HomeMy WebLinkAboutMiscellaneous - 4 EMERSON COURT 4/30/2018Date.Z..�/' 4'!�. e ........
40RTk
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..... ��. . k 1. .................
has permission for gas installation ... t:� ....................
in the buildings of .... V1. !,. �'� .........................
at ... 41. . r-. / ........... North Andover, Mass.
Fee ... �-A .—. Lic. No. . J.Z �. 4F:'� . .... .. 1-4 ......
1ASINSPECTOR
Check
5398
MASSACHUSPTIS UNIFORM APPUCATON FOR PERM TO DO GAS FrFnNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
A-
/'� Owner's Name
New 1:1 Renovation El Replacement 0
Date 119 i 19
Plans Submitted 11
Permit # S--3 `�
Amount $ 2_0
(Print or X w ,l l Vi
v�
�9
NameI� U `
AA- A a qJT 11 S 4 -
Name of Licensed Plumber or Gas Fitter
Cjlt&k one: Certificate Installing Company
Corp.
11 Partner.
firm/Co.
INSURANCE COVERAGE Check JW
I have a current liability Insurance policy or it's substantial equivalent. Yes No13
If you have checked yes, ple se ' dicate the type coverage by checking the appropriate
Liability insurance policy Other type of indemnity 13 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 13 Agent 13
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 installation rforr-��mee��ddunder Permit Issued for this application will be in
compliance with all pertinent provisions of the Nlassachusetts S"G fid Chapter 142 of the General Laws.
ty/Town
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 4 o-2 pZ
Gas Fitter Mcense um er
Master
Journeyman
JST. FLOOR
(Print or X w ,l l Vi
v�
�9
NameI� U `
AA- A a qJT 11 S 4 -
Name of Licensed Plumber or Gas Fitter
Cjlt&k one: Certificate Installing Company
Corp.
11 Partner.
firm/Co.
INSURANCE COVERAGE Check JW
I have a current liability Insurance policy or it's substantial equivalent. Yes No13
If you have checked yes, ple se ' dicate the type coverage by checking the appropriate
Liability insurance policy Other type of indemnity 13 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 13 Agent 13
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 installation rforr-��mee��ddunder Permit Issued for this application will be in
compliance with all pertinent provisions of the Nlassachusetts S"G fid Chapter 142 of the General Laws.
ty/Town
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 4 o-2 pZ
Gas Fitter Mcense um er
Master
Journeyman
tmoice
OLD OWRI33
-9. H. WOLF A U-MBLIV6 d HEIS G IW010E NUMBER: WRI37
INVOICE VA TE: 27=00T-05
P O SOX # 2229
SALEM, N.H. 03079 ADOLPH H. WOLF RECEIVED
TEL: 603-234-,9231 AM HASTD? PL UfffflEg # 12299
OV 0 8 2005
CUSTOWEIt. WOOOR1,06£ YONES CO-OP T�LEP�roN�Rv
•
-1 PPRES& lO WOODRIDGE DR. FAX.,
aF sTAM POSTAL Mae NO. ANDOVER, AfA. 01845 PO NUMBER: 4 EMERSONCT
ODDER VA TE WORK REQUESTED 8Y&ACY.•
• i'
UNDP 0, 00 <$0. 00 07 -OCT 0S
Y25.00
0.00 $0.00
0 oo $0.00
YE TF4!_
1) 314 CAMA
$2.50.EA.
3) S/4C 90
') 3%4X3-rl2 SSS NIP $3.75 Eat.
3/4 COP ME "L , $ 1.50 PEA
V NlKNIP .
') 314CSLIP COUP
f j 4..Sp9O
TOTAL ACTT COST.,
(ET. I ODA YS THANK YOU TOTAL SILLM: $353. 10
tmoice
-11-1'
,kORT
0
Y
Date. ...
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .... uk, ....................
has permission to perform ... A/ .77 .......................
plumbing ih the buildings of . .'� �. #. ! -�.j ...................
at .... 1-(. . 0!!. 01. ... C,,e .......... Nokh Andover, Mass.
Fee. . 7. . Lic. N* o. . ....... k . .
PLUMBING INSPECTOR
Check #
6759
i
j
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
New 11
� i i1: I _.
�Ybt Q1�S91. `� Owners Name �nJ�lr�1r� �� Jde(� Date
Permit # ? J�
J
-
Type of Occupancy Amount
Renovation E] Replacement �j Plans Submitted Yes ❑ ❑
No
FIXTURES
rA I I-,
I . .........
(Print or type) Check one:
Installing Company Namelf2� l/rj,(� Corp. Certificate
Address
-S 14 42 jW.3 Partner.
Busmess a ep one_
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicathe type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installat' s performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachu
Code and Ch
I ,. apter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY
V Type of Plumbing License
cense Numnof - Master 9 Journeyman ❑
Location
No. Date
,t0ffT#j TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
emus Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # "?7/,)
il
6760
Building Inspect 0!�/
The Commonwealth of Massachusetts
Name (Print)
State Board of Building Regulations and
Signature;.
TOWN OF NORTH ANDOVER
Standards
BUILDING DEPARTMENT
Massachusetts State Building code
S
Telephone (O
780 CMR
Signature
TelephoneCo Ig'
APPLICATION TO CONSTRUCT REPAIR, RENOVATE„ CHANGE THE,USE.OF OCCUPANCY OF, OR DEMOLISH ANY
BUILDING OTHER THAN A ONE
OR TWO FAMILY DWELLING
Building Permit Number.. 0113
Date Issued: �/ 0/—C2 001,3
/
Company Name
AddressExpiration
_
l
Signature:
f 7 —1
Building Commissioner for of uildin s
Date
1.1 > 1.2 Assmaors M and Parcel Numbar. Y n aP
1.3
o¢ Setback
107 Water 91MI-C.40.4 1.5. Flood Zone Information: 1.8 Saw Disposal System:
Public Private Zone Q__ Outside Flood Zone Q Municipal Onsite Disposal system
2.1 Owner of Record
!41oCCC RLe l->�ov>1es
Name (Print)
Address:. 10 (. a.AbY t d e 12 c) e /
Signature;.
Telephone q 7 (� 82 7093
2.2 Autlmrized Ag'. C4 cL�'Cy+T (3 l d r
Name (Print �v 0.
affiq
Address 3 Ljo /' l ct r-43 k4 W to od"
!p
S
Telephone (O
v
aIIlTrnN a MNCTQ7tlTtrtN aIIDVrlRa Yrt4 DOrtiII/Ta l FCa 7'i7AN a[ Mfl r`fTRi!' YRRT AA 4NR f1aAT aDarm
3.1 l Licensed Construction Supervisor:
ic
Not Applicable Q
Licensed Construction
Supervisor:
License Number
d 33��43
vvl b rec)
a��
ExpuationDaUc
15
?-Oo
Signature
TelephoneCo Ig'
3.2 Res6stered Ho a
emtrnt Cc A
C( ge 55 Gl
T
Not Applicable Q
Registration Number ' O 4
Company Name
AddressExpiration
_
l
( CL 1 ci
f 7 —1
Date
Z
Sip,turo///
Telephone
SO (o 2-3
q g
Revised 1997 ]MC
SECTION 6 - DESCRIPTION OF PROPOSED WORK check all licable
New Construction Q 1 Existing Building Repairs U Alterations Addition
Accessory Bldg. Q 1 Demolition 13 1 Other Q Specify
Brief Description of Proposed:
✓1 C,� S 0 'P -1- S . T S r r1 S. 4-
CII!"rrnm ,7 _ rmR r mrp Amn mV1ZTRiTTmm TVPP.
USE GROUP Check asapplicable)
BUILDING AREA Existin ifapplicable)
CONSTRUCTION TYPE
A Assembly A-1
A-4
A-2
A-5
A-3
IA
1B
Total Area
8
B Business E3
2A
2B
2C
O
Q
Q
E Educational Q
F Facto Q F-1 F-2
H High Hazard Q
3A
3B
Q
Q
I Institutional Q I-1 I-2 I-3
M Mercantile
4
13
R Residential R-1
R 2
R
5A
5B
Q
Q
S Storage Q S-1 S-2
U utility Q Specify:
M Mixed Use Q Specify:
S Special Q Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS.
ADDITIONS AND/OR CHANGE IN USE
Existing Use Group:
E)dsting Hazard Index 780 CMR 34
Proposed Use Group: A-644, C—
Prosed Hazard Index 780 CMR 34
SECTION 8 - Building Height and Area
BUILDING AREA Existin ifapplicable)
Proposed
Number of Floors or stories include
basement levels
SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPJ.1ES FOR BUILDING PERMIT
Floor Area per Floor
Signature of Owner Date
Total Area
Total Height ft
SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPJ.1ES FOR BUILDING PERMIT
L , As Owner of subject property
hereby authorize 7 4 &4 to act on
my beh , in ad matters relative t9 work authorized 6y this building permit application.
G44— K44J -3
Signature of Owner Date
revised bldg form/state JMC
SECTION 10b - OWNER/AUTHORIZED AGENT DECLARATION
1, 96 q "y i 4g— xz! Fe" -7 , as Owner/Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
`fio [-F -o i' "+ F F -L
Print Name
-o2G — d
Date
SECTION n - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to
be completed b permit
applicant
Official Use Only
1. Building--
'
(a) Building Permit Fee
Multi lier '
2. Electrical
(b) Estimated Total Cost of
Construction from 6
(�
3. Plumbing
Building Permit Fee (a)x(b)
/
6� �Q
4. Mechanical AC
5. Fire Protection
6. Total = 1+2+3+4+5
Check Number
MU
• • �,°,%x. �r+w�on�rwa� o�✓l.�uaoao�u�aelta
WARPQF-0,�I�4P1N�i`F��V6A►TIONS II
CONSTRUCTION SUPERVI30R I, ,
m
JOHN T HAFFE
3 WILLIAMS RO
WAYLAND, MA
1.7 ..... .
a
0
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
7-a Qnior , Moss - Ea-flaLv) b c t, Pa sR I
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
"'; M -W
x.>
The Commonweal. Ausetts
•,.
De artment oft- hi lr ,dents
P
, , R'• ..,.
Offlce of lnvesfl axlQnsi
1 do hereby certify under the pales and penalties of pedury that the Information pruir dgd above Is true and correct.
.,:.•
600 Wa$hl.h 'n;Street
Boston, Mess; ' 021.11
Workers' Compensation Insurance Affidavit
Location: OOd R t. c4- -e,
City: IV o rt-tn (� ncto ve r MA phone #
❑ I am a homeowner performing all work myself,
❑ 1 am sole proprietor and.haye no one working in any capacity
I am an employer provldlpg workers' compensation for my employees working on this Job.
company name: J' I H ak Ee If3u i (den's Tr►c—
Address: { 3 7 l� t ci 'vnz s
City: W L4 (c, ',j Mi) d) t -1 Phone #
Insurance co. o cep policy # WC(o2 4-T 1 3 8a •-U42 12
❑ I am sole proprietor, general contractor, or homepwner,(olrclO one) and have hired the contractors listed below who
have the following workers' compensation policies:
Company name:
Address:
City: phone #
Insurance co. policy #
Company name:
Address:
City: Phone #
InaUranCe CO. 1 .. ,..,, L.... i x` . policy #
F.ailute to,t eCure coverag0 ads I QI-"'0-''de;Saotion .¢A of Mc3L1 2'Cstt'�ep�'to th`� (dip lhon of crlriminal penaltle:'of a tine up to $1,500.00 and/or one
years imprisonment as weU as olyp. Penaltief In the.torm of a STOi�,WORK ODE�`snd.s nda,of $100,00 p day against me. I understand that at copy or
this statement may be forwarded 19 09 Oifice of Investigations of thy DIA f9r coverage veri�catlon.
1 do hereby certify under the pales and penalties of pedury that the Information pruir dgd above Is true and correct.
Signature
Date
Print name
_�` PiiO�e # 50 Sr (0
1911 (0 8
.. s.,:ji ,.;:,
OtflClai use only
•.._ : 1 fir' ::: ` ' �� .. , `.' :", �.,. y.:�n.4y�;��''t��j�'� ���M;�' s:.� '•
d of writo'In this area to be completed b'�lty o' d11V�m o(floial .
� +'..
City'
�4 ' •'} nrtttllicense #
[]Building Department
:.:., ::.
kl ��, s• ��,' '
„ 7'1'� "
Q Ucensing Board
0 8electriien's Once.
pcheck tf Immediate response•Is required : }...+ �4„t.
'
(] Health Departmerit
oot?tad pennon:
,>, : • �:..,,, ,:,:,:,.ite:.t'
: .1 'l,•,!',.•,. •
: O Other ....
.. ,, :4n }
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SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT 1M.G:L. a 152 § 25C(6)l
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 No
SECTION 5 - PROFFESSIONAL DESIGN AND CONSTRUMOIR SERVICES - FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION
CONTROL PURSUANT TO 780 CMR 116 LCRNTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPA
5.1 Registered Architect:
No Applicable
Name (Registrant):
Address
Registration Number
Signature Telephone
Expiration Date
5.2 Registered professional Engineer(s)
Name
Area of Responsibility
Address
Registration Number
Signature Tel hone
Expiration Date
Name):
Area of Responsibility
Address
Registration Number
Signature Telephone
Expiration Date
Name
Area of Responsibility
Address
Registration Number
Signature Telephone
Expiration Date
Name
Area of Responsibility
Address
Registration Number
Signature Telephone
Expiration Date
53 Geaeml Contactor
o r L< G
Not Applicable
Company Name:
0 r L -r_ ✓ 2— L< S— M w X= 0 6 tic A -C t4 -
Responsible in Charge of Construction
Address SK 9 (7 vis L Q ov R- t AT -
.Signature 16,Telephone
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Building Locations
rrictvi,<�—
S`
. NOR�N
lo t4
O _..a G%
ASSAC
/• �}•r� l f ,
�d °
tbaL
cext'f'es fox
'Cr's ��ssi°� ��. • ' � . SPG pA
�aS pet
� the by�a ,) l�•,✓' � ���'
1 �l`: . ' • • ' •�`•• gyp.• •
at eef rr;,...r4 -
(
Ch
eone: Certificate Installing Company
Corp.
Address vZ ? - ❑ Partner.
Vusmes� s Teelep one ( Firm/Co
Name of Licensed Plumber or Gas Fitter 3 � U - A 6k 1I LSn1•�
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No 13
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑.
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have sub (or enterea) in aDove appncanon are true an a accurate to me
best of my knowledge and that all plumbing work and ins ations pe onn under Permit Issu d for this application will be in
t compliance with all pertinent provisions of the Massa usetts Stat a ode Chapter of the General Laws.
y,.
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 3 /3
❑ Gas Fitter License Number
❑ Master
® Journeyman
Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...........................
has permission for gas installation .............
in the buildings of ...............
'4) .......... (�!r .......
at ........................... orth Andover, Mass.
Feec�j. . Lic. No..�Mh�
Check # //Z/
50 81
(Type or print)
NORTH ANIC
Building Locations
New ❑
UNUMMAPPUCATONFOR PERNIlTTODO GASFPITNG
MASSACHUSETTS
rbyfT
Owner's Name
❑ Replacement ❑
Date 3
a
Permit # ELS/
Amount $
Plans Submitted ❑
(Print or type Check one: Certificate Installing Company
Name ❑ Corp.
Address a La ❑ Partner.
� K1-71 ll a 1 &3a
Vusmess Te�p one � 2A �� �� Co lJ�j Firm/Co.
Name of Licensed Plumber or Gas Fitter .l \J t Jl, LSCZ
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 11No ❑
If you have checked y_es, please indicate the type coverage by checking the appropriate box. 13Liability insurance policy �— Other type of indemnity [3Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the uetails ana mtormaaon i nava
best of my knowledge and that all plumbing work and ins
compliance with all pertinent provisions of the Massa uset
BY:
Title
(OFFICE USE ONLY)
but cutctw� iii uvv �.+ arra............................................. .....
-7o
rm under Permit Issu d for this application will be in
ode Chapter of the General Laws.
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber ;>a 3 /3
❑ Gas Fitter License Number
❑ Master
® Journeyman
��������w����■�i������
IST. FLOOR
6TH. FLOOR
(Print or type Check one: Certificate Installing Company
Name ❑ Corp.
Address a La ❑ Partner.
� K1-71 ll a 1 &3a
Vusmess Te�p one � 2A �� �� Co lJ�j Firm/Co.
Name of Licensed Plumber or Gas Fitter .l \J t Jl, LSCZ
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 11No ❑
If you have checked y_es, please indicate the type coverage by checking the appropriate box. 13Liability insurance policy �— Other type of indemnity [3Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the uetails ana mtormaaon i nava
best of my knowledge and that all plumbing work and ins
compliance with all pertinent provisions of the Massa uset
BY:
Title
(OFFICE USE ONLY)
but cutctw� iii uvv �.+ arra............................................. .....
-7o
rm under Permit Issu d for this application will be in
ode Chapter of the General Laws.
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber ;>a 3 /3
❑ Gas Fitter License Number
❑ Master
® Journeyman