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HomeMy WebLinkAboutMiscellaneous - 4 FIELDSTONE COURT 4/30/20180 111sol- Date ... (.,-z�. I �.Jl. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... ..... oVt.,.�. ........................................... -has permission to perform ...... C-"-, .. ........ VIA -e , .................................................... plumbing in,the buildings of ..... at ............ ................................................. ............. North Andover, Mass. Fee37A.' ... Lic. No. ................................................................................. PLUMBING INSPECTOR Check # N r1ov P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PEPNIT TO PERFORM PLUMBING WORK CITY — A 11111 k-N-0 .—MA nATF PERMIT # JOBSITE ADDRESS OWNER'S NAME 40 '01 OWNER ADDRESS ` r? r • TEL FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL]-- NEW: ❑ RENOVATION: ❑ REPLACEMENT:40— PLANS SUBMITTED: YES ❑ NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOlUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE l MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 942 YES ❑ NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW. LABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Q OWNER'S INSURANCE WAIVER: I am aware thatthe licensee does not have the insurance coverage required by Chapter 942 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY. OWNER ❑ AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are and accurate to th of my Imowled and that all plumbing work and installations performed under the permit issued for this application will be in co with all Pe ' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME PKL&Xy'\ .tom S LICENSE #�9j'�i SIGMA RE MP 2'� JP CS( CORPORATION [] # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME-40tML.° S � � ADDRESS R L& CITY—, ,,kVe- C j �, STATER ZIP_ I TEL FAX CELL-' 7( (� EMAIL I t Date ... �--I . .... ... ) ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that A ............ A ........................................................ ............ has permission for gas instaUation ..... .......................... in the buildings of U-)Oox . . .. ........ ... ....................................... at ................. 1� ...... - ............ . North Andover, Mass. Fee.... Lic. No. I.CI.C35 ...... ..................................................................... GASINSPECTOR Check # CITY MASSACHUSETTS UNIFORM APPLICATION FOR A MA DATE PERFORM GAS FITTING WORK PE=RMIT # JOBSITE ADDRESS (^� Y OWNER ADDRESSra✓' _ TE - - FAX [7 TYPE OR � ..��. PRIOCCUPANCY TYPE COMMERCIAL [ EDUCATIONALj RESIDENTIAL R— CLLARLY NEW: E-1 RENOVATION: [JI REPLACEMENT: Et' PLANS SUBMITTED: YES Q NOJ4-- APPLIANCES 'l FLOORS-* BSM 1 2 3 4 5 8 7 8 s 10 11 12 13 14 BOILER ... ____f_ I _ r..1.M _ .E _r_ BOOSTER I -:, i I� -i - F i - --a� r- �-, r =-1 .. 1 r --- , COOK STOVE DIRECT VENT FORY COCKS AIR UNIT OVEN ROOM fSP ROOFTOP " iNWHANW: t;VVkt{AVL I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES3--( NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0BOND OWNER'S INSURANCE WAIVED: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application wa1 es this requirement. CHECK ONE ONLY: OWNER Q AGENT E-1 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the detalls and information I have submitted or entered regarding this application are true and 8(4u to the iaestnf my nowledc and that all plumbing work and Installations performed under the permit issued for this application will be In compliance erfinent proViisl n 4f t QP Massachusetts State Plumbing Code and Chapter 142 of the General Latus. PLUMBER-GASFITTER NAME 11L'� M f 1 5 LICENSE #� SIGNATURE MP VMGF JP �JGF LPGI Q CORPORATION ®# � PARTNERSHIP#E LLC,01# COMPANY ADDRESS CITY � he- t STATE IP� EL - FAX - l h%EO�T hh.lh LICENSE NUMBER EXPIRATION DATE. SERIAL NUMBER (��� COMMONWEALTH OF MASSACHUSETTS 100,12 Date TOWN OF NORTH ANDOVER ........... has permission to perform ....... ...... .... /V r— F-- plumbing in the buildings of at .... ............. **N*orth Andover, Mass. Fee ............ Lic. No. �p ............................................................... -35 7V PLUMBING INSPECTOR Check # PERMIT FOR PLUMBING !Q\-, I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYo MA DATE [LO.k-;? PERMIT# JOBSITE ADDRESS `,e u_ C� OWNER'S NAME POWNER ADDRESS ` TEL 1PXI_ __.tl TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL 2--' PRINT CLEARLY NEW: RENOVATION: © REPLACEMENT: EDI PLANS SUBMITTED: YES EO NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01LISANDSYSTEM --III _____ f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR(INTERIOR) 4-j KITCHEN SINK ; LAVATORY ROOF DRAIN 1 _..__.J _.__.J .__._ l I � _ _ l .--..__wl .__.._ 4 ..-_..___f _.__J f SHOWER STALL ....... SERVICE 1 MOP SINK___€ __.—_! TOILET (! _f —__i _ ._I .._ ___� . _,. ( ! f URINAL _ _.—; ---i __ WASHING MACHINE CONNECTION f —Al WATER HEATER ALL TYPES WATERPIPING, dT—H E R ___ =_ _ __�_ ._ f. f ...._._._._ .--.-._! INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 9-<O -_ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY B OTHER TYPE OF INDEMNITY BOND © [I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regal and that all plumbing work and installations performed under the permit issued for thi: Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE # CHECK ONE ONLY: OWNER E-11 AGENT IE -11 Jing this application are true and accura a best of my application will be in complia Ietyt provision ,TUBE IMP L -4r JP Q CORPORATION DJ#©PARTNERSHIPE]#� ---'- �ILLC U � COMPANY NAME _.S ; ADDRESS CITY ���— 1STATE l ZIP --�' 200 TEL 3 FAX _ CELL 2 p yoyJ 1 EMAIL ` 1 o o z LF] �,. The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations quo 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADiolicant Information ! , Please Print Leaibl, Name (Business/Organization/Individual):. Address: -�I City/State/Zip: (, efr / , /W Phone #: 3 s l Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I edlor part-time).* have hired the sub -contractors 2LIa 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 3.01 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing information. Insurance Company Name Policy # or Self -ins. Lie. #: ' compensation insurance for my employees. Below is the policy and job site Expiration Date; Job Site Address:`/ter fr'�4-►ti( Cc ,,-) -r :):�i City/State/Zip: / v` /rt ►��(9 v�� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert provided above, is true and correct. Phone #: ' Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: 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 ofpublic 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 maybe submitted to the Department of Industrial Accidents for coninmation 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) 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 ou 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 CoxxaMORWealth. of Massachusetts Department of Industrial .Accidents Office of Investigations 600 Washington. Stxeet Boston, MA, 02111 Tel, # 617-727-4900 oxt 406 or 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 www-wass,gov/dia IN (0)VCOMMONW6 k'6F MAS ACHUSETTS PLUMI HE FOLLOWQS I EN, -A AVRNEYMANl Date.7!�.h:j.h.-.T ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ....... ...... ... t.y. V,-441 ..................................... has permission to perform .... (&n� ...... .............. e .......................... plumbing in the buildings of ... ...... ......... at ........ ... ... ........................................... North Andover, Mass. . . . ......... ... ... Fee.:�?!>= ... Lic. No. MAr ............................................................... ................. PLUMBING INSPECTOR Check # -62—(Pc5 .� Ir6AVVAVIIVVL � �V VMI VI\Irl r+rrL.IVAIv1Y VI\ h r 1\Irll V rL 1%I %.0myl rL.VIVI LAI IMV VV VI\r% J' U CITY MA DATE PERMIT # JOBSITE ADDRESS9 OWNER'S NAM P OWNER ADDRESS I D r TEL FAX V TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 9DIJCA IONAL ❑ RESIDENTIALJD----" PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: (�� PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL1SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/ MOP SINK TOILET URMAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar t and accurate to the b of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m iance with all Pertin rovi n of the Massachusetts State PI tubing Code and Ch r 1 Ionfthe General Laws. S PLUMBER'S NAME ��V Y �� LICENSE #SIGNATURE MP lzl�j P CORPORATION ❑ # PARTNERSHIP ❑ # ❑ # ` -LLLC COMPANY NAME I �1 WJ �� ADDRESS . R,� ' \ «J� CITY ' 1V� Q� STATE ZIP 0_ T FAX CELL EMAIL r .: _. r Date.7��](.-.7 .. k.-5 ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Ai This certifies that ..-W has permission for gas installatiqn,.U-..0j..e-... qZ .... VA -0. .. . . ....... .. ....... ............. in the buildings of ..... . ....... ... ....................... & Ne_ at ............ .......................................................... I ........... .,.,,.,..,North Andover, Mass. Fee? -.0 . . ......... Lic. NoN ....... ..................................................................... GASINSPECTOR Check #32- (e'� n CITYhAh \ MA DATE PERMIT # T = JOBSITE ADDRESS `19—kA��OWNER'S NAME�X t 6G OWNER ADDRESS TEL FAX r TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:r PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATcR HEATER OTHER INSURANCE COVERAGE I have a current liability insurance its policy or substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [IAGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m liance with all Perti t provi 'on of the Massachusetts state Plumbing Code and Chapter 142 of the General Laws, A AAA PLUMBER-GASFITTER NAME /6&ff) �t `�� LICENSE # SIGNATURE MP � MGIE-❑-P JGF PGI CORPORATION ❑ # ���ERSHIP ❑ # LLC ❑ # _ COMPANY NAME ADDRESS CITY Ue l STATE/—A Ok� � TEL `IP FAX CELL EMAIL n r y, w Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass. Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > ...................................- ........... - .......... ............-.......... ..................................... ............................... ............................... .............................. .............. ......... Check A Professional License By the Division of Professional Licensure LICENSEE Name: ADAM C. HOLMES HAVERHILL, MA NEW SEARCH ..This Licensee has additional Licenses. click here to view them.** Licensing Board: PLUMBERS & GASFITTERS License Type: MASTER PLUMBER License Number: 15685 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 3/18/2010 Exam Date: 3/18/2010 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, February 17, 2015 at 10:06:50 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_code=PL&type class=_M&li... 2/17/2015 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 7411,4,e This certifies that ... 6�km .......... ................. ...................... ............. has permission to perform ................. ... . . ..... (, ... ...... l; plumbing_�u yte u * Wings of ....... .................................................. �North Andover, Mass. at.. 2%, ........ .............. �n ....... Fee!� Lic. No. /S7�K ........ - ..; MB -i ....... ................................ Check* S64ig V 4wi-i- �-XNSPECTOR M MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY � 1q l o Jo t/-P.- MA DATE S � PERMIT # JOBSITEADDRESS t^o 6 t eU �n cru r+ OWNER'S NAME cJ(,, C y_L,_ POWNERADDRESSIO Gl,do�r,`J.,TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW. ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO FIXTURES 1 FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 19 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KfTCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE! MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabirfir insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0''NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E/ 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and ccura a best of in e e and that all plumbing work and 'installation performed under the permit issued for this application will be in compria Pef the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P PLUMBER'S NAME 4kie1f \ 0— 5 . - LICENSE # l j� SIGNATURE MP JP 'CORPORATION ❑ # PARTNERSHIP [I# LLC 0 # COMPANY NAME 40i M° S ADDRESS R-LL CIN STATE M ZIP fi TEL FAX CELL —�O ` 4;� EMAIL M ��/ �Sssl/r�� PLUMBERS ---AND GASJjTE SSIES SHE FOLLQWI#G t f CENSE £1C SE AS.� MASHER PI:UMBEW . 0 ?LUMBER AtO GASI �lR I SSV:ES,JTHE FULL0WI V,c--- : (CENSE -' L k q JOURNEYMAN 'PLUMBR u �< AI1A `� C hOLPIES .� 6 RUTH"TI'1E `A'�tRil i LL !A 01832-16 PLUMBERS ---AND GASJjTE SSIES SHE FOLLQWI#G t f CENSE £1C SE AS.� MASHER PI:UMBEW . 0 Date .6.7.1 7476 . TOWN OF NORTH ANDOVER kRMIT FOR PLUM13ING This certifies that ........................ has permission to perform Ft ...... A. wpm plumbing the buildings of 3 X at. VO -VA' 11 d5e .................. North Andover, Mass. Fee,3)45"P. Lie. No..P�.53 .............................. PLUMBING INSPECTOR Check # ft D, 1 3p -4.,U-0 0+ 6!;kffl 6976 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location j b,!e w -o fou f*ners N Type of Occup if New 1:3 Renovation Date 611,16 1-11 Permit # (o w 6 Amount Replacement Plans Submitted Yes 13 No ❑ (Print or type) Check one: Certificate Installing Company Name ❑ Corp. Address FlPartner. 1-7 32 - Business e ePhonen>^o Name of Licensed Plumber: -7tJvt-ce Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy Other type of indemnity a 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 a ccurate to the best of my knowledge and that all plumbing work and installations perfo WuP mit Issued fort is a icatwill be in compliance with all pertinent provisions of the Massachusetts State P>1 r J? teyl'42 t e eneral Laws. D (OFFICE USE ONLY Ty e of Plumbin License icense Numner Master ❑ Journeyman n 1' • .r ..- --------------W-- .`DD N.......W.WMM..... .. WWM MM .......................-. �....-�.-.....�...------- fit' ...........M............. mi 1 ' ......................... 1 t t:' 5 ........................ (Print or type) Check one: Certificate Installing Company Name ❑ Corp. Address FlPartner. 1-7 32 - Business e ePhonen>^o Name of Licensed Plumber: -7tJvt-ce Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy Other type of indemnity a 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 a ccurate to the best of my knowledge and that all plumbing work and installations perfo WuP mit Issued fort is a icatwill be in compliance with all pertinent provisions of the Massachusetts State P>1 r J? teyl'42 t e eneral Laws. D (OFFICE USE ONLY Ty e of Plumbin License icense Numner Master ❑ Journeyman n Date. . TOWN OF NORTH DOVER PERMIT FOR P MING 41 This certifies that ... ...................................... has permission to perform ....................... plumbing in the buildings of .......... at.... ........... .. 7� ... ;e., North Andover, Mass. .......... Fee— Lic. No.. . PLUMBJNG,INSPECTOR Check # AIJ6 70,10 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location �G/i,/ �-�„,1 a New Renovation 6ners NameDate C ' I` )' f 'lQ S Permit # of Occupancy Amount Replacement ©--- p and s Submitted Yes ❑ No (Print or type)Check one; Installing Company Name-/—//,)X-ko •S Certificate II __ II ❑ Corp. Address i� R tJ 4L C t I–L 1 Partner. I L ✓�l C� S CJ 3� Business Telephone 9L �rm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type ot ins cc coverage by checking the appropriate box: Liability insurance policy her type of indemnity ❑ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application (toes not have any one of the above three insurance Signature Owner ❑ I hereby certify that all of the details and information 1 have submitted (or best of my knowledge and that all plumbing work and installations perfo compliance with all pertinent provisions of the Massachusetts State Plu By: Title City/Town APPROVED (OFFICE USE ONLY Agent ❑ 1–tllove application are tru ,nd accurate to the P,errmit ed for IiVpf lication will be in nd T o c Gyneral .Laws. type of Plumbing License "cense INUMDer Master ❑ Journeyman 1' '4ft.� • d M � _ I � • �� NM N N N MM um MW W MM N N MEN a s� -MMMMO MMMMM MMMMMMM��� (Print or type)Check one; Installing Company Name-/—//,)X-ko •S Certificate II __ II ❑ Corp. Address i� R tJ 4L C t I–L 1 Partner. I L ✓�l C� S CJ 3� Business Telephone 9L �rm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type ot ins cc coverage by checking the appropriate box: Liability insurance policy her type of indemnity ❑ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application (toes not have any one of the above three insurance Signature Owner ❑ I hereby certify that all of the details and information 1 have submitted (or best of my knowledge and that all plumbing work and installations perfo compliance with all pertinent provisions of the Massachusetts State Plu By: Title City/Town APPROVED (OFFICE USE ONLY Agent ❑ 1–tllove application are tru ,nd accurate to the P,errmit ed for IiVpf lication will be in nd T o c Gyneral .Laws. type of Plumbing License "cense INUMDer Master ❑ Journeyman Date ... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... ................. has permission for gas installation .... ............ in the buildings of .... r. 1 ................ at ...... r7A-.F."( .'ix-Jr—� ............ North Andover, Mass, Fee. Lic. No../ G S INSPECTOR Check # 5402 MASSACHUSEM UNN ORNIAPPUCATON FOR PERM TO DO GAS FTFnNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 44 ✓•, Owner's Name New Renovation Replacement Date �'►.espermit #6 Amount 31- 6� Plans Submitted 11 Name or type) � I � O I t" � CCorp, Certificate Installing Company Address t r 1-3 Partner. usiness a ep one 3 _ q LA Firm/Co. Name of Licensed Plumber or Gas Fitter i I INSURANCE COVERAGECheWon I have a current liability Insurance policy or it's substantial equivalent. Yes No O If you have checked Yes, ple e i dicate the type coverage by checking the appropriate bo Liability insurance policyrvi Other type of indemnity 13 Bond 0 Owner's Insurance Waiver: r1am 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 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 installations peqqrmed`` �u++nder Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sta[*: � � Ater 142 of the General Laws. tie ty/Town PPROVED (OFFICE USE ONLY) NO- 6ignature of Licensed Plumbber Or Gas Fitter Plumber % z-- 2'9 Gas Fitter LicenseNumber'- Master Joumeyman I Name or type) � I � O I t" � CCorp, Certificate Installing Company Address t r 1-3 Partner. usiness a ep one 3 _ q LA Firm/Co. Name of Licensed Plumber or Gas Fitter i I INSURANCE COVERAGECheWon I have a current liability Insurance policy or it's substantial equivalent. Yes No O If you have checked Yes, ple e i dicate the type coverage by checking the appropriate bo Liability insurance policyrvi Other type of indemnity 13 Bond 0 Owner's Insurance Waiver: r1am 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 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 installations peqqrmed`` �u++nder Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sta[*: � � Ater 142 of the General Laws. tie ty/Town PPROVED (OFFICE USE ONLY) NO- 6ignature of Licensed Plumbber Or Gas Fitter Plumber % z-- 2'9 Gas Fitter LicenseNumber'- Master Joumeyman INVOICE NUMBER: INVOICE DATE: 24 -AUG -05 P. 0. BOX # 2229 SALEM, N.H. 03079 RANDOLPH& JYOLF TEL: 603-898-65o5 AfA. MASTEIR PLUMBER I 1229y FAX:SAME CALL AHEAD CUSTOMER: WOODRIDOE HOMES Co-op TELEPHONE: ADDRESS: 1O'WOODRID6E DR. FAX: CITY, STATE, POSTAL CODE: NO, ANDOVER, MA. 01845 PO NUMBER: 5 FIELDSTONE ORDER DATE GARY: • i . ' START/ AMOUNT RANDY I:60 X90.00 28 � , 05`. :90:00: 0.00 $0.00 TOTALCTIYITY COST: i NONE REMOVE /'INSTALL FAS ... ,. RANGE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL. MATERIALS COST: NET. 10 DAYS THANK YOU TOTAL BILLING: X90.00 Invoice Date / �-AV-1. .0 - "> TOWN OF NORTH ANDOVER PERMIT FOR PLUMBINGw� CHU51 This certifies that ."I".h.1 .... P. * .................... has permission to perform .... R -C ..................... plumbing in the buildings of ............. at .... �A� ............ North Andover, Mass. Fee. Lic. No. .2 ��4 ? �� . ...... ......... PLUMBING INS�ECTIOR Check # 7537 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location '.�S �"'t E J. Owners Name (� �vl r(Lz l� Permit # ,f` 7 Amount Gf r Type of Occupancy CDJhN'1 f' -C1 a New Renovation M-/ Replacement1:1 Plans Submitted Yes 1:1 1:1 ❑ KIN IM , i. • (Print or type) r lj Installing Company Name ClC%s l u �i ns s Check one: Certificate ❑ Corp. Partner. 11 Firm/Co. Name of Licensed Plumber: 14f n,^Y -I L)my*s VC «o,; Insurance Coverage: Indicate the type of ifisurance 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac se is State Plum ing Code and Chapter 142 of the General Laws. By:igna ure o icerTSe' a riumoer Title Type of Plumbing License � City/Town Icense���0 INUITIDer MasterElJourneyman APPROVED (OFFICE USE ONLY Date. . ...... '114�- 14. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that w (, p. c ................... ........... has permission for gas installation .... ............ in the buildings of ... �k-.9 ...................... .:r. North Andover, Mass. at 4Z.1. � . . . . . . . . . 3 Fee. .3. Lic. No../2 A 9. !� ..... �L . �. .... GAS INSPECTOR Check # 5401 MASSACHUSEYIS UNN ORNI APPUCATON FOR PERNIIT TO DO GAS F rnNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations G v L9 $ j rr�e Owner's Name New 1:1 Renovation Replacement a Date Plans Submitted 11 Permit # 5��6 Amount $ ;IB AS EM ENT FEE M • • (Print or Name _ I� Name of Licensed Plumber or Gas Fitter z C one: Certificate Installing Company Corp. 11 Partner. Firm/Co. INSURANCE COVERAGE • Che on . I have a current liability Insurance policy or it's substantial equivalent. Yes NoO If you have checked yes, plPla 'ndicate the type coverage by checking the appropriate bo Liability insurance policy Other type of indemnity 13 Bond Owner's Insurance Waiver: 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State d and Chapter 142 of the General Laws. tie ty/Town VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber / 7� Z—'54 2 Gas Fitter Licehse Number Master Journeyman R N. WOLF PLUMMBMG d HEATN6 INVOICE NUMBER: Wft1 30 INVOICE DATE: 17 -SEP -05 P. 0. BOX # 2229 SALEM, N.N. 03079 TEL: 605-69$-6505 I:AX:SAME CALL AHEAD RANDOLPH H WOLF MA. MASTER Pt UMBER 1122,99 CUSTOMER: WOODRIDGE HOMES CO-OP TELEPHONE: ADDRESS: IO.WOODRID6E DR. PAX: CITY, STAT£, POSTAI. CODE: NO. ANDOVER, MA. 01$45 PO NUMBED: 7 FIELDSTONE ORDER DATE GARY: • ®START / END DATEi RANDY 1.00 $95.00 14 -SEP -05 9.5.00 0.00 $0.00 TOTAL ACTIVITY COST: 1) 1!2X9 DLK NIP REPLACE OAS STONE 5.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL MATERIALS COST: NET. 10 DAYS THANK YOU TOTAL BILLING: Invoice 00- Date. *...' �.- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING / , I I This certifies that has permission to perform plu binVin j-he,buildin2s of . ..... m at ZZ orth Arrdover., Mass. Fee,--�AAM. . Lic. No -,A". /;�. ..... PLUMBING INs P t-ci& Check # 6394 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building �T Tvne of TION FOR PERMIT TO DO PLUMBING Date' d Permit #2L? Amount �-J�' NewE �Plans Submitted No ■ F44-URES • .r / .r / • • .. 25 (Print or type)` -l �► Installing Company Name /� %/ZW ,SC')ri�i MQa Check one: Certificate ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber: (j/ e- s q n Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy /rl Other type of indemnity Bond 11i Az"_ 11 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 Iubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing wo�sachuse install 'ons rformed under P 't Issued for this application will be in compliance with all pertinent provisions of the s SpgPlu 'ng o nd Chapter 142 of the General Laws. By: Signature or Licenseaum r Title 4icensenumuerType of Plumbing License CityYTown Master ❑ Journeyman APPROVED (OFFICE USE ONLY L�1 Date ............. TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING SACHUS This certifies that ...... ....... jj. has permission to perform �141V plumbing,in-the,buildings of, he /A North Andover, Mass. a tzA�.�:�d �')r- - �c �. FeXi. fi) . . Lic. No. - ,AZ -4 -3 Check # Nz - PLUMBING INSPEJ, ... 6 3 9 3 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location/,kJ C.�D New 1:1 Renovation 11 TION FOR PERMIT TO DO PLUMBING Date '2-3' Name o, /��Q Permit #� Amount ` rg ipancy tent F Plans Submitted Yes No FIXTURES (Print or type)// Check one: Certificate Installing Company Name /i /GSC / ��In'KI MQ J R@ Tm- rj Corp. Partner. Firm/Co. Name of Licensed Plumber: '-�V (//j) �tj/LSU n j Insurance Cover e: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy rm 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 0 I hereby certify that all of the details and information I ubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing wo�sacihnuse stall ions rformed under P 't Issued for this application will be in compliance with all pertinent provisions of the s S Plu ng od nd Chapter 142 of the General Laws. By Signature or Licenseam Title Type of Plumbing License / City/ is n Numver -' Master El Journeyman Ej APPROVED (OFFICE USE ONLY� �/ D a t e TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ......... ... ..... ..... This certifies that has permission to perform plumbing,,.iynh �lbuildings of oe Wn D.u'.�d at. . . ..... North Andover, Mass. Feelvlo. Lic. No:,,. — . Check # JA f— PLUMBING INSPECTOR 6392 , MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locatio!�il.JCp i c �(o �iEL,p,�o�E fGuto. I New 1:1 Renovation Owners of Replacement Q FIXTURES TION FOR PERMIT TO DO PLUMBING Date �' a Permit Amount � S Plans Submitted Yes 1:1 No (Print or type) Check one: Certificate Installing Company Name MQa Corp. Addr ss s��% Partner. 11usiness'ie ep ione Fu-m/Co. Name of Licensed Plumber: (//j, (t// Ls (D n Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy tri Other type of indemnity D 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 0 Agent I hereby certify that all of the details and informationI ubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work install 'ons rformed under P 't Issued for this application will be in compliance with all pertinent provisions of the sachuse s S Plu ng o nd Chapter 142 of the General Laws. By Signature or Mcens Type of Plumbing License Title �6 City/Town ` Iccijse NumBerMaster Journeyman W1 APPROVED (OFFICE USE ONLY Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ZZS5 6 7 SU Building Inspector L,57* The Commonwealth of Massachusetts 1.1 Property Addrew State Board of Building Regulations and 1.2 Assacon Map and Parcel Number. TOWN OF NORTH ANDOVER Standards Map Number Parcel Numbs BUILDING DEPARTMENT Massachusetts State Building code 1.4 Property Dimensions: Zoning District 780 CMR Lot Area (sq) Frootege(R) 1.6 Building Setback R 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: a /_ Date Issued: 0/ ` 5)- (/ / L Provided Signature: Required Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Addrew Too 0 1 HQ 1.2 Assacon Map and Parcel Number. Licensed Construction Supervisor: Map Number Parcel Numbs 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Use Lot Area (sq) Frootege(R) 1.6 Building Setback R Front Yard 2 C7 Side Yard Rear Yard Required Provided Required Provides Requited Provided Address l a'A tit 7-7 Expiration Date 50 Co ZC7 Signature Telephone 107 WaterSupply9MO.LC.40.4 34i Public Privi" a 1.3. Flood Zone Information: zone D Outside Flood Zane p 1.8 Sew Disposal System: Municipal On Site Disposal System 2.1 Owner of Record W atxc R Le N6rgo-5 Coo Name (Print) Address: 10 (.l)t'9Gt: hD % 04 e 12 e/ SignaUue Telephone 9 (O 8 2 ` 704 3 2.2 Authorized Agent. Name (Print w Y t a Address 3 W 6 1l a. A3 k a tQ {$ S' Telephone CO SECTION 3 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35.000 CUBIC FEET OF ENCLOSED SPACE 3.1 Licensed Construction Supervisor: Not Applicable Q Too 0 1 HQ Licensed Construction Supervisor: License Number d33�4 Aadn Lit i (1 Q Wls re 10_V_j Expiration Date 2 C7 Signature TelephoneCo 3.2 Rem'ste�Ho a ement Cc tor: 55 Not Applicable Q Company Name Registration Number ) Address l a'A tit 7-7 Expiration Date 50 Co ZC7 Signature Telephone '? Co g 1;7-Z f T1MFk1llufy -2 I SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) New Construction Q 1 Existing Building Repairs U Alterations Addition Accessory Bldg. Q I Demolition Other Q Specify Brief Description of Proposed: 4 3 D -t- -r SJ I Vi 9d9- �1 i' CONSTRUCTION TYPE A Assembly A-1 A-4 SECTION 7 - USE GROUP AND CONSTRUCTION TYPE BUILDING AREA Existing (ifapplicable) Pr d Number of Floors or stories include basement levels SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT USE GROUP Check asapplicable) Signature of Owner Date CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA 1B Q O B Business E3 2A 2B 2C O Q Q E Educational Q F Facto Q F-1 F-2 H High Hazard (3 3A 3B Q C) I Institutional Q I-1 I-2 I-3 M Mercantile 0 4 El R Residential D R-1 R-2 R-3 SA 5B Q Q S Storage Q S-1 S-2 U Utility Q Specify: M Mixed Use Specify: S Special Q Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Propos Hazard Index 780 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existing (ifapplicable) Pr d Number of Floors or stories include basement levels SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES 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 0 SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , As Owner of subject property hereby authoring —7-7 U c i P1r,S Zz-n G . to act on my behalf, in all matters relative to work authorized 6y this building permit application. Signature of Owner Date revised bldg form/state JMC SECTION 10b - OWNER/AUTHORUMD AGENT DECLARATION I, , 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. Print Name Signature of Owner/ARent Date SECTION 11- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of Construction from 6 yy l p� DO 3. Plumbing Building Permit Fee (a)x(b) 4. Mechanical AC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number 1. TIONS (,License: CONSTRUCTION SUPERVISOR Numbs 033843 033U3 81 1955ii i Tr. no: 19350 JOHN T HAFFE 3 WILLIAMS RO o0w*4 WAYLAND, M. 01 F Administrator SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT [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 No SECTION S - PROFFESSIONAL DESIGN AND CONSTRUMOIR SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.1r.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 one 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 5.3 Generel Contractor Not Applicable Company Name: Responsible in Charge of Construction Address Signature Telephone C O O QQ V O LO O O O c9 O N 0d00 O C (1)C m O tn+ A a r�-�/� c'ri • �i•' W CnCn 4 , r, q O O M En CtLn U O bA a cd U N cn �., CA�mo� r�O O N O V M O MO k• W W co m C) U- m c 0 y u � 7 C L _ A L 7 C C 66 u L :v 10 ^ _� E C V oo 00 op .CL c c L y C 2 C Z. C L L a m �.ldCa�m � N � � V L a 4. C I H I L' ►°J E Y O� � 0 I L _ I u I F- Z O � � L _ U O I L � Zd 'C d C R! OL W A W W d L OL i Q y C_ O Q 9 A 1^ m b Q m m aC `l: O 9 W W co m C) U- m c 0 y u � 7 C L _ A L 7 C C 66 u L :v 10 ^ _� E C V oo 00 op .CL c c L y C 2 C Z. C L L a m �.ldCa�m Q 7 � 0 \ N C F- Z O o Q n 7 U O Zd OL W co n j W W d OL i C_ O Q C C d O O 1^ m m m `l: O 9 W F X W J N I� = \)) O tl m O Cy LL Q „3 F 4 The Commonwealthfof,�,far saGhusetts Department of Irl'dla'�ccldents Office of lnvesfl °atlons g; 600 Washington:Sreet Boston, .Mass, ' 02111 Workers' Compensatlon Insurance Affidavit Location: 10 � , W ©odl R L Ll.a e - City: IV o rt'tn V b ve r rM phone # ❑ I am a homeowner performing all work myself, ❑ I am sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: J' Address: ' 3 U rY l u s City: w 4 •vid Mil d) 1 '1 Z 9- phone # SCS S Co 2p `i t �0 8 Insurance co. o '"� c Q pollcy# WCtoL� 3.3-0 =Y2 2 12—,37.0 ❑ I am sole proprietor, general contractor, or homeowner` (clrole 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: We # Insurance co. policy # Failure to secure coverage a:'flquh d and '( Secjfon,;,5A of Moo 142:catf �0.a0 toth4, ltnp lkJon of criminal penalties'of a fine up to $1,500.00 and/or one year's Imprisonment its well as.civil penalties In the form of s STOP W0RK.0RpE� and,a ll ta,of $100.00 a day against me. I understand that at copy of this statement may be forwarded to the office of Investigations of the DIA forooveraOe 4erification. I do hereby certify under the pains and penalties of perjury that the lnformatlori;pro'lded above is true and correct. Signature Date Print name ph one # f5o S- Co ZU `� l to 8 Official use only dp of wrIW;I i this area to be completed 6y'a c official . tire.; City or.town• ❑ Building Department Licensing Board ❑check ff Immediate response'Is required contact person - f .. ,; )X' ���•1 v h�' y T 1��,,jj �1 p, Y. 'i� �..iA '11•�}f$ O Other �•` t r official . tire.; imlltillcense # ❑ Building Department Licensing Board 0 Selectmen's Office: ❑ Health Department tone:.#: ” O Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: —1CL uy�-f�✓1, n'I G ss – 3–,11C -,n b t s ►00 50..1 (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 z K ►c m c O L C y O C 0C.2 •dam Q O.0 A CD c o Ea O At w _Ao a� c 0 0 0 a .. I : : CD a� E 4.0 A C �A w� C3� �' y co 3� m � N co =-0 .r • + �" o 0 to h m A 1.4 CC rcm O: a:COSX: S w O m •�; HZ O ow- Q► a c ~ 0 y O r0. I -- g. p M CLIj Z cm ci a .7 4D.7 O1H .0:w = C3 s a m 5 O 4 x 4-4 a 2 0 COD CD CD L CLi 0 CL COD 0 .Q CO) O V Ci! h L C CD O. CIO C CD CM c C3 p 'a cc m 0 CD ev � 3 .o �CD O �a o a. �a ev .0 O CD Z CD O. CIO C • 0 U) w w W Ir ``w^ vJ Cd a a A U U UW z w w co z° cn o cn m c O L C y O C 0C.2 •dam Q O.0 A CD c o Ea O At w _Ao a� c 0 0 0 a .. I : : CD a� E 4.0 A C �A w� C3� �' y co 3� m � N co =-0 .r • + �" o 0 to h m A 1.4 CC rcm O: a:COSX: S w O m •�; HZ O ow- Q► a c ~ 0 y O r0. I -- g. p M CLIj Z cm ci a .7 4D.7 O1H .0:w = C3 s a m 5 O 4 x 4-4 a 2 0 COD CD CD L CLi 0 CL COD 0 .Q CO) O V Ci! h L C CD O. CIO C CD CM c C3 p 'a cc m 0 CD ev � 3 .o �CD O �a o a. �a ev .0 O CD Z CD O. CIO C • 0 U) w w W Ir ``w^ vJ Date ....... k. Al 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION 'o SACH This certifies that ........... rgasinstal*l*'*'*** .............. has permission fo tion (AI in the buildings of at ( AV, n o e ��,North A d r, Mass. - a Fee�X.... Lic. No.-,&-:�1,3 'Check 4 GASINSPECTOR 513 4 MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 2 /E�D New ❑ Renovation a •t - ,S' c ---- PERM TO DO GAS FrITNG Date / O j 's0 zz— Permit # Amount $!' , s Name �,� �-1�G'P �iNtP S 7 Plans Submitted ❑ (Print or t pe)Check one: Certificate Installing Company Name Corp. Address %� Partner. Business Tele one ::�Firm/Co. Name of Licensed Plumber or Gas Fitter 0�fe--Y 4: // Z, CJ -11 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes � No Q If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 1��1`'i _ Other type of indemnity 0 Bond ❑. Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perfo d u der P t Is ed for this application will be in compliance with all pertinent provisions of the Massachusetts State G Code d pter 1 2V tl)e'G ,,Oral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber ;21e 3 / 3 0 Gas Fitter License Number 0 Master ERJourneyman 2ND. FLOOR (Print or t pe)Check one: Certificate Installing Company Name Corp. Address %� Partner. Business Tele one ::�Firm/Co. Name of Licensed Plumber or Gas Fitter 0�fe--Y 4: // Z, CJ -11 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes � No Q If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 1��1`'i _ Other type of indemnity 0 Bond ❑. Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perfo d u der P t Is ed for this application will be in compliance with all pertinent provisions of the Massachusetts State G Code d pter 1 2V tl)e'G ,,Oral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber ;21e 3 / 3 0 Gas Fitter License Number 0 Master ERJourneyman