HomeMy WebLinkAboutMiscellaneous - 39 HAWKINS LANE 4/30/2018 (3)N_
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...................... 4 t-, 7-
.......... :V' ........................ . ..............................
has permission to perform ........ 5'�Fe—� b /Z , 7--/ .... 7�� kL-r
............................. .. ... . . .............
wiring in the building of ..... S' -77 .... ...................................................
I at .................... I .... ... ...... Le North Andover, Mass.
Fee.4( Lic. No..CY ................ .... I ......
Check It 3Z / r7
9257
2�parlmeni 0 1 1 -
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 7
Occupancy and Fee Checked
[Rev. 1/07] (l,av, blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All x%ork to be performed in accordance with the Massachusens Electrical Code (IMEC), 527 CNIR 12.00
(PLEASE PRrVT IN IjVK OR TYPE ALL-LYFO TIOA9 Date: -,2
City or Town of: _A JaC-rW XV-46�!104 To the Inspector of Wires. -
By this application the undersi"nelgives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) Ad LA)
ONvner or Tenant Telephone No. -7
z /:� onn fa:� &--6 77, —
Owner's Address
Is this permit in conjunction with 2 buildin2 permit? Yes El No 0 (Check Appropriate Box)
Purpose of Building — Utili6', AuthoriZ2tion No.
Existing Service Amps Volts Overhead 7 Urid-rd No. of rlete,s
New Service Amps Volts Overhead U.dgrd No. of Nleters
Number of Feeders and Ampacit-,
. A U42
LoC2tion and Nature of Proposed Electrical NN"ork: V41
ComDletion of the following table mav be waived by,the Insoevor of [Vires.
,No. of Recessed Luminaires
— f Ceil.-Susp. (Paddle) Fans
T-10. 0
No. of Total
iTrpnsformers KVA
No. of Luminaire Outlets
No: of Hot Tubs
Generators KVA
No. of Luminaires
_ pool Above E] In-
IS,A,im , in
m , c -r r n d. grrid.
Emer-encv LiEhtinz
NO. ot b . - -
lBattery Units
No. of RecepTacle Outlets
No. of Oil Burners
FIRE ALARAIS IN,. of Zones
No. of S,,vitches
No. of Gas Burners
No. of Detection and
InitiatinEr Devices
No. of Ran -es
No. of Air Cond. Total
Tons
No. of Alerting Devices
Heat Pu p
I
No. of Self -Contained
No. of Waste Disposers
Toramls:
Detection/Aler-tinZ Devices
No. of Dishw.3shers
Sp2ce/Are2 Heating KW
Municip?['I 0 Other
Lo�3�-Connection
No. of Dryers
Heating Appliances KW
t,
((curity Systerns:Y alent
NNg.,of-b-evilceg-or Equiv
No. of Water
KW
No. of No. of
Data Wiring:
Heaters'
Signs Ballasts
No. of Devices or Equivalent
No. Hydromissaae Bathtubs
No. of Nlotors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
JOTHER:
Attach addit' :Ono! detail if desired, or as required by the Inspector of lVirL
Estimated Value of Electrical Work:
Work to Start: (�' 0,, (When required by municipal policy.)
Inspections to be requested in accordance with N/JEC Rule 10, and upon completion.
INSUR.ANCE COVERIAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the license -e 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 EZ BOND [I OTHER E] (Specif�,:) Self Insured
I cert�(Y, under the pains andpenalties ofperjury, that the in rmation on this application is true and complete.
If,, o"On 0', n,-, u ,
FIRININAME: P -DT Security Services N LIC. NO.:
Licensee: Mark A. BrciphV Sianature LIC. NO.: C-45
(Ifopplicoble, enter "exenipt " in the license numbcr line.' Bus. Tel. No.:. 603-594-5928
Address: 18 Clinton Drive Hollis, NH All
Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953
OWNER'SINSURANCE WAIVER: I am aware that the Licensee does not have the liability insura . nce coverage normally
required by law'. '�y my signature below, I hereby waive this requirement. I am th6 (check one) 11 owner El owner's a2ent.
01A,ner/Aaent
Signature` Telephone No.* PERMIT FEE,: S V5
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-Ra Q ect"OlNj 30 .10 Lots 4 ZIN 5,
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yerjj�jt Aladel Loll io 10sisig, X b -j
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aplvlo,ves ty�s SP Testflctlol�l tihat uo Islo. re
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each C�m les ov At
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ala'a zo,�O% B-Ylavl
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Ile desig of
cea on t selNee
4. AOpose
Specia. 'hove te 4.ae to the
stga(laf �s appTo'PTI-0,
Pacqwat' n of the lot(s) ,
cove'eills. oithe, commoll 1pov�lo . Ca.
a0d the bWlla;al?' all ge
10 froj�vtage
6. "lle the stvee
Ce'a
apavt of
1. N con�l as
of I)ee
Couelwoust 'he J()T a
f.,IecX Witt, t mcxo�CT
be
aecislola fOXIONS
TWIS ave the -?Jap, of spec�j'aj -PeT
t�jsaecls`O" fAlea.. 'accolnpa, 'Y
Ylans yo 'a afivesa Scott
COVOO djhovoos
6 -P 6 aT :v Sued OISIO
sjq9
'cale'Date*.
39 Lane Comm --------------------
08/07/00
b) Easements pertaining to the rights of access for and agreements
pertaining to the maintenance of the driveway shall be presented to
the Town Planner to review. When the Town Planner deems the
easement adequate, a copy must be recorded with the Registry of
Deeds and a certified copy of the recorded document filed with the
Planning Office.
2. Any changes made to these plans must be approved by the Town Planner. Any changes
deemed substantial by the Town Planner would require a public hearing and a
modification by the Planning Board.
3. Prior to any site disturbance:
a) The location of the driveway must be marked in the field and reviewed by the
Town Planner.
b) , All erosion control devices must be in place as shown on the plan.
c) . The decision of the Planning Board must be recorded at the North Essex Registry
of Deeds and a certified copy of the recorded decision must be submitted to the
Planning Office.
d) Tree clearing must be kept to a minimum. The area to be cleared must be marked
in the field and reviewed by the Town Planner.
e) A performance guarantee of five thousand ($5,000) in the form of a check made
out to the Town of North Andover must be in place in accordance with the plans
and the conditions of this decision and to ensure that the as -built plans will be
submitted.
f) A construction phasing plan and emergency response plan are must be provided to
the Town Planner.
4. Prior to FORM U verification:
a) This site shall have received all necessary permits and approvals from the North
Andover Board of Health, Conservation Commission and the Department of
Public Works.
2
39 Hawkins Lane — Common Driveway
08/07/00
5. Prior to Certificate of Occupancy issuance:
a) The Applicant shall place a stone bollard at the entry to the common drive off of
Hawkins Lane. This stone bollard shall have the street numbers of all houses
engraved on all four sides of the stone. The dimensions of the stone shall be as
follows: 8" x 8" x 72". The stone shall have 48' exposed and 24' buried, and all
numbering on the stone shall be 4" in height. This condition is placed upon the
applicant for purposes of public safety.
b) The proposed dwellings on Lot 5 shall have a residential fire sprinkler system
installed as required by the North Andover Fire Department.
6. The contractor shall contact Dig Safe at least 72 hours prior to commencing any
excavation.
Gas, telephone, cable, and electric utilities shall be installed as specified by the respective utility
companies.
No open burning shall be done except as is permitted during the burning season under the Fire
Department regulations.
No underground fuel storage shall be installed except as may be allowed by Town Regulations,
The provisions of this conditional approval shall apply to and be binding upon the applicant, its
employees and all successors and assigns in interest or control.
This permit shall be deemed to have lapsed after a two (2) year period from the date on which
the Special Permit was granted unless substantial use or construction has commenced. Therefore
the permit will lapse on
CC. Conservation Administrator
Director of Public Works
Health Administrator
Building Inspector
Police Chief
Fire Chief
Assessor
Applicant
Engineer
File
39 Hawkins Lane — Common Driveway
TOWN OF NORTH ANDOVER PLANNING BOARD
REVIEW OF SPECIAL PERMIT APPLICATION
FOR CONFORMANCE WITH THE TOWN OF NORTH ANDOVER
ZONING BYIAW & STANDARD ENGMERING PRACTICE
Location; 39 EtAWKINS LANE
Owner: Maureen and Thomas Scott
Applicant; Maureen and Thomas Scott
Applicant's Engineer: Merrimack Engineering Swvices
Plan Date: 06-29-00
VHB No.: 06716,21
Review Date. 07-27-00
The Applicant nibinitted plan and documents to VIM for revi6w. Both the Common Driveway and the
Access Other than Legal Frontage Special Permit submissions were reviewed for conformance to the
appropriate sections of the 1972 Town of North Andover Zoning Bylaw reprinted in 1998 and standard
engineering practice. The following comments now non-conformance with specific sections and
questions/cQmments: on the proposed design. VHD offers the following comments -
1. The proposed driveway is within the 50 -foot No Build Zone of the flagged wetland. A Notice of intent
is required by the North Andover Conservation Commission (NACC)�
2. The NACC may require relocation of the now driveway outside the No Build Zone.
3. VHB recommends that erosion and sedimentation control measures be added to the plan like hay bales
and sedimentation fences adjacent to limits of disturbance.
It is recommended that the applicant provide WRffTEN RESPONSES, as appropriate, to the issues and
comments contained herein.
Reviewed by:
1�� —�c 1 Date: -Q(40
Timothy B. mcintosh, PA- C-�
Senior Project Engineer — Highway and Municipal Engineering
Daniel H. Wong, EIT.
Civil Engineer — Highway and municipal Engineer
AML
1W
T.\0671611\d=Nrcpom\67.162liMe.wi.dc.c
A6"y appeal shall be filed
within (20) days after the
date of fiJng of this Notice
in the Office. of the Town
Clerk.
0
TOWN OF NORTH ANDOVER
MASSACHUSEWS
BOARD Of APPEALS
NOTICE OF DECISION
G3
Thomas Scott
Date ... Aqgt!q t.
39 Hawkins Lane
North Andover, MA 01845
Petition No.. . .16379A ........
Date of Hearing.. Apgqsi t .13,. �9,9. t
Petition of Thpmas. scQt�
. . . . . . . . . .
Premises affected ... 39.Hawkins;Lane, .....................................................
Referring to the above petition for a variation from the requirements of the .................
Sec. . .7.,. Para.. .7-3, . Table .2. . of. the . Zonig Bylaw ........ j ...........................
so as to permit ... relief.f.rom-the,rear-setback-to-bulld.a.-family.room ..............
After a public hearing given on the above date, the Board of Appeals voted to ... GRANT.. : the
.... variance.on.rear.setback ...... and hereby authorize the Building Inspector to issue a
permit to - Thomas Scott
for the construction of the above work, based upon the following conditions:
Signed
or
Frank Serio, Jr., Chai man
...........................................
'William. S.ullivan.,, Vice -Chairman
....... ....... .....................
.R.ayrj9p4. .........................
Anna.O.'CAnnor .......
.................................
Board of Appeals
'Dpeal shall be filed
(20) days after the
0 f fl�ing of tilis Notice
the Office Of th.0, Town
;lerk.
Thomas Scott
39 Hawkins Lane
North Andover, MA
TOWN OF NORTH ANDOVER
MASSACHUSE77S
BOARD OF APPEALS
. Petition: #163-90
DECISION
The Board of Appeals held a public hearing on Tuesday evening, August 13,
1991, upon the application of Thomas Scott requesting a variation' -of
Sec. 7, Para.-7.3,-'Table-2-of-the-Zoning-Bylaw'so�'as-to-permit-relief from
the rear setback to build a family'room located at -39 --Hawkins Lane. The
following members were present and voting: William Sullivan, Vice -Chairman,
Raymond Vivenzio, Anna O'Connor, Louis Rissin, Robert Ford.
The hearing was advertised in the North Andover Citizen on July 24 and 31,
1991 and all abutters were notified by regular mail.
Upon motion by Mr. vivenzio and second by Mrs. O'Connor, the Board voted
to grant the variance as requested. Voting in favor were Mr. Sullivan,
Mr. vivenzio, Mrs. O'Connor, Mr. Rissin and Mr. Ford.
The Board finds that granting of this variance will not adversely affect
the neighborhood or derogate from the intent and purpose of the Zoning
By -Law.
Dated this 26th day of August 1991.
FS/ld
2 7
BOARD OF APPEALS
P"rank Se7iio, Jr.
Chairman
7
13
PER31rr NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
MAP 440. LOT NO. 2 RECORD OF OWNERSHIP
*ZONE . cz SUB DIV. LOT NO.
LOCATION .2
..., 7 .. . 1,1/,,
A) eve -
PURPOSE OF BUILDING
OWNER'S NAM E-77AV41.0"fis
NO. OF STORIES
OWNER'S ADDRESS 3W
BASEMENT OR SLAB
. .0�
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS
FSPAN
BUILDER'S NAMEPe
DISTANCE TO NEAREST BUILDING
DIMENSI
DISTANCE FROM STREET '5,� v * -
DISTANCE FROM LOT LINES - SIDEU, VC, REAR
AREA OF LOT FRONTAGE,2;00
HEIGHT
IS BUILDING NEW
SIZE OF
IS BUILDING ADDITION
MATER:,
IS BUILDING ALTERATION r
IS BUILI
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 'yo
IS BUIL
BOARD OF APPEALS ACTION. IF ANY
IS BUIL
IS BUIL
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS I - 3
PAGE 2 FILL OUT SECTIONS I - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
F E E
PERMIT GRANTED
19 -
JU 2 3 199!
PAGE 1
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PER11IT NO
MAF
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE I
4-40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
ZON E
SUB DIV. LOT NO.
r
EOCATION
PURPOSE OF BUILDING
OWNER'S NAMEm7y"
SIZE
NO. OF STORIES 16
OWNER'S ADDRESS'
BASEMENT OR SLAB
,9A
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST41A,/
at 2ND 3RD
BUILDER'S NAMEJ&J.4
PAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET 3S* It
POSTS
DISTANCE FROM LOT LINES - SIDEU_ b *., REAR
GIRDERS
AREA OF LOT / - -
--o FRONTAGEO?
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION r"viv
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION f
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 10
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGNATURE OF OWNER OR AUTHORIZED AGENT
FEE
PERMIT GRANTED
19
(f)6-1�e4 9.0
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST /1-157j2e)
EST. BLDG. COST PER SQ. FT. lv6s-
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
I f
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
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Location
-71 No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee i", Z— $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
Building Inspector
Div. Public Works
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This certifies that .... L
has permission to per
wiring in the building of'..!�4Lf //ff'r;
Fee 7�7-.77-�nf .......... Lic.
/� I /7��/ —
Check # /,, (/ ��If
5 7 /'- ?-
Date..................................
NORTH ANDOVER
.....................
<41-1, Commonwealth of Massachu tts Official Use
J
Permit No.
Department of Fire Servic s
Occupancy and Fee Checked
Massachu "S
Fire Servic s
BOARD OF FIRE PREVENTION REG LATIONS [Rev. 11/99]
(leave blank)
APPLICATION FOR PERMIT T PERFORM ELECTRICAL WORK
C
All work to be performed in accordance \ith the assachusretts Electrical Code (M�C), 527 CMR 12.00
T
1 4
(PLEASE PRINT IN INK QR A L N5, Date: /-/—ov —o5
City or Town of. To the Inspector of Wires:
By this application the undersigrild givq notice of)lis or hbL; ijitention to perligi;rn the electrical work described below.
Location (Street & Numl-e-)
Owner or Tenanr �117
Owner's Address
Is this permit in conjunction with a building permit?
Telephone N
Yes. Eli .1 No.. (Check Appropriate Box)
. 11 1 W
Purpose of Building Utility uthorization No.
Existing Service Amps Volts Overhead UndgrdE:l
New Service Amps Volts Overhead Undgrd
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: Installation of Security system
C.'nn7 )IpYinn nftht� fnilo—ii— t�bla —, 1--;-,4 1— il_ I_. ------- - r
�&y
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above o In-
_ grnd. grnd.
I'R—o. of Emerge-n-ey—Lighting
Battea Units -
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
[No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
ffeat Pu .. p
Totals:
I.Number
I Tons
KW
I
No. of Self -Contained
Detection/Aleirting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municipal El Other
Connection
No. of Dryers
Heati-ng Appliances,, KW
Security Systems:
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunication; Wiring:
S
No. of Devices or Equivaient
OTHER:
Attach additional detail if desired, or as required b ' v the Inspector offires.
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 [:1 BOND F1 OTHER FJ (specify:)
Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date)
z/ ') - &J 3
Work to Start:7—,O,!5 —0,5 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under thepains andpenalties ofpeijury, that the information on this application is true and complete.
FIRM NAME: ADT Security Services 12 ('14+An q NIH LIC NO.:
PC, Hol I i
Licensee: John S. Bassett -_ Signatur &Jfj���_1049 LIC. NO.: 1533C
(Ifopplicable, enter "exempt -in the license nuinberline) Bus. Tel. No.: 603 594 5928
Address: Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Li4fisee does not have the liability insur'ance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [D owner El owner's a g*ent.
Owner/Agent
Signature Telephone No. FEE: $ to
I
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health ng cord must
be submitted to the local Board of Health or other approving ruth%o"Viff"
Important: A. Facility Information LTOWDEC 10 2007 R
N 0 N RTH ANDOVdER
F 01
LT
When filling out 1. System Location: TOWN OF NO'
forms on the HEALTH DEEpARTMENT
computer, use
only the tab key Address
to move your
cursor - do not A/. MA
use the return cit�/Town State Zip Code
key. 2. System Owner:
5eoy�
Name
rew Address (if different from location)
City/Town State Zip Code
qn-,764 -75-c99
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 1000
Date Gallons
I Type of system: E] Cesspool(s) EYSeptic Tank r-1 Tight Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Yes Eff"No
5. Condition of System:
6. Sy�jem Pumped By:
If yes, was it cleaned? n Yes n No
"Utr- -7 (,o 3- Lp JV�:- — PJ 1i
K* e Vehicle License Number
ompany
7. Location where contents were disposed:
I, �ro &I /-/I
Signafu-i'e-of HYuler I
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
- 11-1q - X C 7
Date
t5form4.doc- 06/03 System Pumping Record - Page I of I
Commonwealth of Massach
Department of Fire Servi,
BOARD OF FIRE PREVENTION REG
APPLICATION FOR PERMIT T(
All work to be performed in accordance \ith the
(PLEASE PRINT IN INKQR A L NF1
City or Town of.
v�s r
By this application the undersign d gives notidceof)[is or h
ZA
Location (Street & Num
�m
Owner or Tenan
Owner's Address
US Official Us
Permit No.
Occupancy and Fee Checked
ILATIONS I [Rev. 11/991 (leave blank)
PERFORM ELECTRICAL WORK-(
issachusetts Electrical Code (MEQ 527 CMR i2,0C,1
Date:
.To the Inspector of Wires: " ' —1
ention to perf%rn the electrical work described below
I
Telephone
Is this permit in conjunction with a building permit? Yes, F-1 No. (Check Appropriate Box)
Purpose of Building Utility Xuthorization No.
Existing Service Amps Volts OverheadEl UndgrdF1 No. of Meters
New Service Amps Volts OverheadEj Undgrd [:1 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: of Security system
Con lefion nithefoll—d— -1-
�0 y
Attach additional detail �/ dcsired, or as required bv the Inspector oJ'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 OTHER [-] (Specify:)
Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date)
Work to Start: -T-J 15 -el 5 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under thepains andpenallies ofpeijury, that the information on this application is true and complete.
FIRM NAME: .4.131 Sacugity Servires .12 r iQ+An PC HOW MW LIC. NO.: I
Licensee: John S..Bassett Sig ature --9-30.49 LIC. NO.: 1533C
(�fapplicable, enter "exempt - in the license number line) .............. . .. . . --
Address: Bus. Tel. No.: 603 594 SU28
Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licosee does not have the liability insuiance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one2 1:1 owner El owner's agent.
Owner/Agent
Signature Telephone No.
eciorSLIPPires.
No.
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above
Swimming Pool El In- El
o.o mergency ighting
p,rnd. grnd.
Battery Units -
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zo
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
—
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
Tons
No. of Self-C�-n—tained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
a
Local El mun'c'p! 1 El Other
Connection
No. of Dryers
Heati�� Appliances KW
Security -S—ystems:
No. of Devices or Eg ivalent
No. of Water KW
Heaters
No. of No. of
Da ta Wiring:
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications W . irking:
No. of Devices or Equivaient
OTHER:
Attach additional detail �/ dcsired, or as required bv the Inspector oJ'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 OTHER [-] (Specify:)
Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date)
Work to Start: -T-J 15 -el 5 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under thepains andpenallies ofpeijury, that the information on this application is true and complete.
FIRM NAME: .4.131 Sacugity Servires .12 r iQ+An PC HOW MW LIC. NO.: I
Licensee: John S..Bassett Sig ature --9-30.49 LIC. NO.: 1533C
(�fapplicable, enter "exempt - in the license number line) .............. . .. . . --
Address: Bus. Tel. No.: 603 594 SU28
Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licosee does not have the liability insuiance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one2 1:1 owner El owner's agent.
Owner/Agent
Signature Telephone No.
Office Use Only
of C90M==4 of Mug Permit No.
0
Eepmtutrut af Public frafttil Occupancy A Fee Checked
3M peave blank)
BOARD OF FIRE PREVENTION REGULATIONS 527 CMIR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
M* or Town of NORTH ANDOVER To the inspectorof Wires:,
The udersigned applies for a permit to p orm the electrical work described below.
Location (Street & Number.) NA/ KC-,DC>VJ 9-0
Owner or Teniant
Owner's Address
Is this permit in conjunction with a byi I ding permit: Yes No (Check Appropriate Box)
Puraose of Building Utility Authorization No.
-210
Existing Service Amps ?-2-2J Izo Volts Overhead Undgrnd No. of Meters
New Service Amps —Voits Overhead Unclgrno No. of Meters
k;
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work -�o 7L
Total
No. of Lignting Outlets No. of Hot -�--Cs No. of Transformers KVA
Above— In -
No. of Lighting Fixtures Swimming Pcoi gma. — gma. Generators KVA
-0
0",
fll�,X
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of MaSSaC.--uSerS general Laws
I have a current Liaoijity Insurance Policy including Ccmcpec Ccerations Coverage or its substantial equivalent. YES NO 1'
have suomirtea valid proof at same to the Office. YES ,40 Z -if you nave cheCKeO YES. please indicate the type of coverage oy,
CnecKing the approortate Dox.
INSURANCE = BONO = OTHER),k= (Please Soec:�.,)
(Expiration 9atet
Estimated value tncal Works tN 000
Work to Start V1 Insoec-ion Date Recuestec: Rough Final
Signed under th analties of perly —17
FIRM NAILAP C glut,( LIC. NO.:933yi
k
Licensee Sig.-M-ure (764Z, LIC. NO.
Bus. Tel. No.
Address Lp K)N -- Alt -
OWNER'S INSURANCE WAIVES: I am aware that the L:censee coes not mave ine insurance coverage Or Its Substantial equivalent as to-
quirea by Massachusetts General Laws. and Mat my signature on :his permit application waives this requirement. QYfier Agent
(Please cnecx one)- I r*).
.eieonone No. PERMIT FEE
(Signature at Owner or Agent) x-6565
No. of Emergency Lighting,
No. of Receotacie Outlets to
No. of Oil Burners
Batt" Units
No. of Switch Outlets No. at Gas Bumers
FIRE ALARMS No. of Zones
No. of Detection and
iotat
No. of Ranges
No. of Air Cana. tons
Initiating. Devices
No. of Sounding Devices
No. of Seit Contained
No. of Disposals No.of Heat Totai 7otai
Pumcs Tons KW
No. of Dismwasners
SoaceiArea Heatina
DetectionlSounaing Devices
Local 1—i Municipal 1—.Other
Connection i—'
No. of Dryers Heating Devices
No. at No. at
Low Voltage
No. 'of Water Heaters KW Signs Bailasts
Wirina
No. Hyaro Massage -lubs No. of Motors -Iotai HP
-0
0",
fll�,X
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of MaSSaC.--uSerS general Laws
I have a current Liaoijity Insurance Policy including Ccmcpec Ccerations Coverage or its substantial equivalent. YES NO 1'
have suomirtea valid proof at same to the Office. YES ,40 Z -if you nave cheCKeO YES. please indicate the type of coverage oy,
CnecKing the approortate Dox.
INSURANCE = BONO = OTHER),k= (Please Soec:�.,)
(Expiration 9atet
Estimated value tncal Works tN 000
Work to Start V1 Insoec-ion Date Recuestec: Rough Final
Signed under th analties of perly —17
FIRM NAILAP C glut,( LIC. NO.:933yi
k
Licensee Sig.-M-ure (764Z, LIC. NO.
Bus. Tel. No.
Address Lp K)N -- Alt -
OWNER'S INSURANCE WAIVES: I am aware that the L:censee coes not mave ine insurance coverage Or Its Substantial equivalent as to-
quirea by Massachusetts General Laws. and Mat my signature on :his permit application waives this requirement. QYfier Agent
(Please cnecx one)- I r*).
.eieonone No. PERMIT FEE
(Signature at Owner or Agent) x-6565
i2
1156
140
..........
S ACHUS
I
Ve�7- -7
Date ........ 71-----:� . ............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... ....... Q .......... J—:�- ( f C � , -( (' r Q
..............................
has permission to perform ......... ......... ............
wiring in the building of ...... GQ��. ...... .... :f.w�y..-� .........................
at ... 1.1.7 ....... �/a.y ...... r-. -6 ... 4. ..... . North Andover, M
Fee fL16 ......... Lic.No.1.-17/.-'2'x) ................ -�7_/_4 ......
CTRICAL INSPECTOR
C 0 -375- C/ 7��
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
//000
Bay State Gas Company
GAS INSTALLATION AUTHORIZATION
Date 7-1--il - f /
Issued to
Address
For Installation of: e!�4-4-
BTU Input 3 ;QS' -
Restrictions
BSG Representative eZel
PERMIT ISSUED -BY
INSPECTOR
This Portion of Authorization To Be Returned to BSG.
Inspection Has Been Made of the Following Gas Equ ' ipment:
C3 Heating System (BTU Input E3 Range
0 Water Heater 13 Clothes Dryer
0 Room Heater
Location
All Work Has Been Done In Accordance With The Massachusetts
State Gas Code And Is Ready For Use.
INSPECTOR
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or TAe) I I
6, 0 & d4 19(:�'/ Permit #
Mass. Date
Building Location H4WAIIA)s- e-~&- Owner's Name 7-H66L�,L. TS;6777—
.1
I Type of Occupancy RfT1VdW6T-
New E] Renovation �g Replacement E] ed:- Yes 1-1 No IQ
A All AP41TSI-S% Ur- itit I /� j
Installing Company Name M. C. Cusci a. Inc. Check one:, Certificate #
Address 97 So. Broadway Corporation 1348
Lawrence, MA 01843 El Partnership
Business Telephone 683-3175 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter Michael Q. Cuscia —
INSURANCE COVERAGE:
I have a current lipbility Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 93' No 0
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
.1
A liability insurance policy T( Other type of Indemnity 0 Bond 0
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 OwnerO Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
T, e of License:
Plumber Signature of Licensed Plumber or Gas Fitter
Gasfitter
Master License Number 7380
City[Town Journeyman
APPROVED (OFFIC-E-LTSF —ONLY)
Monson
MEMENNENEEMENEEMM,
OMENS
nommommonsommommom
son
son
Installing Company Name M. C. Cusci a. Inc. Check one:, Certificate #
Address 97 So. Broadway Corporation 1348
Lawrence, MA 01843 El Partnership
Business Telephone 683-3175 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter Michael Q. Cuscia —
INSURANCE COVERAGE:
I have a current lipbility Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 93' No 0
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
.1
A liability insurance policy T( Other type of Indemnity 0 Bond 0
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 OwnerO Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
T, e of License:
Plumber Signature of Licensed Plumber or Gas Fitter
Gasfitter
Master License Number 7380
City[Town Journeyman
APPROVED (OFFIC-E-LTSF —ONLY)
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Date...
0* tkORTH . .141 0 TOWN, OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that C/ ........
has permission for gas installation /.4 (1. 1% j .......
ui m7 df ' f /? ..................
in the b *ld* g i
North Andover,
at Mass.
Fee. 7t-:—Liq. No. . 11j. . ..... ......................
WHITE: Applic." /,< GASINSPECTOR
CANARY: Building Dept. PINK: Treasurer GOLD: File
e,
Date. . . .............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .................................. .
has permission for gas installation � ........
in the buildings of ..............................
9.V
f-�. . North Andover, Mass.
at ..... .
L c. N o c7:�o 2,11
Fee'. ..... i ...........
GASINSPECTO
Check #
6801
MASSACHUSEM UNWORM APPUCA-TON FOR PERM To DO GAIS ffrrJNG
(Type or print)
NORTH ANDOVE MASSACHUSETTS Date 3 1:5,q
B �in Lo�ati
uild' ons LAI
Permit#
rT 0 1 wner's Name Amount S
New Renovation Replacement Plans Submitted
El
G
SU B -BA M ENT
BASEM E T_—
I S T F L 0 0 R
2N F L 0 0 R
3 R D F L 0 0 R
41 H. F L 0 0 R
5TH. F L 0 0 R
6 T H Fi.nnD
V L 0 0 R
8 T H F L 0 0 R
I rmt or type)
Name )�
Address /3 0
Z e,
I
Name of Licensed Plumber'or Gas Fitter Aco
INSURANCE CO—VERAGE
Chock one: Certificate Install ing Company
0, Corp.
Partner.
nFirm/Co.
C—o7i m—, , L I o I -
_nt liability I' nsurancepolicy or it's substantial equivalent (Check one -L,-'
avear
140- ha:errheoked ves Please indicate the Yes Ml -
Liability insurance poli type coverage by checking the appropriate bo EWA" No E3
Other type of indemnity X.
Bond
am aware that the licensee does not have the insuran
Owner's Insurance Waiver 13
Mass. General Laws, and that my signature on this Permi7ap_pfic�_j-0rj'W' le coverage required by Chapter 142 of the
aives this requirement
Signature of Owner or Owner's Agent Check one:
I hereby certify that all of details and information 1 Owner 13 Agent
,e su� 13
)MItted (or entered) in above application are true an accurate to the
best of my knowledge and that all plumbing work and installations Performed under Permit Issued for this application will -be in
compliance with all pertinent Provisions of the Massagkfi-s)e
�s a/4, 9s I e G an
I. ! . , I o e Pt 2 of the General Laws.
By:
Title Signature of Licensed Plumber Or �as Fitter
City/To Plumber
Gas Fitter
kPPR . OV, ED (OFFICE USE ONLY) Master
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Name of Licensed Plumber'or Gas Fitter Aco
INSURANCE CO—VERAGE
Chock one: Certificate Install ing Company
0, Corp.
Partner.
nFirm/Co.
C—o7i m—, , L I o I -
_nt liability I' nsurancepolicy or it's substantial equivalent (Check one -L,-'
avear
140- ha:errheoked ves Please indicate the Yes Ml -
Liability insurance poli type coverage by checking the appropriate bo EWA" No E3
Other type of indemnity X.
Bond
am aware that the licensee does not have the insuran
Owner's Insurance Waiver 13
Mass. General Laws, and that my signature on this Permi7ap_pfic�_j-0rj'W' le coverage required by Chapter 142 of the
aives this requirement
Signature of Owner or Owner's Agent Check one:
I hereby certify that all of details and information 1 Owner 13 Agent
,e su� 13
)MItted (or entered) in above application are true an accurate to the
best of my knowledge and that all plumbing work and installations Performed under Permit Issued for this application will -be in
compliance with all pertinent Provisions of the Massagkfi-s)e
�s a/4, 9s I e G an
I. ! . , I o e Pt 2 of the General Laws.
By:
Title Signature of Licensed Plumber Or �as Fitter
City/To Plumber
Gas Fitter
kPPR . OV, ED (OFFICE USE ONLY) Master
i J2E L'o"no"wealth Of Massachusetts
I DePartment 0
Ifo _f r,,d=&,�,j
Acidnts
Off'['c e 0
Jftvest�gations
600 Wash -
DT't-lon Street
Bostopz, MA 62111
r
C
Workerg ompensation Insurance.Affidav-
A ficant Information It: BU]Hders/Contrartors/Electridians/pimmbers
Namt (Busirtess/organizwon,11, Re Print L biv
Addrtss:
cit3r/state ip:
Are yoc &in empi
lin empli yer? Check the appropriate box:
an a employer with 4, roject (required):
M*Yees W1 and/or �Part-time).* Type of P
1 a"' a 'erleral contractor and 1
2. 19/1 ; "Ole Proprietor or partner- have hired the sub -contractors New COnstruction
ship and have no employees listed On the attached sheet 1 7. R.-Modefinc,
working for me in any capacity. Th �Re sul>-cOntraztors have 8. D_
worke;rs, C'molition
COMP. insurance
[No workers' comp. insurance 5.7 9. ED Building
reqwred-] We are a Corporation and its addition
3.[] lffil--rs have exMised.their ca
aTn R 110TI'mowner doing all work right of ex- Electri I repairs or additions
motion Per MOL Plumbing repairs or additions
myself [No. work=' comp. c. IS2, (4j and we have no
instzrance req I uiredj t employe:es. , 110 Poof repairs
[No workerg,
*Anv aPPlimmt.thai checks b . ox #I must also.fill 0 Comp. in'surance. req I uired.] 13.[] ()th._r
iH3 ------------
on1Ww11= W"(j subillil -111i�k affludavii jildi ut the ; scafion btiow shmking their worken, compe i,
lnuu=a; thal chcol, this box.mu. cati4l thek ult daip- Efl, w.—Li r, Polic3, infornmtion,
m arc ih-M hir- Gutsidp, w -my
htd an additional sh= the . namtofth:�u�_cor aciurl;ltlugl.subrn"&Lnrwafiidal,itin'-
t=tom Rnd their workerr � r�omp, al=znr such.
am an enwjoycr J*X is proviourz: woL-Mrr I P01icY infamwion.
ig/ormadom Comipansadoiz
"Uttrancejor ny) emplyem
insurance Company Name: Below' is thc Pofiqy andjoh sim
Policy 4 or Self�ins- Lic. #-
Job -Site Address: Expiration Date: ------------
Attach 2 c9PYGf the workery compensation policy declamtion City/Stat-,/Zip: --------------
Failure to secure coverage, as required under Section 25A Of M OL I s2 ran u the PolirY number and expiration d2te�.
fine up to S1,500.00 and/or one-year imprisonmenL as we], as c,v 'cad to the imposition Of criminal penalties of a
il penalties in tht form of a STOP
of up to S250.00 a day against the violator Btadvised that a copy ofthis WORK ORDER and a fine
investigations of the DIA for insurance c '- 'f state'Ment may be forwarded to the Office, of
overage. ven Icatio,11.
I do hcrebj, c under p
rj 'forma ab,=Pp.,�,,&
iol? jor(
"I the i
j"
'r
fp"
0
P th'r the informadan
Signature: pr"'ded abO Pic is true and correcL
Dat,�-
/1% -7 �r
offIcia, Me onip. Do not wrifC i17 this area, 10�
comolezed bJ1 ciOl or to,,, ofjLciaL
City or Town:
lssuilm.- Authority (circle one): Permit/License R -------
1. Board of f-lealth 2. BUijCji
6. Other n� Department 3. City/TWln
C*ierk 4. Electrical Inspector
Contact Pemclu:
Phone *-
S. Piumbincr
e, Inspector
iniormation 2and Instructions
Massachusetts General Laws chapter 152 requires all em-1=)Ioyers to provide workers, compensation for their employees.
Pmuant to this statute. an em
playee is defined. as ".--v�r-y person in the service of anothr'r under any contrazf of h ire
express or implied, oral or written." I
An employer is defined as "an individual, partnership. as--�ociatiori, wrporation or other legal . entity, or any two or more
of the fortgoing engaged in a joint enterprise, and inc)UfL-i-ng the legal mpres -ntariv
L es of a dzceased -employer, or the
receiver or trustee of an individual, partnership, associati (z)n�'or other lecral entity, empioyin
owner of a dwelling house having not more than thr= ap zL g gtinployees. Howeve-rthe
T-ti-ritnts and who resides therein, or the occupant of the
dwe4ling house of another who employs persons to do m.--*-iT1t--nance, construction or- repair work on such dwelling house
o7 on the grounds or building appurt--nant thereto shallncDbt because of such -employment be d--erned to be an einpbyer."
MGL chapter 152, §25C(6) also states that "everY state cim- r local licensing no
gency shall withhoid the issuance or
renewal of a license or permit to operate R business or to construct bufidings in the commonwealth for- any
applicant who has not produced acceptable evidence M -F compfiance with the insurance coverage requireV
Additionally, MOL chapter 152, §25C(7) states 'Neither -the rommonwcalth nor any of its political �ubdivisioris shall
enter into a:nY cent -act for the performance of pubdic worl< until acceptable evidence of compliance with the insuranre
require:ments ofthis chapter have been presented to tht D<:3intrazting authority."
A�pplicants
please fill Did the workers' compensation affidavit comPl-etely, by checking the boxes that apply to yoir situation and, if
necessary, supply sub-contractor(s) name(s), address(es) --and phone number(s) along with their cerrificate(s) of
instnmct. Limited Liability Companies (LLC) Or Limitt� Liabfit, Partnerships (LLP) with no employees other than the
members or partners, am not required to F-arry..%�vorkers'Dcz)rnpensafion insurance. If an LLCor LLP does have
employees, a policy is required. Be advised. ew this Z'ffid�avit maybe submitted to the Dcpartrnent of Industrial
Accidents for confirmation of insurarim aoverage. "Aiso 11be sure to si-n and date the . affidavit. Theaffidavitshouid
be returnad to the city or town that the application for the p--Tmit or lic;�se is being requested, not the Dtpartment of
Industrial Accidents. Should vou.have any "
questions re="-c�-rding the 1prw or if you are requi-,-d to obtain a worLn,
.comry nsa�iorn 6clicy. please call the Department at the narrnbcrlisted below. S:If-insurcd ao-inpanies should enter the':ir
self-insurance license numb an the ap
propriatt line.
City or Town Officials
Please be sure that tl� ;kffida�itis conipictt and printed
Tb-- l3tvartment has provided
a space at the botiorn
of the, affidavit foryou to fill but in the event the Office of- Investigations has to contact you. regarding the appli=L
Please be sure to fill in. the permit/iicense. number which Will be used as a reference number. In addition, an applicant
-that must submit multiple ptrmi0icense applications in arry given year, need only submit one affidavit indicatingo current
policy information (if necessary) and under "Job Site Addr-ess- the applicantshodid write all locations in city or
town)." A mpy of the affidavit that has bt--en officially sita�iped ormarked by the city or town may be provided tothe
applicant as proof that a valid affidavit is- on file for futum permits or licenses. A new affidavit must be filled out -each
y=. Where, a home owner or aftizzen is obtaining a licens� or permit not related to any business or commercial veriture
(i.e. a. dog license crr permit to burnlzaves etc.) said persorl is NOT required to completz fhis affidavit.
The OfFireof Investigations would like tothank you. in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Departnent's address, taiephont and fax nurnber:
The CommonWt2dth Df M=aZhUS_-ttS
D�partnant Of L-ndustrial Accid=ts
Office of Eltvestigations
600 Washdngtc)n Str.
et
Bciston� MA G2111
Tel 4 617-727-4900 e= 406 or 1-9-77-h4ASSkFE
Revised 5-2645 Fax 4 617-7-7-7749
wlml-mass.gov/dia
This certifies that . )7
.......... A ....... / ...........
has permission to perform .... Pf (r 0
..................
plumbing in the buildings of ...... 5�!:� rr .. .................
at ... Ilei ........... North Andover, Mass.
Fee. 6/? . Lic. No .. ....... ... (� ..... .
Check PLUMBING INS4C
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
8145
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location 3 4-1 144r L4./ �4 14 5 L Kwners
New ri Renova tion 1:1
of
Date 7,elq—
Permit #
Amount yj
Replacement Plans Submitted Yes No
Ea--- . 1:1 1:1
(Print or type) Check one: Certificate
Installing Company Name i e-hA 44 Corp.
—k f ri
Address /P/") fa-�'4 �� Partner.
Aj to m - J/ 9
Business'l elephone 0-15irm/Co.
Name of Licensed Plumber: /J�- -*
Insurance Coverage: Indicate the typ
Liability insurance policy
/PA -a
-ance coverage ny cliecking the appropriate box:
Other type of indemnity 11 Bond F1
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner Agent
Z' 1:1 rl
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mapqc4l9sfs Stp&jlumb&10a� and Chapter 142 of the General Laws.
By:
WgildLUle U1 I-XenSe(i ejUmDer
Title Type of Plumbing License
City/Town 3 4 !�l
APPROVED (OFFICE USE ONLY INum5ers Master Journeyman
MMMMMMMMMMMM
MM
=L-j101rW-e-,=MMMMMMMMM
NOMMMMMMMM
MM
Wig"UMMOMMOMMOMM
MMMMMMMMM
MMMMMMMMMMMW
NOWNWOMM
MMM
MMMMMM
WM
MM
WSRMIMTTMM�M�M�
lm�m
-
MM
(Print or type) Check one: Certificate
Installing Company Name i e-hA 44 Corp.
—k f ri
Address /P/") fa-�'4 �� Partner.
Aj to m - J/ 9
Business'l elephone 0-15irm/Co.
Name of Licensed Plumber: /J�- -*
Insurance Coverage: Indicate the typ
Liability insurance policy
/PA -a
-ance coverage ny cliecking the appropriate box:
Other type of indemnity 11 Bond F1
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner Agent
Z' 1:1 rl
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mapqc4l9sfs Stp&jlumb&10a� and Chapter 142 of the General Laws.
By:
WgildLUle U1 I-XenSe(i ejUmDer
Title Type of Plumbing License
City/Town 3 4 !�l
APPROVED (OFFICE USE ONLY INum5ers Master Journeyman
Vk
Uhl
\ I/
The CoMmazzweaft of Massachuseft
Department of Industrial A cciden&
Off
�e ofI
ftipe�w
gat�trs
600 FMaykingffin Street
Boston, MA 82111
www_m=sgov1dia
Workers' CompeR1,11tioll 1witrance Affidavit. Builders/COntractors/Eiectrir-iins/.plumbers
10ficant Warmatinn
NaM'e (Businms/organization/individual): Y21 e
Address: 1A)
cityst.wZip: PY2
�J_ Phone#..
Am you an employer? Check -the appropriiate -box:
I - El 1: aln a employer with 4. 0 1 am R general contractor and I Type Of PrOjed (required):
.4&P-10yees (fun and/or _pwt_tjme).* have bired the sub-contracton; 6- Now construction
2. am, -asole proprietor or partner- listed on the attached sheet 2 Remodeling
T of pro,
6 "Iew I
7
F7.
0
ship and have no employees 8
TbeSe SU&COTIbUtDrs have 8. Demolition
working fbr me in any capacity. workers' comp. insurance. 9
[No workers' cornp. insuran 5. 'We are a corporation and its 9. BFuflding addition
required.) 10 Ele=
officers have exercised their 10. F7 Electrical repairs or additions
3. El I Rm a homeowner doing all work right of exemption Per MOL I 1 -0 Plumbing repairs or additions
myself. [No-workirs' comp. C. L52, § 1(4), and we hErve no
insurance required.],T .employees. [No workers' 12.7 Roof re,pairs
13.[].Other
comp. Msurancerequired.]
*Any applicant thar checks bco�#j must 019) fill outthe�
t Holneown6T who sainnit this stridavit indicati section Wow ShOwing theirwDrkers'competisojon poiicy inTarrnatiotL _j
4C�Mtrzctors titat check this box raust ng thOY mr, doing all wort and ther him otaside contractors must'submit a new affidavit indicatiq suciL
Attached an additiowj sheer showing- tk9c name of dw sub -contractors and their workmrs, paii-y forolati n
am an emplaper thar is prqvidfing:workers compensadon _ in 0
informadom insuraucefornVenFloyem Below isr�&e_—_--
00&7 andjok site
Insurance Company Name -
Policy 9 or Self -ins. Lie.
Expiration Date:
------------
Job Site Address:
City/state/zip:
Attach a copy of the workezV compeawtion Policy declar-atiou page (showing the Policy number and expiration dat-4
Failum 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 fbnr of a STOP WORK ORDER and a fine
Of Lip to S250.00 a day against the violator. Be advised that a copy of this stalement may be forwarded to the 0- flice of
Investigations of the DlA for insurance coverage velification.
1 ado h7ereby c the
,n r the p a, n4penqMes ofperjury that the inforiftadon pro vided above is
Si_ &ue and rorrect
_na
Si
ture. Date-
QKJCiat Do not wrhe in tA* ama, tvbe coxrjer�ed by dV or jtvNn offldd
City or Town: Permit/License #
Issuing Antitority (circle one):
I. Board of Health 2. Building Department 3. City/Tovvn Clerk 4. EleeVical Inspector S. Plumbino I'ners—f-
6. Other,
Contact Persom— Phone #.-
Information a nd Ins�tructions
Massachusetts General Laws chapter 152 requires all emp I oyers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...evm-y pmon in the service of another under any contract of hire,
express or implied, oral or wriftn."
An employer is defined as "an individual., partnership, mc:)diation, corporation or other legal =tity, or any two or m ore
of the'foreping engaged in a joint enterprise, and includirikg the legal representatives of a dectased employer, or the
receiver ortrustee-of an individual, partnership, amciatioin or other legal entity, =ploying =ployees.
own6r.of a dwelling house having not more thin three apax-tmeft and who resides therein, or the occupant of the
dwelling house of another who employs persons to do malmtamce, construction or repair wdrl� m such dwelling house
or on the grounds or building appurtr.=it thereto shall not bemuse of s=b amployment be dearned to be an employer."
MOL chapter 152, §25C(6) also states that "every i state or- local tictinsing agency shall wiffibeld the issuance or
renewal of a license or permit to operate a business or .*a construct buikfiugs in the commonwealth foir any
applicant who has not produced acceptable evidence,oC compliance with the insurance coverage required."
Additionally, MGL chapter I 5Z §25C(7) states 'Neither the commonwealth nor any of its political subdivisions shall
enter into any contmct for the pmfammnce of public woric until -acceptable evidence of complh�ice with the insurance
requiremmts of this chapter have been preswftd to the corttracting authority."
Applicants
Please fill oat. the workers' compmsation. affidavit complentely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es). Eund phone number(s) along with their cerrificate(s) of
insurance. Limit5d Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are. not requiredu carry workers' coirnpamation insurance. If -an LLC or LLP does have
employees, a policy is require;d. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of iramince coverage.. Also k3we sure to sign and date the affidevit. 7he affidavit should
be returned tc) the city. or town tf= theapplication fo.r.the peimit ar license is being requested, notthe Department of
Industrial Accidents. Should you have any questions regar-ding the law or if you am required to obtain a work=!
ooMpensation policy, please -call the Department at the nurriber listed below.
self-insurana'e-ficense number on the'appropriate line.
City or Town Officinis
Please be sure that the affidavit is compleft and printed legibly. The Department his provided a space at the bottom
of the affidavit for yo"u to fill out in die event the Office of lnves�pfions has to con= you regarding the applicant
Plewe be sure to fill in the permit/license number which Nvill be used as a reference number. In addition, an applicant
that must submit multiple permit/licensc applications in any given yeg, need only submit one affidavit indicating -current
policy'information (if necessary) and under "Job Site Address" the applicant should wrift "all locations in city or
town)." A of the affidavit that . has been officially stzmp.ed or marked by the city 'or town may be provided to the
copy , I
applicant as proo� ff& a valid affidivit is on file for fifture pe:rmits or licenses. A new affidavit must be filled out each
year. Where a home; owner or citizen it 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 pers6n is NOT required t . o complete this affidaviL
Tbe Offi= of Investigations would like to Owk you in advance foryour cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number
The Commonwcalth of Massachusetts
Department of IndustrW Accidents
Office of Investigations
600 WasbLington Str�et
Rost� MA 02111
TeL 9 617-7274900 6Xt 406 or 1-9-77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www-mem.gov/dia
Date.. . .,-,? .....
40RTH
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ............
has permission for gas installation ........
in the buildings of
.............................
....... North Andover, Mass.
Fee�...�k ...... Lic. No. �� .... . �
GASI�,SPECTOR
Check # a
7U22
MASSACHUSET5 UNHORM APPLICATON FOR PERNUr TO DO GAS FrFrING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New [:] Renovation [:] Replacement a
Date i,
Permit#—
Amount$ c9,A,
C 0
Plans Submitted 11
'(Print or type) Check one: Certificate Installing Company
Name_ X A-2, Corp.
Address ox Partner.
ill- AIJ 00 --.4- 41-,
7usmess I elephone 'i tz 970 L) Or Firm/Co.
Name of Licensed Plumber or Gas Fitter ze
INSURANCE COVER -AGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes NoO
If you have checked yes, please ��dicate the type coverage by checking the appropriate box.
Liability insurance policy 0 Other type of indemnity E] 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 0 Agent 0
— �y - LAAy "IaL all — ul� U�Lallb MILL 1111U1111dLIU11 I n2ivr: SuDrrurce(i �or enterect) in at)ove application are true and accurate to the
best of my knowledge and that all plumbing work and installatiqja<p?f6rn# under P nit Issu for this application will be in
, er
compliance with all pertinent provisions of the Massachusetts tate G s e ck.'Fa 142 f the Veral Laws.
74
itle
own
(OFFICE USE ONLY)
Signature of Licensed PluSber Or Gas Fitter
[3—Plumber
E]Gas Fitter License N7m—t)er
[a,'M-aster
[:] Journeyman
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'(Print or type) Check one: Certificate Installing Company
Name_ X A-2, Corp.
Address ox Partner.
ill- AIJ 00 --.4- 41-,
7usmess I elephone 'i tz 970 L) Or Firm/Co.
Name of Licensed Plumber or Gas Fitter ze
INSURANCE COVER -AGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes NoO
If you have checked yes, please ��dicate the type coverage by checking the appropriate box.
Liability insurance policy 0 Other type of indemnity E] 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 0 Agent 0
— �y - LAAy "IaL all — ul� U�Lallb MILL 1111U1111dLIU11 I n2ivr: SuDrrurce(i �or enterect) in at)ove application are true and accurate to the
best of my knowledge and that all plumbing work and installatiqja<p?f6rn# under P nit Issu for this application will be in
, er
compliance with all pertinent provisions of the Massachusetts tate G s e ck.'Fa 142 f the Veral Laws.
74
itle
own
(OFFICE USE ONLY)
Signature of Licensed PluSber Or Gas Fitter
[3—Plumber
E]Gas Fitter License N7m—t)er
[a,'M-aster
[:] Journeyman
The Commonwealth ofMassachusetts
Department of 1ndustrial Accidents
Office of Ln vestigations
600 Washington Street*
Boston, M4 -02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone#:
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet
ship and have no em loyees
p
These sub -contractors have
I
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
requii.ed.]
'a
officers have exercised their
3. F-1 I am 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"
A I.'
Comp. insurance required.] I
Type of project (required):
6. E] New construction
7. Remodeling
8. Demolition
9. Building addition
10 Electrical repairs or additions
I I.0 Plumbing repairs or additions
12 -El Roof repairs
13.[] Other
_-.7 -rr w . . lul 014 me SeMOn below showmg their workers' coml)en-wtion policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire Outside contractors must submit a new affidavit indicating such.
I �Contractors 1hat check this box must attached an additional sheet showing the name of the suh-contractors and their workers' comp. policy informatiom
V, am an eMPLOYer that isPrOviding wOrkeff'COMpensadon iftsurancefor
information. HU eMP10Yee& Below is thepolicy andjob site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as 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 an d a fine
of up to $250.00 a day against the violator. Be advised that a co ' py 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 andpenalties ofperjury that the infOrmation provided above is true and correct
Sip -nature:
Phone#:
Official use only. Do not write in this area, to be completed by city or town offtciia
City or Town.-
Permit/License #
Issuing Authority (circle one):
15
1. Board of He21th 2. Building Department 3. City/Town
25 Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ft
Contact Person:
Phone 9:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an enWloyee is defiried as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, assor--iation, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a. deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartrnents 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.r
MGL chapter 152, §25C(6) also states that "every state or I-ocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has Dot produced acceptable evidence of compliance with the insurance c overage 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 umtil acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited LiabilityPartnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
e . mployees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application ior the pei-mit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
-1 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 Irivestigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc-) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us !a call.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial A=idents
Office of Investigations
600 Washington Street
Boston, 1%4A 02111
Te.l. 4 617-727-4900 ext 40.6 or 1-9.77-MASSAFE
Fax 4 617-727-7749
Revised 5-26-05 NAr"-A7.Ma&&.gov/dia
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN, MA 01833
978-352-8318 fax 978 —352-2858'
cell: 978-502-5921
July 22, 2009
Mr. Kevin Murphy
169 Boxford Street
North Andover MA- 0 1845
RE: Scott Residence, 39 Hawkins Lane, North Andover, MA. 0 1845
Dear Mr. Murphy
As you requested I visited the site to review the installation of LVL members as
utilized in the construction of the addition. These LVLs consist of a ridge beam, Hips,
ceiling beam and first floor girder.
Based on my site visit and engineering review I can certify that to the best of my
knowledge the LVLs utilized in the above structure are acceptable and meet the loading
conditions required by the 7th Edition of the Massachusetts State Building Code.
Should you have any questions please do not hesitate to call.
Yours truly,
—av,,,re;c--e H. Ogaden RE,
I0 F
71a z-/
HMO 09
00 rn
2 65
NAL E
-C\- Commonwealth of Massachusetts Official Use Only
10000 0.
Department of Fire Services 'erm"'
VBOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 9/05] (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
(PLEA SE PRflVT IN INK OR ITYPE A LL INFORMA TIOA9 Date: 7U�y -L5-1 09
CityorTownof. f�o�ik 1*-'NVN00UPP, 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) .
OwnerorTenant lory" t
Owner's Address SQtnc
Vl\
U �efK sciD
Telephone No.
Is this permit in conjunction with a building permit? Yes [S No El (Check Appropriate Box) '-(
Purpose of Building Utility Authorization No. (og7glo
Existing Service Amps Volts Overhead Undgrd No. of Meters
New Service Amps /C)C)/ oq ��olts Overhead UndgrdK- No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 20040^ + P�C\\'S�A (-)C\ V61PA: J I P-C)O M I
-Z- �S--+-V\100,cns Ke\occky, 2- nS- cor\dgissov, -I- sulPonkA
frve/ftd 01 --e, lel?- Completion ofthe followin-a table mav be waived bv the InsDector of Wir�s.
No. of Recessed Luminaires Zo
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers RVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In-
Swimming Pool grnd. grnd.
0. of Emergency Lighting
Battery Units
No. of Receptacle Outlets 2�C)
No. of Oil Burners
FIRE AL�RMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
1
J
.......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
M mcipal
Local El c u
onnection 0 Other
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
I Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ifdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: G SM (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE X BOND 0 OTHER f-1 (Specify:)
I cerfify, u nder the pdins andpenaldes ofperjury, that the information on this application is true and complete
FIRM NAME: 13,
LIC. NO.: A 2�0Q`rj
Licensee: Signature Kj-r-)r�, \3,ez-ztrL LIC. NO.: E
(If applicable, enter "exem t 11 in the license number lin Bus. Tel. No
Address: 04GOPS60(\f ?-r� Alt. Tel. No.: 101'Z'l tf- )WL
*Security System Contractor License required for this *6rk; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) owner El owner's agent.
Owner/Agent
Signature Telephone No._ PERMIT FEE. $
-51�^ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
nermit—lication-F-m- --de—i—M-11 V :�4 U-11 L -.4?- �U
F ono w ngs eu rin rouviout we Commonwealth, and applications snail be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. GI c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits sball-be limited as to the time of.ongoing construction activity� and may be-deemed-bythe-Tnspector-of-Wires abandoned-and.invalid-ifhe—
or she has determined that the authorized work has not commenced or has not pro'gressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the. permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
p�ipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extendingthrough August 15, 2012.
Rule 8 — Permit/Date Closed: ***No :Reapply for new per;�<
Krmit Extension Act — Permit/Date Closed:
Date .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... 7
e,. 7, 11Z . . .........................
has permission to perform
wir
,qng in the building of ............... . .... ...............................................
I
at .......... ?
..q. . ........ .......................... rNorth Andover, Mass.
Fe� ... Lic. No. ...d.OJI�49-10V .......
E 6-iR�I C �AL� S 7PE C 101
Check # 4 3 ;�
89201-
Date -1,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that A.Dr ..... LU . .......................................................................
has permission to perform ..... 6'P.P o,& ......................................
wiring in the biy*ldlng of ..... �le X
.........................................................................................................
at ... ..... Lrj .................................. .�,,North Andover, Mass.
Feef.3�.!�� ........... Lic. No. 02 . ..... ....... M
i��,P, E**C,* *F-0, k*
Check. (7
2 3 5,
De artment ofFtre Services Poi -mit No.
W-1 =,i p 'M
BOARD OF FIRE PREVENTION REG ULAMNS
0oc-upaiicy aud Foa Chooked
lip
t kfan."', celljR [Rev. 11071
'Y
APPLAICATIOM FOR PERM& TO P15RFORMELECTRICALW. ORIK
(TLF,4, 100 PZ�WLY AF,- OR TY_PXlTXM- OMMMO-A),
\r, To t7l.e Inspeofor qf Maw:
Ci4r or TolsA d' v
)3y tli�s appilraxon f�o w. dcv&ood 0 -Mg nafice of his orhprhatenuon jope._-.fo.m tht� --kotdoal jyoxj,�- desriibpd b4cny,
vv.� V,
olme)rg
(Cfiek Approplat','GOX)
'Volk avellheado un'T"rd
Amps I
A
Y0ltq Ov`rh-�`60 -'Vo' of feters
Nawl? ext o f Ti ei,, dars a n. cl Amp city
.Lowifoxx axAl ll?ature oaxoposod
Ov.3 VVIX337. : I
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Work f a S t
sp F otio'�g to b a re pos'L e 1 n ac c 0 )�d aw a lvith AE, C F 11jo 10, and q G'a c 0 Mp otf.0 a
COWMRAGN,� %le s g wah, E.a by tho Omar, no � =21 't for oifaumwc B of p lectdo al -work, may rMles S
t� c E b 611 s c a p ro 71.4as pro 0 f 0 f I i a� il ity ills umc, 0 L-101 L, d�ag "i�O Mp lote d. o p.�rxdo a-'covera ge o riL3 s ub s ta rit lal o qpival pat �O a
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Address: Alt T,
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0.. Of
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of CID31maers
MRKALARMS _Nro.o9zon.ea
No. Of&I"Ches
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NO. .00dectf oix. an
I __ UffielWE'r. D eq,ceq
INIO, ofRangns
No. ofAir CO)JIL
"10 11
1
No OfAlq�gcppavlces
W�O. Off , 0
HeatRa Mp
52
0
Number Tons lKw
M
;,NlO. Of
INO. of Dy, vRSlL6x*,q
M
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y
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No
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lleaters
No. of
17, 1 Las io, OX
Balya��
f No. of �K�lcp_s or yqa1y4lent
Ov.3 VVIX337. : I
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Work f a S t
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COWMRAGN,� %le s g wah, E.a by tho Omar, no � =21 't for oifaumwc B of p lectdo al -work, may rMles S
t� c E b 611 s c a p ro 71.4as pro 0 f 0 f I i a� il ity ills umc, 0 L-101 L, d�ag "i�O Mp lote d. o p.�rxdo a-'covera ge o riL3 s ub s ta rit lal o qpival pat �O a
nad ersiga. o d o ord fff,-s lh at S iT Ch 0 0 It crago is ju fQ � r p, and b aq o -q i bi'Le apxo OXF d,9 am B to th 6 p Um it i S s dD. o, Of ffr i�.
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(Please print)
DATE
JOB LOCATION
.HOMEOWNER"
Town of North Andover
BUILDING DEPARTMENT
Homeowner License Exemption
Nujpber - Street
ress
bection of town
iName I Home Phone Work Ption�
PRESEN
---j, 0 Lcl LU Lip cocie
The current exemption for "homeowners" was extended to include owner
-occupied dwellings of six units or less and to allow such homeowners to
engage an individual for hire who does not possess a license, provided
g -hat the owner acts as supervisor. (State Building Code, Section 109.1-1)
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to
reside, on which there is, or is intended to be, a one to six family dwell-
ing, attached or detached structures accessory to such use and/or farm
,.structures. A person who constructs more than one home in a two-year
period shall not be considered a homeowner. Such "homeowner" shall submit
,.to the Building Official, on a form acceptable to the Bulding Official,
... that he/she shall be responsible for all such work performed under the
.-building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the
,,State Building Code and other applicable codes, by-laws, rules and
regulations.
The undersigned "homeowne certifies that he/she understands the Town of
e ce rLi'
tm
..North Andover Building D partmoen�jminimum inspec ion ocedures and
e w
,requirements and that h she w* comply wil cedures and
HOMEOWNER'S SIGNATURE
�.APPROVAL OF BUILDING OFVICIAL
''Note: Three family dwellings 35,000 cubic feet, or larger, will be
required to comply with State Building Code Section 127.0, Construction
Control.
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SUBDIVISION
ASSESSORSIMAP
SUBDIVISION LOT(S)
PERMANE D
"TREET
IA'PPLICANT
(.-'�XTE OF APPLICATION
PLANNING BOARD
FORM U
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
S ()A;iSIGNED B &P:.W�.)
PHONE
TOWN USE BELOW THiS LINE
DATE APPROVED
*"o (q 1) ,
TOWN PLANNER
DATE.REJECTED
CONSERVATION COMMISSION
4R-
DATE,,APPROVED
CONSERVATION ADMIN.
TION ADMIN,
D
D
REJECTED
BOARD OF HEALTH
DATE
APPROVED
HEALTH SAN.11*1(.*rA
DATE
REJECTED
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
This form shall be signed by tile agents of the Planning and Health Boards,
the Conservation Commission prior to tile issuance of any building permits
for the subject lot. This form shall not releive the applicant from tile
compliance of any applicable Town requirement or Bylaw.
0