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HomeMy WebLinkAboutMiscellaneous - 41 APPLETON STREET 4/30/2018 (" Office Use Only The Commonwealth of Massachusetts Permit ao. Department of Public Safety 5 Occupancy t: Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be periormed In accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date—/ City or Town of N d( (' To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) A �Ge! &I'l �7~� Owner or Tenant eYL- Owner's Address VI/ /yl'n� 1}wt SJ,' Is this permit in conjunction with a building permit: Yes ❑ No ®� (Check Appropriate Box) Purpose of Building +�S1,61"l__ Utility Authorization NO._, 10 l Existing Service tO Amps 17-0 / 2-ye Volts Overhead © Undgrd❑ No. of Meters / New Service (LO Amps (7-0 / Z C(0 Volts Overhead Undgrd❑ No. of Meters_ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work t1_11,o C IL Vkc 5045_4 Cavi��. ' (,_( Iv 1a a els,'t-6e No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total RVA No. of Lighting Fixtures SwimmingPAbove In- ool grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency LightingBattery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and tonsInitiating Devices No. of Disposals No. of Heat s Total Total No. of Sounding Devices Tons KW No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal ❑Other Connection No. of Water Heaters KW No, of No. of Low Voltage Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: 1ZFC g 4��� INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or ft"s-substantial equivalent. YES[l NO❑ I have submitted valid proof of same to this office. YES[5' NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) Expiration Date Estimated Value of Electrical Work $ Work to Start 12-b'-At Inspection Date Requested: Rough /� Final �2 7 Signed underthepenalties of perjury: FIRM NAME /�S eei� te�V� .' f-- �elt V` .� N C. LIC. NO.J401f_ . Licensee � �- y� zc Signature r� ' LIC. NO. Address 3 a S c� �,,. S j� �Gl��,C tu.� � 0? l�S Bus. Tel. No. 6 f7- J- Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit C([ application waives this requirement. Owner Agent (Please check one) /p-- Telephone No. PERMIT FEE $ J c'� Signature of Owner or Agent ELECTRICAL APPLICATION PERMIT $� DATE: ELECTRICIAN LOCATION DATE COMPLETED f . x �I4.'....�Os�-��:..-.cY�;.�.._....-�'w..w-..-�.....-5�-.:r5i.-.,,,rti�,,r�1..-.. -..r„-• ,-.'�r-•''df,. � ��_ � _�, -.. Date..� J/Jj{��yu T •I' 656 HORTM ° TOWN OF NORTH ANDOVER °L p PERMIT FOR WIRING �,SSACMus� This certifies that ..... . O✓t Se !.l�c{k..ca ......... ........ ......... has permission to perform ....... v �2.`P�r)G ............................... ... y. wiring in the building of t T P.G.............��. .R.................................... .;'; ........... ,North Andover,Mass. Fee... Lic.No. ..-7..?;.... ............................................................... ELECTRICALINSPECTOR Q,9,t� ca1212A3 15.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Location No. •— C Date pORTIy TOWN OF NORTH ANDOVER i F p • i ^ # Certificate of Occupancy $ �'�s'•^°•tt� Building/Frame Permit Fee $ _ ncMus Foundation Permit Fee $ Other Permit Fee $ o~ TOTAL $ Check # 18670 �/ `'Building Inspectat TOWN OF NORTH ANDOVER BUILDING DEPARTMENT ! APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: m s SIGNATURE: 1 r - Building Commissioner/Inspector of Buildings Date /0- SECTION 1-SITE INFORMATION O 1.1 Property Address: �1 1.2 Assessors Map and Parcel Number: O� 6 G5 C Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Requir=ed _ Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSEIPtAUTHORIZEDAGENT Historic District: Yes No m 2.1 Owner of Record u 1 D q �' - Name(Print) Ad ress for S 'ce Signature _ Telephone /_ 576`3/ 2.2 Owner of Record: C.p Nanje Print Address for Service: z i M �r Si nah,.re Telephone 90 SECTTbN 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: a 3,r- 6 4-7 2 /- License Number jwn, Address / Expiration Date Sign,4ure Telephone �• `�"7g'Co8'77f1qzr,�� ---- , < 3.2 Reg6e#Home Improvement Contractor Not Applicable ❑ 9441 C'ompanNalrie) Registration Number Addc ac r egg 7.g Expiration Date �y Si tU4 Telephone Y/ - r SECTION 4-WORKERS COMPENSATION(NLG.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) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: � t k r lr..vL SECTION 6-ESTIMATED CONSTRUCTION COSTS "Item Estimated Cost(Dollar)to be OFFICIALFUSE`ONLY Completed bypermit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X(b) 4 Mechanical HVAC O rrlJ 5 Fire Protection r� 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIXATfON 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 behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 N e Si a of O. er/A ent Date WOR NO.OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR VERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DLMENSIONS OF GIRDERS HEIGHT OF FOUNDA'T'ION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ..: ✓�6 VGl7L7iGQ)t(IJCIGGLft �l � .�7.(L;Jg�4 � _ - 4 BOARD OF BUILDING REGULATIONS . License: CONSTRUCTION SUPERVISOR Number: CS 035867 Birthdate: 12/15/1941 I Expires: 12/15/2005 Tr.no: 11958 Restricted: 00 RAYMOND V BERUBE 361 CHICKERING RD N ANDOVER, MA 01845 + Administrator ,A..... k lio.!!•u o �n• m�; etiu !b< is ar: �t^cu ! il�.. . -0,40E IM PROVEMENT CONTRACTOR .i t Registration: 105523 Fxpi ration: 7/17/2006 Type: lnd.ivid!:al r: RAYMOND V BERUBE. Raymond Beruhe. :;61 Chickering Rd 'x N Ar„dover, MA 018 • . _ AU!numtir::!C!r t n IAoRTH Town of _ Andover No. =, __ _ '� god doo 0 dover, Mass., - A T O �— LA CoCMICMEWICK ADRAT E D PPa\ BOARD OF HEALTH Food/Kitchen PE IT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT............. ........... . .. ................................ ...........::............................................ :::::::: Foundation has ermission to erect...... I dings o; �� .... .. ....................................... Rough to be occupied as ....... . . . Chimney provided that the person accep this permit shall in eve ect conform to the terms of the application on file in Final this office, and to the provisio f the Codes and By-Laws ating 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 T �.�r �^- Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be dispose' d'd in a properly licensed solid waste disposal facility as defined by MGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: S W Cr 11) w 4 /1-1� Ave A (Location of Fa Signature of Permit Applicant Fire Department Sign off: Dumpster Permit Date '� The Commonwealth of Massachusetts h; ! Department of Industrial Accidents Office of Investigations 600 Washington Street \'•'M ,/` Boston, MA 02111 t www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Name (13LIS iness/Organization/Individual): @—r - Address: City/State/Zip: .. L-r Phone#: ' 2C-t ro -7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I em s(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. * 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs, insurance required.]t employees. [No workers' 13.0 Other r V l comp. insurance required.] *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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. I,do hereby ertr under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date- r r11_ Phone#: 7 '2 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 f Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to 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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia is a Location %/ Date U 712-!-$ No. �'7 i F t Of %ORT" 1ti TOWN OF NORTH ANDOVER t. 3? •• 00 � F 9 g .. Certificate of Occupancy $ Building/Frame Permit Fee $ 4 s�CHus Foundation Permit Fee $ 4 Other Permit Fee $ TOTAL $ 3< &el" r Check # c 18383 r building In6do for . r - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING qq p', XP ,,,::, . •'s'xn. x W�.:_. '§ h �,� .4).;` ...Ri,,�G�I�D._ ,� ' ,. � `.,: Y•,> Y,k- x-3e13^ „p z :°?x84.� M BUILDING PERMIT NUMBER: ^) DATE ISSUED: SIGNATURE: , U&f Building Commissioner/I for of Buildings Date - ,3 - 26' z SECTION 1-SITE INFORMATION Q 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 46"a 74" Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided ' 1.7 Rater Simply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: v Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ _J SEOTION2-PROPERTY OWNERSHIP/AUTHORIZEDAGENT Historic District: Yes No M 2.1 Owner of Record t Name(Print) Ad ress for ce: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ K AU Oki � 1�J Li ns onstructron-Supervisor: d -5!T—��e 7 License Number Ad R ),3:r'If" M )a- Co '�T!j/( / Expiration atm v i atur Telephone 3.2Re istered Home Improvement Contractor Not Applicable ❑ Company ame to 551 �_ M S A Registration Number r" Address r -7 6 —,72 -��P Signature Telephone Expiration Date i N SECTION 4-WORKERS COMPENSATION(M.G.L, C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......El No.......❑ SECTION 5 Description of Proposed Work check an applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 6 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be tFCM USE(3NLY �= Completed by permit a licant _ 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) " 4 Mechanical(HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Own Authorized Aaent of s ject property Hereby authorize to act on My behalf,in all ma s rel e to work authtAlt by this building permit application. 7-Sk ature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject F� 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 Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL,OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE J L NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed m a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: (Location of F Signature of Permit Applicant Fire Department Sign off Dumpster Permit Date f BOARD OF BUILDING REGULATIONS � License: CONSTRUCTION SUPERVISOR j Number:,CS 035867 I „ Birthdate: 12/15/1941 Expires: 12/15/2005 Tr.no: 11958 } L Restricted:,,007.r RAYMOND V BERUBE _ 1.36.1 CHICKERING RD r '. N-ANDOVER, MA 01845: Administrator,, 4 136,16 a A!!.: inh C�11 X Of�1 �` ailf:.. f h Yrif . I E IhifiROVEMENT,C s t,'Re , ONTR4CTOR-t tet,glstcatron 105523 .T F: Exptratlon 7/17/2006 I Yype fridivid G -REtYMOND V. E3( RL/BE "rS1r4 a- ” Raymond Berube;�' � J 361 Chickenn ` . gRd N Ardove ' r>MA 01$x` NORTH Town of Ir... Andover No. 42 ~ � 0O �- - LA E o � over, Mass., 7f /43 COCMICHEWICK V �d RATED PP�t�C5 7v �` BOARD OF HEALTH PER IT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................:...... ............................................................................................. Foundation Whas permission to erect..................................... uildings on ,� Rough to be occupied as Chimney .. ... ... ............................................................. ................................................................ provided that the person acce ng 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 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR /�� r............................................. sough ervice . ........................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.