leaking out. ND explain: _N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: N_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _370 Forest Street —North Andover_ Owner: Innovated Properties Date of Inspection: 7/23/2004_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require finther evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _370 Forest Street _ —North Andover_ Owner: _Innovated Properties_ Date of Inspection: 7/23/2004 D. System Failure Criteria applicable to all systems: You must indicate `des" or "no" to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone l of a public well. No Any portion of a cesspool or privy is within 50 feet of a private water supply well. No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _370 Forest Street_ _ North Andover_ Owner: _Innovated Properties_ Date of Inspection: 7/23/2004_ Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes No _Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? _No Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? N/A _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) _No_ Was the facility or dwelling inspected for signs of sewage back up ? House had fire, unable to see cellar. Yes _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _No Existing information. No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _370 Forest Street_ —North Andover_ Owner: _Innovated Properties_ Date of Inspection: 783/2004_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): —N/A _ Number of bedrooms (actual): _3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _N/A Number of current residents: _0 Does residence have a garbage grinder (yes or no): No_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: _On well water _ Sump pump (yes or no): _No_ Last date of occupancy Vacant for 1 year, house had fire- COMMERCIAL/ INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped two years ago, owner _ Was system pumped as part of the inspection (yes or no): _No If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: Unknown_ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _370 Forest Street_ —North Andover_ Owner: Innovated Properties Date of Inspection: _7/23/2004 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _30"_ Materials of construction: _ cast iron _40 PVC other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _Unable to see piping, house had fire SEPTIC TANK: X Depth below grade: _18" Material of construction: X concrete _ metal _fiberglass _polyethylene other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: _7' x 5' x 4' Sludge depth: 1"_ Distance from top of sludge to bottom of outlet tee or baffle: _N/A_ Scum thickness: _0"_ Distance from top of scum to top of outlet tee or baffle: _NIA NIA = tank leaking out Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) Inlet baffle ok. Outlet baffle ok. Depth of liquid below outlet invert. Evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 370 Forest Street_ _ North Andover_ Owner: _Innovated Properties Date of Inspection: _7/23/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): — D -box level & distribution equal. No evidence of leakage. Light carryover. D - Box cover broken, replaced sae._ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 370 Forest Street Owner: Innovated Properties Date of Inspection: _78312004 SOIL ABSORPTION SYSTEM (SAS): X If SAS not located explain why: (locate on site plan, excavation not required) Type _ leaching pits, number: _ leaching chambers, number: leaching galleries, number: _ leaching trenches, number, length: _ X leaching fields, number, dimensions: _1 field 10' x 601 _ overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _ Soil ok. Vegetation ok. No sign of ponding to surface._ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 370 Forest Street _ North Andover_ Owner: _Innovated Properties_ Date of Inspection: 7/23/2004_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 106' Well O Garage House B Z Septic Tank D - Bog A Driveway A to Tank =19' A to D -Boz = 28',6" B to Tank =15' B to D -Boz = 26'6" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _370 Forest Street_ —North Andover_ Owner: Innovated Properties Date of Inspection: 7/23/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ >6'_ Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) X Accessed USGS database -explain: _ Essex County Soil Map_ You must describe how you established the high ground water elevation: _Essex County Soil Map, Sheet # 36, Canton Soil, Water > 6' Deep. _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 370 Forest Street, North Andover Owner: Innovated Properties Date of Inspection: 7/23/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Bateson Enterprises, Inc. Permit Number MECcheck Compliance Report Massachusetts Energy Code MECcheck Software Version 3.2 Release 1 a Checked By/Date TITLE: Re-Hab CITY: Essex STATE: Massachusetts HDD: 5641 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 08/24/04 DATE OF PLANS: 08-23-04 PROJECT INFORMATION: 370 Forest Street North Andover MA COMPANY INFORMATION: Innovative Properties 237 Lantern Road Revere, MA I COMPLIANCE: Passes Maximum UA = 334 Your Home = 334 0.0% Better Than Code Gross Glazing Area or Cavity Cont. or Door Perimeter R -Value R -Value U -Factor UA Ceiling 1: Flat Ceiling or Scissor Truss 286 1.9.0 30.0 6 Ceiling 2: Flat Ceiling or Scissor Truss 156 19.0 30.0 3 Ceiling 3: Flat Ceiling or Scissor Truss 156 19.0 30.0 3 Ceiling 4: Flat Ceiling or Scissor Truss 160 19.0 30.0 3 Ceiling 5: Flat Ceiling or Scissor Truss 130 19.0 30.0 3 Ceiling 6: Flat Ceiling or Scissor Truss 136 19.0 30.0 3 Wall 1: Wood Frame, 16" o.c. 934 0.0 13.0 90 Wall 2: Wood Frame, 16" o.c. 934 0.0 13.0 51 Window 1: Vinyl Frame, Double Pane with Low -E 164 0.290 48 Window 2: Vinyl Frame, Double Pane with Low -E 164 0.290 48 Door 1: Solid 35 0.100 4 Door 2: Glass 40 0.100 4 Basement Wall 2: Solid Concrete or Masonry, 8.0' ht/7.0' bg/3.0' insul 934 19.0 30.0 68 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in MECcheck Version 3.2 Release la. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions fo din the Code. The HVAC equipment selected to heat or cool the building shall be no greater than % s ign loa s sp ified in Sections 780CMR 1310 and J4.4. Builder/Designer � Date Z-3 -c1 MECcheck Inspection Checklist Massachusetts Energy Code MECcheck Software Version 3.2 Release la DATE: 08/24/04 TITLE: Re-Hab Bldg. Dept. Use Ceilings: 1. Ceiling 1: Flat Ceiling or Scissor Truss, R-19.0 cavity + R-30.0 continuous insulation Comments: 2. Ceiling 2: Flat Ceiling or Scissor Truss, R-19.0 cavity + R-30.0 continuous insulation Comments: 3. Ceiling 3: Flat Ceiling or Scissor Truss, R-19.0 cavity + R-30.0 continuous insulation Comments: 4. Ceiling 4: Flat Ceiling or Scissor Truss, R-19.0 cavity + R-30.0 continuous insulation Comments: 5. Ceiling 5: Flat Ceiling or Scissor Truss, R-19.0 cavity + R-30.0 continuous insulation Comments: 6. Ceiling 6: Flat Ceiling or Scissor Truss, R-19.0 cavity + R-30.0 continuous insulation Comments: Above -Grade Walls: 1. Wall 1: Wood Frame, 16" o.c., R-13.0 continuous insulation Comments: 2. Wall 2: Wood Frame, 16" o.c., R-13.0 continuous insulation Comments: Basement Walls: 1. Basement Wall 2: Solid Concrete or Masonry, 8.0' ht/7.0' bg/3.0' insul, R-19.0 cavity + R-30.0 continuous insulation Comments: Windows: 1. Window 1: Vinyl. Frame, Double Pane with Low -E, U -factor: 0.290 For windows without labeled U -factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ]/No Comments: 2. Window 2: Vinyl Frame, Double Pane with Low -E, U -factor: 0.290 For windows without labeled U -factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [I/No Comments: Doors: 1. Door 1: Solid, U -factor: 0.100 Comments: 2. Door 2: Glass, U -factor: 0.100 # Panes Frame Type Thermal Break? [ ] Yes [ /]No Comments: Air Leakage: [ ] I Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. [ ] I When installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin (0.944 L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. Vapor Retarder: [ ] I Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. I Materials Identification: [ ] I Materials and equipment must be identified so that compliance can be determined. [ ] I Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. [ ] I Insulation R -values and glazing U -values must be clearly marked on the building plans or specifications. I Duct Insulation: [ ] I Ducts shall be insulated per Table J4.4.7.1. I Duct Construction: [ ] I All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. [ ] I The HVAC system must provide a means for balancing air and water systems. Temperature Controls: [ ] I Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. I Heating and Cooling Equipment Sizing: [ ] I Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. I Circulating Hot Water Systems: [ ] I Insulate circulating hot water pipes to the levels in Table 1. I Swimming Pools: [ ] I All heated swimming pools must have an on/offheater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. I Heating and Cooling Piping Insulation: [ ] I HVAC piping conveying fluids above 120 °F or chilled fluids below 55 °F must be insulated to the levels in Table 2. ' Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes. Insulation Thickness in Inches by Pipe Sizes Heated Water Non -Circulating Runouts Circulating Mains and Runouts Temperature ( F) Up to 1„ Up to 1.25" 1.5" to 2.0" Over 2" 170-180 0.5 1.0 1.5 2.0 140-160 0.5 0.5 1.0 1.5 100-130 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes. Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range F 2" Runouts 1" and Less 1.25" to 2" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant, 40-55 0.5 0.5 0.75 1.0 and Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD (Building Department Use Only) WD W U" 2) 7D c1 4, cc O y �1 7 •n � cs � W W is-t.js w m Z E r Z• y do _ (� FMMC& g=m o Cc C � y yW4 w t �• E 0w 0ru 7 av` I Z L C 0 S W O 4 SO `o �oow CDc ao c a � QJ`mc 'c = m� aw 30 cc c w z m LU ♦• Z to CL= - z W E 45-0 �•y o CL C.3 a m o CCM F=- _ 00 .0 N = O H Z S dam MI. a I C/) 0 U LM CA CD 0 cc M y O C. 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TOWN OF NORTH ANDOVER Building Permit Number 139 8/25/04) Date: November 18. 2005 THIS CERTIFIES THAT THE BUILDING LOCATED ON 370 Forest Street MAY BE OCCUPIED AS RECONSTRUCT SINGLE FAMILY DWELLING IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Innovative Properties 237 Lantern Road Revere MA Building Inspector 4 o C 16- a c tL tC � cO � : t vp L: E a t: m .00 cm O L Q o �: m 3 go 4, ca - m -�; y � Aw: :r y �� � m Ocm CLG) •t O pm '1 HE o `o Q;o8o CD CIDn F— o r CLOD ev h CD t LOD C : fi t "" F- .y 2m C . C Z LU .E C3.0 0 y o C.3 cm COO a = A ` y O F- r w o. � m O �• L O Z CD O y v � �r C I O CD 0/�� .F MW W CD 0 CD Z cc 3� O di G O oa � o�Q o cc� c CO v C z C13 C.) CO) O C CL COD 0 February 25, 2004 David & Nanette Rutter 370 Forest Street North Andover, MA 01845 Dear Mr. & Mrs. Rutter: `I"O.11X t:IF NOl~1T1=1 ANDOVER Oflire f 7)eveMpinent an:'.S. Sei'-vices -2-1010010- Street Nuia—ffi Madel 'er, 'a`d;<,'ft.4<i3:$' i 45' Y ``f€:x8; 5 '°N r_. i'.:A,X r: i'O Vii8-9542 Please let this letter serve as verification that the structure owned by you at the above noted address was damaged by a fire on May 12 of 2003 and that the structure was damaged to such an extent that it was rendered uninhabitable as of that date. I hope that this letter will serve your purpose. Respectfully, Michael McGuire Local Building Inspector Friday, September 24, 200412:59 PM M. Scott McInnis 978-488-4047 p.02 AUG 20 20134 9:16 AM FR O/H LINES NO ANDOVERS7251337 TO 919784684047 P.01i01 Thwm"Y. Aw9V t IV, ave.,..... ... "Oup . RUG t 9 9904 2, S6 Pn FA 0�,:� 1�Hr1„!„ NG ANpOVERe7t! 1097 TO 9 f �� T6WR of Nwto Andover. ritrw�. � NoRb AWQW6 b16 01143 vu7 4".043 ha ($71) 08-9342 12A'IY �i • 'r U4 _ - • 'pir -M t fill -lilt 1. V .w T'1:,•- •►�A irA..�.�1� dM•DW M11lO •W im, aping L PAGlA IN":. ** TOTAL PAGE.01 ** Date.... /Ct..... . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING i o • ,SSACMUS� �..�r- This certifies that ..... �. ................ . .,, has permission to perform .. ....:�1..`.... . .... . plumbing in the buildings of ..... ........................... . at,%1?...a"`" -114r........... North Andover, Mass. FeeLic. .............. PLUMBING INSPECTOR Check # G3u3 It MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location— fir% s Owners Name Date _ � —e/0 --Q � Permit # / Amount f0 8 Url Type of OccunancV New r Renovation Replacement Plans Submitted Yes No ❑ FIXTURES (Print or type) Check one: Certificate Installing Company Named I ( ❑ Corp. Addr �� s �-Ili❑partner. � t�l&3a Business Telephone Cj ELFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate &e type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature t I hereby certify that all of the details and information best of my knowledge and that all plumbing work app compliance with all pertinent provisions of the M sJ Title City/Town APPROVED (OFFICE USE ONLY Agent ❑ entered) in above application are true and accurate to the id under Pe Issued for this application will be in e%�'-Whapter 142 of the General Laws. Type of Plumbing License 3�3 ❑icenseum er Master Journeyman 2 1 iz �u Date. / ......... 6y TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................. has permission for gas installation .......... in the buildings of .......................................... at . —.-70 ............. North Andover, Mass. Fee. Lic. No -:72G '11-3... --I . ............ GASINSPEC R Check # 4998 MA,SSACHUSEl'I'S UNWORM (Type or print) NORTH ANDOVER, MASSA Building Locations s Name New P Renovation ❑ Replacement 11 111 -4111 X11111 11 1.1 �IYY111� _ Date /-/Cj •—o -s' Plans Submitted ❑ Permit # el Amount $ X21-�-Ov (Print or Name— Name ame_ Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. RFirm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No C] If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 1:3 Other type of indemnity 1:1 Bond D. 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: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I havemitted (9tentered) in above application are true and accurate to the best of my knowledge and that all plumbing work and inst ations pe rme nder Permit Issue or this application will be in compliance with all pertinent provisions of the Massach etts State s IC06 ancyCDaptgP 14 of the General Laws. Title City/Town i APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Or.- 4/ � Gas FittericeL" nse Number ri Master qJourneyman ,OGA Date ...... 11-117 ./.......7/- .................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING L--2 (I Thiscertifies that ... ................... .... :�� ........................................................ has permission to perform ......... .............................................. wiring in the building of X, J ........................................ . North Mdover, Mass. Fee .'4*''?! ..... Lic. N6 � A:.. —2 '-__ELECTRICALi;;iP�i'C*T**O"R"'**"*""*'*** Check # 5429 THECOMMONWEUTHOFMf DEPARTNIDIITOFPUMAC BOARD OF FIRE PREVF V 770N REY APPLICATION FOR PERMIT TO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE I (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical Location (Street & Number) S 7r) Owner or Tenant Owner's Address Office Use only Permit No. 6. CMRI2:QD 0y- Occupancy 8Occupancy & Fees Checked RMELECTRICAL WORK ELECTRICAL CODE, 527 CMR 12:00 Date below. To the Inspector of Wires: Is this permit in conjunction with a building permit: YesNo r7 (Check Appropriate Box) Purpose of Building n / e-/ t/ ! __ �� Utility Authorization No. Existing Service Amps��Volts Overhead M Underground M New Service �01) — Amps 2 / o21(Jvolts Overhead r-1 Underground Number of Feeders and Ampacity �2 — 6116 Location and Nature of Proposed Electrical Work ` No. of Meters No. of Meters / No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round round No. of Receptacle Outlets D No. of Oil Burners / No. of Emergency Lighting Battery Units No. of Switch Outlets h 30 No. of Gas Burners FIRE ALARMS No. of Zones «No. of Ranges / No. of Air Cond. / Total 3 < Tons No. of Detection and 7 Il No. of Disposals / No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers / Space Area Heating KW No. of Self Containt Detectiord: idies Local pal Other No. of Dryers / Heating Devices KW tions No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• A Iffl eCovaage. Pt tDtlr tri T0VsofMassadlm=ttsGmrAI-aws Ihawahnwdvalidptoofofsmvothe011m YES drcldrigflrap cM p OTHER a alalt YB LJ NO E] If you have YES, plea9e indicate the type of cDWrage by E Mm*d VahredE1c ftEal Wodc $ Rizotltt>f�1 Fmal LioameNo. 315-7 % E- _ _ L - v BusnbmTel.No. Address— & 86 Jo S �-3 �/( 1k J%I) &Ja_'D .7i�a JI—A d. Tel No. OWNER'S &SLRANCEWAMT, lam awatedmtdrLxemdmnothavetheummnoecovsagecrit akfttalequval asregtmedbyMmdugcasGemalLam and that my signature on this permitapplication wanes d us ragtmernalt (Please check one) Owner 1:3 Agent M o 0� Telephone No. PERMIT FEES signature o caner or gen � 1 HLJCOMMONWLAUHOFMAS94C Office Use only DEPYlOFPi1BIIC �— �� L Permit No. BOARDOFFIREPREVFNI70NREG�[IONS527Cfi�12:017--- i I O Occupancy & Fees Checked �L7 "PLICATION FOR PERMIT TO PERFORM ELECTRIC U WORK / \ ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 �,_�LEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover ttt /� r/ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wtlrk descAed below. e Location (Street & Number) "� /0 r� Owner or Tenant Owner's Address i Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building / e— (A", 1-k Utility Authorization No. _ Existing Service Amps�Volts Overhead 1:3 Underground No. of Meters �--- New Service on Amps lid / v A!Wolts Overhead r__1 Underground No. of Meters Number of Feeders and Ampacity 2 Gf`„ _ ��• Location and Nature of Proposed Electrical Work ` No. of Lighting Outlets 0. No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above Below Generators KVAKVA round round No. of Emergency Lighting Battery Units No. of Receptacle Outlets `l (J No. of Oil Burners / No. of Switch Outlets ) D J No. of Gas Burners FIRE ALARMS No. of Zones yNo. of Ranges / No. of Air Cond. / Total 3 t < Tons No. of Detection and ^Io. of Disposals / No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices —21o. of Dishwashers / Space Area Heating KW No. of Self Contained Detection/Soundi vices Local Municipal Other No. of Dryers / Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydra Massage Tubs I No. of Motors Total HP hmu�xtoeCoverage. Ptusltarlttotheregtmemafs�GaraalLaws Ihaveaamaxliab>*kmm=Pb yzwkxhgC.mr]eL-Coraageorilssttt�egt� ihave�niWdVd dproofofSa=tDftOffica YES IIT fycuhaN.edeckedYES, Nfc Urdangthe P1indicedtetypeofcoverageby Q�IS[JRANCE BOND � MIER r7 (please Speffy) EViatioriDtie WorklD k6pection D& EstitrwdVaA� dBecir cal Wotk $ Fmal 'e /3J i -) 5_S-_ ' M'S INSURANCEWAIVER,lain awarellildrLxerwdoesnothai .rat mysigrohaeon thispamitapplication waives this regtruemait. (Please check one) Owner Agent signature or Owner or gen LwwNTo. Business Tel No. AkTel. No. incur&McovgagaoritssubsualeWivalergasmpredbyNb%achuserlsCard Laws C� Telephone No. PERMIT FEE $ 5 C5 D p�" � 2 _ i� � �4 yV� i � �� i,D7-� n"y �� J N t c El Date. � \ 1 TOWN OF NORTH ANDOVER r PERMIT FOR GAS INSTALLATION \fin_ • _• v ' This certifies that .`......... has permission for gas installation in the buildings of ...�!�� at . �,d l-�.r �'`-... .,North Andover, Mass. Fee.3v�`dvLic. No.! !. .-3 - !d?.�.1.. �C - GASINSPECTO Check # JUU7 MASSACHUSETTS UNIFORM APPLICATON FOR (Type or print) NORTH ANDOVER, NDOVR, MASSACHUSETTS Building Locations -Icm r'Orest St Innovative Properties Scott McInnis Owner's Name New Renovation ❑ Replacement ❑ $30.50 G SUB-BASEM ENT ABASEMENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. 3 T H . FLOOR FLOOR TO DO GAS FINDING Date 1/20/05 978 468 4800 Plans Submitted ❑ a O U d x z E d F W U Permit # Amount $ , ne.toI I ux er sub (Print or type) Eastern Propane Gas Che one: Certificate Installing Company Name Corp. Address 131 Water St. r _ - • - - - - - ❑Partner. Business Telephone p p �)❑ Finn/Co. Name of Licensed Plumber or Gas Fitter 4 C',1 b INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes^ No ❑ Ifyou have checked yps—pleffdicate 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 requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ 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 undq Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code ati heater I tine. C',pr pmi i ai— OVED (OFFICE USE ONLY) Signature of Plumber w U O C O 2 Gas Fitter a o O w w F ne.toI I ux er sub (Print or type) Eastern Propane Gas Che one: Certificate Installing Company Name Corp. Address 131 Water St. r _ - • - - - - - ❑Partner. Business Telephone p p �)❑ Finn/Co. Name of Licensed Plumber or Gas Fitter 4 C',1 b INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes^ No ❑ Ifyou have checked yps—pleffdicate 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 requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ 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 undq Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code ati heater I tine. C',pr pmi i ai— OVED (OFFICE USE ONLY) §ed P]= Icense Number Signature of Plumber Gas Fitter ❑ Master ❑ Journeyman §ed P]= Icense Number