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HomeMy WebLinkAboutMiscellaneous - 39 LINCOLN STREET 4/30/2018Date .... I? . /,?- . 4 ....... ...... ........ ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..t ......................................................... has permission to perform ...................................................... 11 wiringin the building of,. ...... .......................................................................... ...... .............. . North Andover, Mass. Fee........... Lic. ............ i ....... ELEMICAL NSPE 1; R Check # -PIPPIX 60�� 65tio DIIFUflII�VIYaFPEUXS4FB7Y Ptstnit Na BQ4jPDoFP=PnVw1 RBauwm 1 adRnw O=npancy & Fees Chtxked APPLICATION FOR PERNIlT T10 PERFORM ELECTRICAL WO V woRK TO h ACCORDANCE wrrlt T1iB MA3SACHUSSiS t� bcrRjcAt.con& 527 ctwe 12:00 3 a a (112ASE PRIId'T IN INK OR TYPE ALL IIVFOItMATION) D Town of North Andover To the Inspector of Wires: The undersigned applies for a permit M p dOrIn the electrical work described below. Location (Street A Number) . ,q L) AIC.AV S7— A owner or Tenant owne 's Address is this permit in conjunction with a building Yes CO No 1:3 (Check Appropriate Box) Purpose of Building NT BYO ach Existing Service ... Ampa..L.VDila New Service Amps....L.Volts Number of Feeders and Ampecity Location and Nature of Proposed MectriOd Work Utility Authorization No. Overhead a Underground M No. of Meters Overhead C:3 Underground 1:3 No. of Meters Na of L iShdna Outten Na of Hot Tuba No. of rwldh m TOW KVA No. of Uabdns RMM Swimadna PoolAborti ZMWA Hetow tiettersoors KVA No. of Reeeptede Ootleat Na.of On Botoan Na of F.Merseoey Ugwft Battery Unit: Na of Switcb outlet L Na at CIO scram. FM ALARMS No. of Zones Na of Ramus Na of Air Cool. TOW Tan Na of Deftedoo and Na of Dispoale Na of Hent Tod Ted Tom Kw Mdnling Dowim Na of souaan3 redoes No. of Dishrnaben SPS Ata Hewing Kw Na of Self coaadned Datetim/Soand6ta Devices vocal Munh#d Connections ED Odw Na of Drrn Hewing Devices Kw No. of water Heaters Kw Na of Na of S Bd" No. Hydro Mmop Tale Na of Moan ToW HP , k s x3%eC bvwF PttMtotbChOdLM 7hateaanmtLinhlkyitrrahczR:i�yihdudrBCl�i drys �irlaquNaimt YB4 No ItMs&iiedMOPOddSoabfieOMM YMI r)oul11M&cmfYB4►plAUUMMy¢daote :by Wap �p 6//ot WodcuSlat 3 / /t3 ihhpeceiornD.SigReq�ed trohgb tits Ped Ovel ;Pe Lext 4I CA L ZtiL Lio=Nu 14 4 U A l� A'► i =ANNA t2-`' yCO ►� p � �� 3y /V iV�-ts7' -a�a� I i►ef%weir. IwulgM 9- 2- 7 s r AlTdNa T- 71 C4 OWMUSIIVMAIAMwAMIanawaellrtAtLia�d���dreiiatasooecan orlsa brlegiivairttaga�iedbylNaeatdsza�GmairlLah�is arddWffV g MMCA iupimvtai-finwho " (Please check one) Owns C3 Agent aT(% r elephone No. FBE t J j D>lMllTl MWOFP[1B(JCSd M int No• GS'� o B0M0FFZR8PRLWMMRBUL4TlI011 527C7M1ZM O=v=cy dr Few Owed `�� APP�rAM r0NFOR �o PFor�vrcrruc�r wo ��tA�C,PUASE PRINT IN TYPE ALL II�tFORMATION) D Town of North Andover Tire undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) I., To the Inspector of Wires: Owner or Tenant Owner's Address is this permit in conjunction with a building YesIM No (Check Appropriate Hoa) Purpose of Building w7 Wp itch Existing service Amps./Volts flew Sarvice I Amps__..L.Volta Number of Feeden and Ampscity Location and Nature of Proposed McCtrical Work Utility Authorization No. OverheW [:] Undemound No. of Metas Overhead Q Undaground No. of Meters Na of uoft on" � Na of Hat TuW No. Of TMU&rran TOW KVA Na of U- sb s RMM Swimming Roof Above Below die» "MM KVA No. of Rocepta& Ourlae Na d OU Harems No: of F1oerPO" USMinj HattMy tlnft Na of Switch OOttab L No, of On Harms FUM ALARMS Na Of Zones Na of Pjaws NO. of Air Coad. TOW TOM Na ofDaecdon and No. of Diepoala Na Of Hat . TOW TOW pump Ton KW No. of SowW gR Dedaea No. of Diehwaebas Space Are. Haft KW Na ofSdf Ccntdaed Deteaiaol3oondnR Dnbm 0 Maafcipd Conowdow 0 OMW Na of Dryeea Homing Devt+aes KWLost No. of Water Haran KW Ha Of Na Of 13100 Belinda Na Hydra Maewae TOW Na Of Moana Told HP •. hLnr=CbMW Alauetbberec}iert CfAmKh ftomu lLaas 7tmeawamtlie6ig�itsstae l' ar�suh�iilez}ivalmt YM NO 13 ItaveautrrirardVMpuddstM1of1Vt7ma YM >E)ouh =had1mdYM,1MzirKM.Mbetypeafoompbl 13=0 tax 0 on** 3 / /`i D� Es*n*dValoaafHemWWak S wsiC SM j >�� list MM l i°�p P!6Tdre% �k I; -XA/NNA 2,7— i.,mn�e P � My%we,%. /u 7.Vw�v-Sr rf f i A L t =P-C- r�rb 31100 t= _ R*=Td L9 t - >,s 9r 1aYYsay a�Y•ir�a errr. (Please check one) Owns � Agent Telephone No. FEE s P" NO, P4 �>- 02 Date.2:-:-� ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ . ...... ................................................................... has permission to pe . . . .... ........... ... .... ......................................................... wiring in the building of ..... ................................................ ................. (7 -'t� at.�7� ........... C/ ......... I North Andover, Mass. ................... Fee ............. ............. ................ ELECTRICAL INSPECTOR Check# 47u3 Location 2 -A No. P4/4/ Date aj TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL s Check#V6 I- - 18744 uIlding Inspecf& 0 C) T®WN OF NORTH ANDOVER �. BUILDING DEPARTMENT APPLICATION TO CONSTRUCTREP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING Y ._,•.., .r ;¢,.��zx•.>, ,..,, �*sl`.e. .,., .. -----j BUILDING PERMIT NUMBER: / DATE ISSUED: SIGNATURE: Building Commissioner/I r of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address:1.2 37 tiocyJO f Assessors Map and Parcel Number: 56 ©moo Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Disfrid Proposed Use Lot Area Fronto ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 water supply M aL c.4o. 34) 1.5. Flood Zone Infonnation: 1.9 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIONAUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record LlrY)ao�,w,c (4'r Cvv►rao �,3q t1,14(fC)f n 5f Name (Print Address for Service: 7 (Jj� J�J / a/� / y�1V V l ✓ � ( r//�✓q 105-33?�? Signature Telephone 2.2 Owner of Record: Name Print Address for Service: r4 Signature Telephone SLCTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: vc� CJ�7rt�� Not Applicable ❑ Licensed Construction Supervisor. �o/ {} License Number Address ` ,/p , -` ` p I ✓ > ( r ` `� ExpiratioDatevt Signature Telephone 3.2 RegistlTed Home Improvem t Contractor Not Applicable ❑ G ole YCuo ?/ y / Company Name I �(� Gtr Registration Number L ��L I /(/0 Address / - Expiration Date Signature Telephone 80 M X a a O Z M MM i0 O rn r 00005z a SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......ff- No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: To 9MI SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant (}g71CIISE (a) Building Permit Fee Multiplier UNLy 2 1. Building '7' U // i 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (s) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 r O • 00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _T 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/AUTHORIZZE'Dl AGENT DECLARATION I, � U (`t �` " �� 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 � yr Y( 'h Print Name 'Al no Signature of Owner/A ent Date 11111111111 Ills NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS 1 ST2 ND3 SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DRvIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE N 7Q" W W s: 0 0 z x v lz w � A w ow va a x Ile U) v x U G w a d w E w w a�' ro w w x r� ° cn cn �56 0 C h V Ul a'O a C O O C � O � m Ea y o a N � E � .o m c= O 0 41 �. v, o c J 'mm o z3 42 CI y m = C c col y O O N CD 0 ICD m - vDmOCo=o: N W ouiCO2 C O=r 0 = F- .y a = R C Z W .E 5 ,0 0 �N o 45 h d CD •s 02 am 0 C) a_.. m :10 v NNv �4 •r.a I Com_ CA Q-0 CD■� MOD O O m m CD O O CL a� CD 0 0 Cc O CL a Ca ca c co 2 'p = O tCD C Z CD CL V y O C C c h 0 N j R -I r 'x.11 Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ^& \ �-J1. ►vww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .nnlicant Information Please Print Legibl, Name (BLIS iness/()rganization/Individual): De /u 0110'�Z�� Y Address: _l f�s OAS Coil City/State/Zip: Y 4MIJOVed M,6 9 00S`,5�Phone #: 9'7 F Are you an employer? Check the appropriate box: 1. ©'far a employer with 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 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. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.[D,Other, gei?alt *,any applicant that checks box # I :rust also till out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 1 um an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 4-T C 2 L Policy # or Self -ins. Lic. #:- / 3 -5 V) 7 —7 / Expiration Date: Job Site Address: 1 " C�I n 5� /U�Q�Oot�rV►z City/State/Zip: 011?q _ 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 tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of a STOP WORK ORDER and a fine Of tip 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. 1 do hereby certify under tlVIp ns and penalties of perjury that the information provided above is true and correct. O%Jieial use only. Do not write in this area, to be completed by city or town o�licinl. City or Town: Permit/License # adJ� �5 Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined, as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 Accidents Office of Investigations 600 Washington Street Boston, NIA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia •C 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 at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: UL 5 e lem N -H. (Location of Facility) Signature of Permit Applicant Fire Department Sign off: Dumpster Permit 00-t11Z,)57 Date P q9& C0_%M03aVE,4LW0T9IVUSAaHVSETTS Department of ft6Cu Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official Use Only Permit No. �i Occupancy & Fee Checke9=� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 5277] CMR 12:00 (Please Print in ink or type all information) Date / ^� To the Inspector of Wires: Town of. North Andover The undersigned applies for a permit to perform the electrical work described below Location (Stmt & Number 5l P_7 ►)Z Y 6-) ,/ Owner or Tenant_ 1 1 <� L YZ(2A Loor Owner's Address S' 467 i Is this permit in conjunction with a building permit , Yes . No 0 (Check Appropriate Box) Purpose of Authorization No. Existing Service Amps' Wits Overhead 0 Undgmd 0 No. of Meters New Service Amps volts . Overhead 0 Undgmd 0 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ZZ79 1Z'(t7'_fMtZ - Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA 2 Above 0 In 0 -No. of Lighting Fixtures -Swimming Pool gmd 0 gmd 0 Generators KVA No. of EmergencyLighting No. of Receptacles Outlets No. of Oil Bumers Battery Units No. of Switch Outlets No of Gas Bumers FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. Of Dishwashers Space/Area HeatingKW Detection/Sounding Devices 0 Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wide No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES C% NO c% have submitted valioroof of same to the Office YES C% NO 0 If you have checked YES please i to the type of coverage y checking the appropriate box INSURANCE GOND 0 OTHER 0 (Please Specify) L,,Z 25 � j�vYV li" 4 �' 7G e4 Estimated Value of Electrical vS rk$ 7 Work to Stag ' C� Inspection Date Resquested Rough J G� Final Signed under the OMatties of per)ury: / FIRM NAME _ ` �i�C iC�. LIC. NO. �{ < Licensee r l ` 1 l ` 0- Signature LIC. NO. Bus. Tel No. Address 4- >�+ c�il2C±l,�e h)7, Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have theinsurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) .v Telephone No. (Signature of Owner or - PERMIT FEE Agent) $`