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Miscellaneous - 4 PEMBROOK ROAD 4/30/2018
4 PEMBROOK ROAD 210/021.0-0045-0000.0 Date.... 11422 p10RTl� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING t SSACHUSE This certifies that....... .....................,.................................................. has permission to perform.....!44...''��k4!.UA ............................................. plumb' in the buiings of............................................................................................. at... .. at ?.v.......................................................... North Andover, Mass. 1 7 Fee`C7./6, ..Lic. No. .... ....... ........................................ LUMBING INSPECTOR Check# Date..... ...1 ..�. .................. CF 40RT�y,� TOWN OF NORTH ANDOVER O, 9 PERMIT FOR GAS INSTALLATION sSgCHu This certifies that ... ..... c,..cr...te�..................................................................... has permission for gas installation ........ cum............................................ inthe b 'ldin sof...::.............................................................................................................. at...�.............................. h A( dover, Mass. CPSCLL Fees.'...... Lic. 1Vo:`........ .....} ..... . !"'--' -(..:.......................... } GAS INSPECTOR Check# 10226 7 :J I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYt 10p MA DATE —/ — / PERMIT# JOBSITE ADDRESS ��� �� OWNER'S NAME OWNER ADDRESS ± TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ' PRINT CLEARLY NEW: RENOVATION:0""REPLACEMENT: EI PLANS SUBMITTED: YES N0 ]I FIXTURES'l 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/OIL/SAND SYSTEM l _._...___f ` # ( . _._1 I r _._-....1 .� .A rt_.__._-( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 _1 I J .__._! I .__._ ._....___( __..-_( _I _...[ DISHWASHER I _.�I _._.__._.1 _._. ! [ _. .._3 _a _----_.-. DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK —_.- LAVATORY _ -E l � __----_1 ._-_-- i ( --( __---� .--- 1 _ _...-+ � I [ ____.€ ROOF DRAIN I SHOWER STALLI I _I SERVICE/MOP SINK _.( 1 ( I I ---.i --j __j �_�6 I TOILET I ___. _,_I___.-- J __j _.�_. URINAL WASHING MACHINE CONNECTION ^f WATER HEATER ALL TYPES W,,ATER PIPING OTHER _ _.� � _ " _._._ t INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE TH�TOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY __j OTHER TYPE OF INDEMNITY I BOND M 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: OWNERE-11 AGENT ID 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 an 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 compli a wit Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Q_fi—._�P!!! LICENSE# I SIGNATURE MPM JP EB CORPORATION[-.]]# PARTNERSHIP D# LLC i COMPANY NAME ADDRESSOf CITY _...._.._..._I STATE ZIP �' � TEL FAX _ �� CELL J EMAIL LL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No s'Sl/ af- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT it PLAN REVIEW NOTES The Commonwealth of Massachusetts _ Department oflndustrialAccidents 1 Congress Street,Suite 100 ' d02114 2017 _ Boston,MA �r www mass.gov/dia a^M SJ'., yPo3kers'CompensationTnsuxanc6 Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PERMITTING A.UTHORTTY. please Print Le 'bl A ' licantlnformation J�� Name(Easiness/Oraroization/lndividual): y 7 Addx ess: J ��../ �l� Phone#: City/State/Zip: S Type.� .of project(. required): . : .. • , ' Axe you an employer?Check the appropriate box: em to ees(full and/or part-time).* 7. ElNeVV d6listrUCtlOn 1, am a employer with�_ P y 2•0 I ain a sole proprietor or partnership and have no employees Working for me in 8. Fj Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.] 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q.,pr Mbing repairs or additions 5.❑I am a general cont•ract9r,I!a,ndI have hired the sub-contractors listed on the attached sheet. 13'. Roof repairs These sub-contractors hav6 employees and have workers'comp.insurance.t 14.Q Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. ave 152,§1(4),and we hdo employees:[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill 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 state whether or not those entities have loyees,they must provide their workers'comp.policy number. employees. If the sub-contractors have emp , I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Gt 0�� Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: . � 6 d� L City/State/Zip: 6, Job Site Address: Attach a copy of the wor ers' compensation policy declaration page(showing the policy number and expiration date). e by a fiftb up to 0.00 Failure to secure coverage as required under MGL penalties m? the form of25A is a ra STOPal violation WORK ORDER a fine of up to $200.00 a and/or one-year imprisonment,as well as civil p n day against the violator.A copy Of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er thepa' and penalties ofperjury that the information pi^ovided� is��n ���__ Date: Si ature: Qi Phone#: d Off tial use only. Do not write in this area,to be completed by city or town offzciaL City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.P1ummbing Inspector 6.Other Phone#• Contact Person: r M� 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 defuied 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'drl 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 ofthe 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 commonwealthfor 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 theperformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please 1311 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 certificates)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 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(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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I _ CITYr �- MA DATE / / PERMIT# I O Z1 JOBSITE ADDRESS r0 0yOWNER'S NAME GOWNER ADDRESS _ TEL� _O__jFAX TYPE OR OCCUPANCY TYPE COMMERCIAL(] EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[j RENOVATIO :._.._ REPLACEMENT: PLANS SUBMITTED: YES F-] NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =j L=j iz T l _ a E:.. _[= _ L=-j=- 1_- !=1 Z:- =j BOOSTER - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE `"— FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER C_- I—+_ 1 - [ _.-_` _ �—I_._ LABORATORY COCKS MAKEUP AIR UNITY OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTEDROOM HEATER } WATER HEATER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE ECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND 0] 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 F-711 AGENT Elf SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to th best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Perti nt provision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. of PLUMBER- FITTER NAME _. F._ / d h/1 LICENSE# J 0 ( SIGNATURE _.. `� . MP MGF JP D JGF LPGI n CORPORATION 0#L=PARTNERSHIP©#=LLC # .__ COMPANY NAME: ADDRESS —T�1 _�%!_ 07 CITY / _ t✓ - -� STATE�ZIP Jai'o TEL p C/ -- FAX CELL- EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIOX NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ tv FEE: $ PERMIT# PLAN REVIEW NOTES 4 ` 1 a l `a SN_ The Commonwealth of Massachusetts _ Department of IndustrialAccidents Congress Street,Suite 100 Boston,MA 02114-2017 �r www mass.gov/dia Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORIZE'. please print Legibly A licant Information Name,(Business/Orgauization/Individual):� Address: City/State/Zip: I Gz,s � V l Phone Are you an employer?Check the appropriate box: Type of project(required); _em to ees(Rill and/or part-time). 7. 0 NbvdOristriiotion L am a employer with P y 2QI am a sole proprietor or partnership and have no employees Working forme in 8. Remo deliiig any capacity.[Noworkers'comp.insurance required.] 9, ❑Demolition 3.Fj I am a homeowner doing all work myself,.[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 11.E] i 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole - 1!<. % proprietors with no employees. 12T[]'Plumbing repairs or additions 5.❑I am a general contracto and I have hired the sub-contractors listed on the attached sheet. 13•, Rb6f rej airs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other . 6.C]We are a corporation and its,officers have exercised their right of exemption per MGL C. 152,§1(4),and We have iio employees:[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: I Homeowners who submit this affidavrt indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. r; tContractors that check this box must attached'an additional sheet showing the name of the sub-contractors and state whether or not those entities ave sub-contractors have employees,they must provide their workers'comp.policy number. employees. If the sub-cont rs'compensation insurance formy employees. Below is the policy and job site Y am an employer that is providingworke information. �� _ 4' Insurance Company Name: '� C�` �J Expiration Date, Policy#or Self-ins.Lie.#: 4CO-7 &,C(C)k City/State/Zip: t (' Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). e by a fuib up to 0-00 Failure to secure coverage as required under MGL c.es in the form of§25A is a aSTOP nal WORK ORDER ation Iand fine of p to $2500.00 a s well as civil enalti s imprisonment,a P insurance and/or one-year imp ations of the DIA.for Y Invests violator.A copy of this statement may be forwarded to the Office of g day against the vi P coverage verification. X do hereby certify er the ns andpenalties ofperjury that the information provided above is truand orr Date: l/ J Si ature: Phone#: d 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): epartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Building D 6.Other Phone#• Contact Person: 4 fi� I 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 hixe, express or implied,oral or written." An employer is'defhied 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 receivef6#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 xegitired." 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=contractors)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 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 peimit.P r license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding thel6 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 Off'icials 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(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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date.... .-....................................... a CF.r►OR7ly,� TOWN OF NORTH ANDOVER o 9 PERMIT FOR WIRING ,s`SACHUS�t 5 This certifies that :........:..... f.. ... has permission to perform ......--�z .." TiTT...1'p`7-� ,�,,...... ��/'. /en.... wiring in the building of........j .,...t1,t�,�'R.,�,.......� ........ 1 at .............L�........;L..('..�h.E�.d11. .4'�.....1 o!........... North Andover,Mass. lFee.......��.....................Lic.No. ................. . ,... ...........:... -. ELECTRICAL INSPECTOR Check# 2 12777 � Commonwealth of Massachusetts Official Use Only .;= y Permit No. Department of Fire Services .,� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 MR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: (� /� do City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives 40 ice of his or her intention to perform the electrical work described below. Location(Street&N7 �e_l b ) �"r Ade ClL Owner or Tenant C k Telephone No. Owner's Address &% b goo JL Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building F� Utility Authorization No. Existing Service _D DD Amps oZVd /I a a Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 7 No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ISA No.of Luminaires Swimming Pool Above ❑ In- ❑ No—.—OTEmergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 9 No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers / Heat Pump Number Tons KW No.of Self-Contained p / Totals: ............._.......... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Security Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent " OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: / I7 /.S Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA=NCE JR BOND ❑ OTHER ❑ (Specify:) Icertify, underthepAins andpenalties ofperjury,that the information on this application is true and complete. " FIRm N !_,fat✓®Plc LIC.NO.: 1317yS1�2_ Licensee: c)b P1 t Signatur LIC.NO.: 3 7A',5-9 (If applicable,e t `exem t"in the license num er lin .) Bus.Tel.No.�'2 7& 952.2 G Address: 7 ��� S7 ell O Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ �j'6— Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an �s electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. r Permits shall.be limited as to the time of ongoing construction activity,and may be-deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: - - Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: If7 �1 FINAL 1NSPE YON: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: . Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com V b f Massachusetts The Commonwealth o pepartment of IndustrialAccidents I Congress Street,Suite 100 _ Boston,MA 02114-2017 9r www.mass.gov/dia rOf,y SY.V Workere Compensation Insurance Affidavit-Builders/Contractors/Electricians/Plum ers. TO BE FILED WITH THE PERIMTTING AUTAORITY ,lease Print Legibly A ' licant Information Name(Business/Oiganization/Individual): b Address:_j•�O ���y/'`�`�� S ' p33-0hone#: 9�� gS� 26 City/State/Zip: � Are you an employer?Check the appropriate box: Type of project()required): em to ees full and/or Part-time).* 7. ❑New'constriiotlon 1.[]I am a employer with P y 2- I am a sole proprietor or partnership and have no employees Working for mein 8. Remodeling any capacity.[No workers'comp.insurance required.] 9, E]Demolition 3.0 I am a homeowner doing all work myself,.[No workers'comp.insurance required]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions _W1, 12 ;;:Plumbing repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I3•.O Roof rep airs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and We haverno employees:[No workers'comp.insurance required.] *Any applicant that checks bbx#1_must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit+this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Tcontractors that check this box must attached'an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub contractors have employees,they must provide their workers'comp.Policy number- employees. am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance CompanyName: Expiration Date, Lia#: Policy#or Self-ins. . City/State/Zip: Job Site Address: compensation policy declaration page(showing the policy number and exp Attach a copy of alae vvoxkers' iz•ation date). olation 0.00 Failure to secure coverage as requiredell asc civil penalties enalties2inthe form of criminal25A is a TOPrWORK ORDER punishable nd a fine f up to $2by a fbio up to 50.00 a and/or one-year imprisonment,a p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do Hereby certify un tl e pains and penalties of perjury that the information provided above is true and correct. .I _ Date: Si ature: Phone#: official use only. Do not write in this area,to be completed by city or town official. Permit/License City or Town: # Issuing Authority(circle one): i epartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Building D 6.Other Phone#• Contact Person: i I .0 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their em"16yees'. 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 receivet'6r trustee 6fan 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." er. " 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 subdivisionss hall 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 certificates)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' compensationi 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(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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia 10/19/2015 Mass.gov Licensing and Permitting Portal Licensing Entity: Board of State Examiners of Electricians License Type: Journeyman Electrician Type Class: E License Issue Date: 03/07/1995 License Expiration Date: 07/31/2016 Status: Current Current Discipline: Other Discipline: Name: ROBERT H LARIVIERE Business Name: DBA Name: ©2015 Commonwealth of Massachusetts. Mass.GovO Site Policies Mass.GovO is a registered service mark of the Commonwealth of Massachusetts. https://elicerising.state.ma:us/Citizen Access/ �archaUcense.htm 212 10/19/2015 Mass.gov Licensing and Permitting Portal 3 .zz State Offices&Courts State A-Z Topics State Forms Accessibility FAQs An Official website of the Commonwealth of Massachusetts y � Y el-icensing and ePermitting Portal Announcements Register for an Account I Loain Need Help? For technical assistance in using this web application, please call the ePLACE Help Desk Team at (844) 733-7522 or(844) 73-ePLAC between the hours of 7:30 AM-5:00 PM Monday-Friday, with the exception of all Commonwealth and Federal observed holidays. If you prefer, you can also e-mail us at ePLACE helpdesk .state.ma.us. For assistance with non-technical, please contact the issuing Agency directly using the links below. Translation Information -Click Here Alcoholic Beverages Control Commission Division of Professional Licensure Browser Compatibility: - - - • For Application/Renewal:If your application requires a file upload, Microsoft Silverlight is required to do so. Please see the link below for instructions to download Microsoft Silverlight. Silverlight Download • File a ComplainUnstructions aboveapply for filing a complaint if you are uploading a file/picture. Home Manage Licenses& Permits File&Track Complaints Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below. For DPL information,please visit the DPL website. For ABCC information, please visit the ABCC website. Information Pertaining To: Journeyman Electrician 37452 Licensee Detail License Number: 37452 ht"://elicensing.state.ma.us/CitzenAccess/���$oarchaUcen6e.htm 1/2 ,. as� : �g.k4�•.r:� ` 0410310RB 16,s ��..� Date.. . . . . . . . NORTH - 3= TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SSACMUS .� This certifies that A.w.l�/�-C.•C.�-'� . . . .//1 . . .r. . . . has permission for gas installatior���. in the buildings of . . • . /1 at `� >. ort h Andover, Mass. FeeO—� Lic. Nb � N GAS INSPECTOR .Check 4687 MMSSACHUSEI'IS UNDDRM APPUCATONFOR PERNW TO DOORS FTnl% (Type or print) Date 7— 1 NORTH ANDOVER.,MASSACHUSE 100i BuildingLocations / Pe it# Amount$ Owner's Name "' 4--,l New Renovation ❑ Replacement Plans Submitted El x w QE U O � .7 H 'X x C CIO wx a w . a w Ena w z5 w z WWH z C4 cn O o z w p c4 x O w A c�7 a U a > A a H O SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3R D . FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . F L O O R STH . FLOOR (Print or type) C eck one: Certificate Installing Company Name Li Corp. Address ❑ Partner_' Business Telephone 1r�� �'� �!� 6Hr Co. Name of Licensed Plumber or Gas Fitter r � H INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes,please indica a type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond 0 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent 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 IMs application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1422f tGene aws. Si re Title of Licensed Plumber Or Gas Fitter By. lumber 'Z_.5 3 City/Town ❑ Gas Fitter =se um er ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman i 9, �1 y Date..... ... ..... . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... ................ h5s permission to perform ..........-; .......C-1nq--v--Pk.................... 4 wiring in the building of.......... c.t.. I1191r,11 JUP It-*,,' at...................... .........4�. ................. .............. No rth And ver s. Fee.. ...... Lic.No.,,"&;��7.......... ............ E ECICAL NSPECTOR Check # 5 U 30 _ Commonwealth of Massachusetts Oficial use only � PerPermitt No. t/130 " Department of Fire Services ' 91Qccupancy and Fee Checked ,. BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERF M ELECTRICAL WORK All work to be performed in accordance with the Massaausett Electrical Code(MEC),527 CMR 12.00 10, (PLEASE PRINT IN INK OR,TYP ALL INF RM IDN) Date: —/lf—Q!f City or Town of: To the Inspector of Wires_ By this application the undersigned giv notiod.of his or her i te$'tion to perform the electrical work described below. Location(Street&Number) Owner or Tenant F Telephone No. Owner's Address Is this permit in conjunction with a b,�uildping ermit? Yes ❑ No (Check Appropriate Box) Purpose of Building ���J JA LI Utility Authorization No_ cRo 01 a Existing Service __60 Amps 16/ UO Volts Overhead� Undgrd❑ No.of Meters / New Service c7 00 Amps It / d9 Volts Overhead v Undgrd❑ No.of Meters Number of Feeders and Ampacity l Set Location and Nature of Proposed Electrical Work:' Completion o the ollowin table may be waived by the Inspector of Wires_ No.of Total No.of Recessed Fixtures No.of Cell-Susp.(Paddle)Fans Transformers KVA No.df Lighting Outlets No.of Hot Tubs Generators KVA Above ❑ In- o.o Emergency Lighting No.of Lighting Fixtures Swimming Pool d d. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Air Cond_ Total No.of Alerting Devices No.of Ranges Tons Disposers Heat Pump. Number Tons KW No.of Self-Contained No.of Waste Dis P Totals: Detection/Alerting Devices Space/Area Heating KW Local ❑ Municipal El Other No.of Dishwashers Sp g Connection , Heating Appliances ces Security Systems: _ g PP KW 'valent No.of Dryers No_of Devices or Equivalent No.of Water „ No.of No.of Data Wiring- ..W . .. >! Heaters Signs Ballas`s No.o,Devices or urv...e..� Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Aaack additional ddail if desired.or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation coverage or its substantial equivalent. The undersigned certifies that such 7BO ge is in force,and has exhibited proof of same to the t issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify.)Nr tri( 114 �7 b (Expiration Dae) {Estimated Value of Electrical Work_f/ _,5 P V&1 (When required by municipal policy.) Work to Start:. ,,2 ©y Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the ains and penalties of perjuu ,that the information on this applicgtion is true and complete. FIRM NAME: C LIC.NO.: / a 3 Q ' LIC.NO.: Licensee: �1� Signator _��— � (7f applicable.enter! empt"in the license number line.) �/ Bus.Tel.No.- Addresso1l ld r'✓1 � fir � A ie A g,,14 �_ c ® 42' It.TeL No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does of have the liabilit insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signa PERMIT FEE: S r9p Signature Telephone No. 17nnn�nf � APPLICATION FOR ELECTRIC WORK PERMITI S (DO NOT FILL OUT THIS F9LD) r N0. SERIAL N0.---.•- ST. & NO. OWNER ELECTRICIAN PERMIT. ISSUED REPORT OF. INSPECTON OF WIRES -------------- i .MA LIC.NO.:A12369, kri NH LIC,NO.:10225M FULLY INSURED CARMINE-D'AMBROSIO ALL'TYPES OF ELECTRICAL WORK 268.MAIN STREET ' PMB 328 CELL: 1-508-6542056 NORTH READING,MA 01864.. - FAX:978=256-5701 Date.... ..... . .... r� 6 I f NORTH q TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACMUSE� . This certifies that ... .. ZZ26. illd�r[•f/.J {! ✓... has permission to perform .........k ........................... wiring'n tthe building of...i�......, .... . .......................... 4 at.�..... ... ...... �........... ,North Andover,Mass. Fee .S LiC.N0. dJ..It....................................................... ELECTRICAL INSPECTOR � Check # 50.76 Commonwealth of Massachusetts Oficial Use Only Permit No. 7� Department of Fire Services Occupancy and Fee Checked - BOARD OF FIRE PREVENTION REG LI TIONS F Rev. 11/991 eave blank) APPLICATION FOR PERM1IT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massa iusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -! 3', 49 [, City or Town of: ✓V ! r To the Inspector of Wires. By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&NumbeAoe-44 -n gad Owner or TenantTelephone No. J-f x7do_d�,�" 3 5 Owner's Address S 4 M c Is this permit in conjunction with a building permit? Yes V No ❑ (Check Appropriate Box) Purpose of Building / i"thvsq,l L6g. Utility Authorization No. , Amps [/p / a Am New Service P ?a,Volts Overhead Undgrd❑ No.of Meters Feasting Service .1061? t' Amps 1/0 /a1 O volts Overhead F Undgrd❑ No.of Meters / �_ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �� �2 vin Completion o the ollowin table may be mived by theins erlor o iYires. No.of Total No.of Recessed Fixtures 10, No.of Ceil.-Susp.(Paddle)Fans 'Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KYA Above In- o.o Emergency ig mg No.of Lighting Fixtures Swimming Pool d. ❑ End, Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Gas Burners No.of Detection and No.of Switches Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges a Tons Disposers Heat Pump. Number Tons KW No.of Self-Contained No.of Waste Dis P Totals:I I I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Conne munichon El Other Heating Appliances Kms, Security Systems: No.of Dryers No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Suits Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total AP No.of Devices or Equivalent OTHER: Attack additional detail if desire4 oras required by the Inspector of Wins. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent_ The undersigned certifies that such coverage is in force,and has exhibited proof/of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER El (Specify=)L a 4,:-e vt X-Gn&s& 1— (ExpirationDate) Estimated Value of Electrical Work (When required by municipal policy.) Work to Start: '"7-/r 42 4 Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: T�tO LP �� _ LIC.No.: Licensee: /q H.brosi•f Signature �- 94y?6J/ LIG NO.: (If applicable.enters/"ecempt"in the license number h e.) � Bus.Tel. `Address., /r/K,, S T AlyS aw i►�-�� a ' ( c Q /d'6 L[ Alt.TeL No.: 'OWNER'S 1T\1age normally SURANCE WAIVER: I am aware that the Ltc see does not have the Iia ility insurance cover required by law. By my signature below.I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. bivner/Agent PERMIT FEE: $ t Signature Telephone No. I)nnn rrf t♦ APPLICATION FOR E� CTRIC WORK PERMITI (DO NOT FILL OUT THIS F9-LD) N0. SERIAL N0,-- f ST. & NO. OWNER i ELECTRICIAN • t PERMIT. ISSUED REPORT OF. INSPECTON OF WIRES d i i • Location No. �C Date Y f NORTN TOWN OF NORTH ANDOVER • ; , Certificate of Occupancy $ "sT cMUsEt� Building/Frame Permit Fee $ /70 Foundation Permit Fee $ - Other Permit Fee $ TOTAL $ — Check # �l s 17 Building Inspector i� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIP,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: C( DATE ISSUED: _ i SIGNATURE: CV"_ Building Commissioner/Inspector of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: L Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin DistrictPr osed Use Lot Areas Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply M.GL.C:40, 54) 1.5. Flood ZUne Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record (A\ A2d --/ NamJ(Print) Address for Service: Signa re Telephone 2.2 Owner of Record: N+me Print Address for Service: Signature Tel ne SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ I i 1 Company Name Registration Number F` Address Expiration Date Signature Telephone SECTION 4-WORKERS COMPENSATION(NL 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.......0 No.......0 SECTION 5 Description of Proposed Work check all applicable New Construction ❑ Existing Building ❑ Repair(s) 11Alterations(s) 11 Addition ❑ Accessory.Bldg. ❑ Demolition ❑ Other ❑ Specify i Brief Descnntion of Proposed Work: ` i SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be X " HF�CIAL IIs 0A Co leted by permit applicantM, f•b5v... u5 E5 h ...: 5 .X:J-S. 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of 10�1 ® Ca Construction 3 Plumbing .26-12 Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 d'd cr Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My bei,lf,in all matters relative to work authorized by this building permit application. Si dture of Date ► SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Own er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T MBERS 1 2ND 3 SPAN DIN ENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS x HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X j MATERIAL OF CH VINEY r IS BUILDING ON SOLID OR FILLED LAND NATURAL IS BUILDING CONNECTED TO GAS LINE i t=O Digo Town of North Andover e� Building Department 27 Charles Street �$ North Andover, MA. 01845 �s ^�°� - - SAG}#LY'�E' D. Robert Nicetta . Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION �G n'►�/d d e 7�: ��•- ��d/rJ �,,,i�a✓�f- sl �/ C_-- Number Street Address Map/I t �l "HOMEOWNER G �a/q 74 efft/`` Name Home Phone Work Phone /� PRESENT MAILING ADDRESS 'r �� ---� / City Town State Zip Code The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one a home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other . Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL�����9 NORTH Town of Andover No. �� O LAKV dover, Mass., COC MIC KE WICK ADRATED o'PCO S � BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPEC'T'OR THIS CERTIFIES,THAT ....... .......� ............. .........o.��.a..�................................................................................. Foundation has permission to erect... . . ............. buildings on ....�....P ."k.. ......?4............. Rough tobe occupied as............K. .......{,...........................B. ...................... .......................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the In ion, Alteration and Construction of Buildings in the Town of North Andover. da 1 lyy�-- PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STTTS Rough ..`..... ..... Service BUILDING INSPECTOR Final Occupancy Permit Required t® Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises Rough Do Not Remove Final No Lathing or Dry Wall To Be Done I FIRE DEPARTMENT Until Inspected and.KApproved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. %40RTH TOWN OF NORTH ANDOVER OFFICE OF a2 BUILDING DEPARTMENT * 27 Charles Street a q�AAtm� ` � North Andover, Massachusetts 01845 �SSAC14U Telephone(978)688-95454 D.Robert Nicetta, Fax (978)688-9542 Building Commissioner June 7,2004 Edward Morgan 4 Pembrook Road North Andover MA 01845 Dear Mr.Morgan, Pursuant to your question on the clay liner of the gas boiler,please be advised that the clay liner to your chimney is within the Massachusetts Code CMR 148. If you have any further questions please let me know James Diozzi, Plumbing/Gas Inspector BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 4 r Location -- No. Date NORTH TOWN OF NORTH ANDOVER A Certificate of OccupancyIt $ A ` ` Building/Frame Permit Fee $ s°4C E Foundation Permit Fee $ � s�cHus t. � Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ lV Building Inspector Div.Public Works PERMIT NO. / Q1`7 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. t/ PAGE 7 MAP 440. LOT NO. 2 RECORD OF OWNERSHIP JDATE BOOK +'PAGE ZONES I SUB DIV. LOT NO. �I j LOCATION /�A �� PURPOSE OF BUILDING t/`�v E GWNER'S NAME .� � , NO. OF STORIES SIZE OWNER'S ADDRESS �a ,,�� Fes- BASEMENT OR SLAB ' ARCHITECT'S NAME �+ SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME /,fin/n SPAN, DISTANCE TO NEAREST BUILDING " DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS - 4. AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X _ IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER o' 16 BUILDING CONNECTED TO NATURAL GAS LINE ` INSTRUCTIONS 3 PROPERTY INFORMATION,:.' -y LAND COST SEE BOTH SIDES EST. BLDG. COST 1� EST. BLDG. COST PER SQ. FT. PAGE 1 FILL OUT SECTIONS 1 - S '- PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED NP APPROVED BY BUILDING INSPECTOR DATE FILED SUILDING INSPKCTOR RE OF QWNE R AUTHORIZED AGENT FEE OWNER TEL# PERMIT GRANTED CONTR.TEL# 19 CONTR.LIC.# H.I.C.# mal , 17 too _h I IV BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY s�oR1Es THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I I _RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ 3 1 2 I3 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ sY UNFIN. s' 3 BASEMENT ( �` AREA FULL FIN. B'M'T' AREA _ 1/.1/11 FIN. ATTIC AREA N_O 8 M-T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW'D !' ASBESTOS SIDING COMMGN _ VERT. SIDING ASPH.TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICKATTIC STRS. b FLOOR I_ . BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR 11 ADEQUATE ONE 5 ROOF * 10 PLUMBING GABLEHIP 'BATH•(3 FIX.) _ GAMBREL MANSARD TOILET RM. FIX.) ) FIAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES 'KITCHEN-SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR . . TILE DADO ~r 6 FRAMING i l HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. ` TIMBER BMS. 6 COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT.HEATERS 7 NO. OF ROOMS GAS OIL j B'M'T 2nd _ ELECTRIC Ist' 13rd I NO HEATING rIORT�y �c o Of g __ _ Andover No.- s Over, Mass., Z 19?2 0 LAKE OCMICHEWICK iY'�• . s gArEo `G BOARD OF HEALTH Food/Kitchen PERMIT Septic System 1 n BUILDING INSPECTOR THISCERTIFIES THAT'::...........................................�.�...U.414.................................................................................... Foundation has permission to erect........R.0-0.................. buildugs-OAR..........I........Rz. .!'. J.MA ......................... Rough to be occupied as................................................... Chimney .............. . . .......................................... ... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STAR° Rough ........................... ............... ..... . .. Service B DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough , Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det.