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Miscellaneous - 410 BEAR HILL ROAD 4/30/2018
410 BEAR HILL ROAD 2101064.0-0102-0000.0 Date...l.�. ��..� -:. NORTry °ft"`° '• '"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING •O•�rr°��`� �tssACNUSEt Thiscertifies that ........ ` ................................................................. has permission to perform ..... ................/ ........................... wiring in the building of.....�Z?/ ..... � ..................................... at.....�I1..........Z1 ....... ( .... ,North Andover, ass. Fee.. r,j ........ Lic.No. �, .. ?'... .. 3 ELECTRICAL INS CTOR Check # "� 0570 u �; It I Official-Use Only �-- Ca7-.rt:cr2.�oT !/a��aYr�.c,a£u-- - - � >J� ?'erinit'0. — i n or.J-ra .ary cad ? r Occupancy and Fee Checked 40. :-',0 OF FIRZE PRE`:EM ION REGULATIONS '(Rev. 1/071 .� ( (leave blah:,} l L-L AL til 1Vur1:to Ce Dcrib,-.ed in accordance 3u'i LRe iVi?ss2ci1,jsetts Elecu`ICal rode 11E-C,527 f'1�i I2.170 \� (PLE,4SE PPI-T' LAI tt>/-0 PE /.L I O TOr�J ate: Z li y cr To;in of. (3Ur''� To the Inspector o!'�YYires: 3y this application e tlldeFsit?ieo glues nor Of fits or her il:t�eFJtion t0 per`o:rt,`l a electrical work described bel ow. Loc2tion(Street&Number) � C � `'��Q I� t C ILL —r— �.1 Oviner"orTen2nt. ICC (e Telephone No. Owner's Address _. Is this permit-in conjanc ien with a"building permit? Yes ❑ No. 9,1 (Check Appropriate Bov.) Purpose of Building utility i'Il.uthoiization No. — Existirg Service Amps / Volts Overhead Undgrd No.of Meters New Se-.Vice _4FLmns l Voits Overhead Fj U,egrd n No-of Meters `Cumber of Feeders and'iMpac]Ty Locatiofi and Nature of bloposed EIectricaI Work: compiefion ofthe following table may be waivad by Me Inspector of 7irer-. It 0.of 1No. of Recessed i.ulmin aire I-o.of Ceil.-SUS addle i+anS 7 r I- p �' ) iTransformers INN.of Luminaire-Ocitle>~ i-N of I otTabs �GeaeraiQrs KVk St. ^ r Above r- in- 1NO.or Emergency Ligp-ring V 'No.of Lura-inaireS im-n.in.a PQoI arnG. '--t �Td. L1 ��aitea_+�Ur1iCs - F ?�lo.of Receutacle Outlets No.of Oil g,�rners FIRE "L4I�N�S �l�'o.at�.bnes No.oMetcrtion 2n0 € �No.of-Sivitche €'�o.'?Gas Burners I,.itictinE De,'ices } ftl! } No. rif Ranges 'ado_of Air Con d. ot2_ No. cfAlert;n�Deices t j Tons Y=_at Pump I Nuti7i<er l Tons —K tv i 0.of elf-Con-i2ined. lNo.of Vv`aste Disposers { Totals' 1 I �Detection/Aierting Devices _ ',ht�nici-al I ��o.of iJish:,as iers 1Space/Area Headn Ica' Lo ` � onneca Cr�:_et• `J I' t Security Systems! ` F r He--iia g Appliances KW No.ofDryers p Devices .ui�'alent i 1e-.CfWater I No.of No.of Data Whin¢: I='}' i?ji? yIQ.e!Devices or E5uivalent Fleaters Si�'z asrs ♦ ITelecommunirntions 4=iring: !No. Yyororsiassaae Sark-tublo !No.of!elotors Total iia t l`li0.of I'-}.Ltices or Ezgeiy2lent — 00 I DT HER: `.teCCh^_�idltlCrG!G�EI^-il J desireGT Or e-5 rz cf:i 2C1 bj�t..e I:sy-sC1Cr GI y r25. s:ilea ed 'lzluP n deet-,Aal Q— V'.hen required by,runic=.gal policy.) War::to�tei `Z 2�' insoecuons_o be - este in-2ccor I--with MILE RL Ie 1 D,and upon ccF,^letion. 1._� r i- r � t is$Uc uP-'lees Li�ISUI-A-NcE CO SiRAGx+: Unless w?�ved by the owner,no permit for the I -rf nla!Ce O:eleC: .r81 1",OFiC I31<_y the!i%en5ec pFOYiCeS proofo-[142tiility iF1sU 23iCe Iz1Cii?Cula"coinnleted Operations'cove:cge or-its substantial eGm valent, i li-c "undersigned CeniFes d,-at:much coverage is in force,and has exhibited vrQOi4I 52iZ?e t,0 the permit issuing OMCc. CHECK ONE: INTSUTR A_NCE. j� EOIN`i% C 03 HER D (Specify:j ? Cc^711 jt under f:e paLms and pEna'-rfies OfPerju,y,-'kat the an enation--on 0;is appiica_ioY ss true and complete. _ �-F + `�_ �t�s, LIE. NO.: FIRM NAME: 0 1 � _- L•lcensee: G1 t ` ✓Z:J�Il Sianzri V _ -' � lj G?711C�C1, ?Y.fSr ? 2.:ami' :n're ItCanse tit ni?e+-'lire j ti 4'� 'Pus.Tel.i�o.: �}�- Address- C.c E r-n r. �w 1ES: h O 3U` ik I Alt.Tel.No.: _ — ` v143A teGUi1et3:CP.L Qs PUbi1C Se-:iy S"T FCenSe: LiC. O. �s OVi,NIER'S I?,IStiR�i?('E-WAIYER-- I ann aware that,Cr:--?Licensee does r: have the lilt I:3iy InsU1cr1CZ Cf1 f?T`cQ'USii?'cii} FdQuiFed by law. l e V rnV smile I' uCluiv;" iereby T`td1V�LLifS ietlL'ireinent. rn ine(Chef!:one}l7owneF [�J`:7rlei'S agent. Owner/Agent PER.IT I±EE; 3 Signature Telephone No. ��-- ._ _ _ -• .' r _.��1 I,r1-Iia.._.i,t(•t.�a•J.r:..._ - - \ q_FEGIS i FRED SYSTEMCOI�I.it�C OF z= "issU=sSHE%A60V`uCENS2_i0 =1 ?P.K-A :BROPHY<.SR 41.0_ U.N,j�ERciTY. AVE = 07/511-3 9 �:'--" _ - _' Fet�.'itwn Otns;'I:Je��7S Pefer_.'.•rs . Keeptop.or receipt and chance of address n6tiflMti0;s, �P&lAs v 3 ;Qv3•taSfi2G�_UC�-NScFO,^,r.51 ✓f,�-�inrmcosactsee��,,��:;�«tX. l D PARTAEFIT OF PugL_IC'SAFE! owl S-ucanse }} Numoer._SS CO 000 Fxpiras -4Z/�r1Z013 Tr.no: 195.0 S Uj;ense: ADT _ I�J,PK A BROPHY•SR 410 UNIVERSITY AVE ✓l,- /� OIG SAFE CALL CENTER {s$$j 3u.'i 233 WESiVJOOO. IVA 62090 ComrissF I y ' - I Date../K ........./-I...... h f HORTN 1 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �S.t CHUSE� This certifies that .... . ...� ....-4f....................................................... has permission to perform ... ........................................... wiring in the building of ..�f .......................J.�.................................................. • 1 f t ....�...:.:.......... .. .North Andover;Mass. Fee ....�r..... Lic.No ` ............. .�...`' ' ELECTRICAL INSPECTOR Check # 9126 p ruuaa h o/Q aOfficial Use Only x/1/1a1� � Permit No. Occupancy and Fee Checked " BOARD OF FIRE PREVENTION REGULATIONS ev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordancewith the Massachusetts Electrical Code(MEC),327 CMR 12.00 (PLEASE PRINT EV IAtK OR TYPE ALL 17VFORMATIOM Date: //—& ' 0 City or Town of: Ao er<-! AvdUJ&oe, 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&Number) qla Owner or Tenant J�m E , /2 0 Telephone No. O 7-7 J J Owner's Address t5�9/10 is this permit in conjunccttiio-nn with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building J L.FJ`���/�7JUtility Authorization No. Existing Service Amps / VoIts 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: /p)1A?>A/G-r 0 Completion o the ollrnvin Coble may be waived b the Li!Lyector of Wires. o.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA � No.of Luminaire Outlets No.of Hot Tubs Generatorsf'j KVA Alcove In- o.o mergency i ng No.of Luminaires Swimming Pool ❑ d, ❑ &geM 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 Heat Pump Number Tons KW o.o f ontained No.of Waste Disposers Totals; Detection/AlertingDevices. Munrcipa! 13 Other No.of Dishwashers Space(Area Heating KW Loc21❑ Connection Heating Appliances KW Sect o.of Devices o r Equivalent No.of Dryers N No.of Watero.of No.of Data Wiring: Heaters KW Sp Ballasts I No.of Devices or E uivalent Telecommunications iring. No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. en required by municipal policy.)Estimated Value of Electrical Work: (� � �p ry' Work to Start: inspections to be requested in accordance with NEC Rule 10,and upon completion. 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 ❑ (Specify:) I certify,under the mins and penalties of perjury,that the tnformatio n this a cation is true and complete: FIRM NAME: t)- /.�5 Licensee: 5 Signature LIC.NO.:a8lle5 ('If applicable,enter"exempt"in the license mrmber line.) Bus.Tel.No.r.;r ��'�3'��f`� Address: 'vT .eyE%: � r-YJXO.eO 96 Alt.TeL No.:•'m "�� *Per M.G.L.c.147,s.57-61,security work requires Departm of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the censee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive s requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $.-OQ Signature Telephone No. Iwa I z-8-0 ? Al (9a 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.Atter a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an 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. Permits shall-be limited as to the time of.ongoing construction activity,and maybe_deemed.by the.Inspector_of_Wires abandoned_and_invalidaflre—. ._ 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: -- � i� ***Note:Reapply for new permi ❑Permit EXtension Act—Permit/Date Closed: Date.. ...... ............. ,40RT" t".. 't. 0 *-e 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING US This certifies that �' ........... ........ ............................................................. has permission to perforin,.... .................................................. wiringin the building,of............................... ..... ............................................. ........ ....... .................. ................ .North Ando,vel,Mass. . ... ......... L i c.No- ............... P'% Check # :7 8'15 4 00// / Official Use Onl �mmon,wealth o�cc�ae�achu�e� / Y e 2epavt.d o�,tire Seevicee Permit No. (�1� _ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeE C), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYP ALL INO�`RP TION) Date: ' /t� O � City or Town of: �_Pi�J at`tom To the Inspect r of Wires: By this application the undersigned gives notice o is or her intenti n to perform the electrical work described below. Location(Street&Number) / p " Owner or Tenant s $I Telephone No. 27W ;15F 70a Owner's Address i cs. e...` H7L/ Is this permit in conjunction with a building permit? Y s No,O (Check Appropriate Box) Purpose of Building //_)QAOCA— Utility Authorization No. Existing Service Amps / 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: GJ L Completion of thefollowing table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above o e❑ In-L-rn —0.0 mergency Lighting grnNo.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etection and Initiating Devices No.of Ranges No..of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I Number Tons KW No.of elf-Contained Totals: "'""""'"""""""""""'"""""""' Detection/Alertin2 Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent i' No.of Water KW No.of No.of Data Wiring: + - Heaters Signs Ballasts No.of Devices or Equivalent I No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent . OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: OU (When required by municipal policy.) Work to Start: ATWInspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE 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 cov rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) 3 ZZ e, �J L I certify, under the pains an era ties of perjury,that the information.on this application is true and complete FIRM NAME: LOiL._ LIC.NO.: ' Licensee: Signature .NO.: ��- (If applicable,enter "exe t"in the lice numb r li e.) Bus.Tel.No.:QGvtOYb G4T Address: '7 / y' ,Q,i t)(/�� r (J j' a/$ 7 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of ublic Safety fety"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 Signature Telephone N.o. PERMIT FEE: $ 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 e ectrical 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. Permits shall-be limited as to the time ofongoing construction activity,and may be.deemed.by the.Inspector-of_Wires abandoned-and-invalid.if-he—_. ._ or she has determined that the aufhorized 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: —�Z � ** Note:Reapply for new permit/ ❑Permit Extension Act—Permit/Date Closed: r Date......Z-7../�O NORTp TOWN OF NORTH ANDOVER 3? ��'� ... .-�• OL p PERMIT FOR WIRING ,SSAGMUS� This certifies that ................ .�_..�,?o. .................................................... has permission to perform /JA® c—........ wiring in the building of........... ........................................ f.?.` at........�...q....�-�. �.0<...�......... ,North Andover,Mass. a G+ Fee��..-r:; .. Lic.No.-.3..Z.Z 6 ........ .. .... i ELECTRICAL INSPE a Check # / Commonwealth of Massachusetts official Use Only Department of Fire services Permit No._ Z BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked U [Rev.'1/07] Qeave blank APPLICATION FOR PERMIT TO PERFORM WdAL WORK All work to be performed in accordance with the Massachusetts Electrical C0 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:City or Town of: NORTH ANDOVER To the res By this application the undersigned 'ves notice of his or her intention to perform theelletrical wor ctor o described below. Location(Street&Number) �� ��� Nth/ Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und d �' ❑ No,of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion o the ollowin table may be waived b the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans 90fof Total Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above11In- o.o mergency Lighting ' d• d• stte Units No.of Receptacle Outlets No. of Oil Burners FIRE ALMS No. of Zones No.of Switches No. of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. otal Tons No.of Alerting Devices No.of WasEDisposerEsEEE.Heat PumpNumber TonsTotals• -- _.__ No.ofSelf:C�- -___ Detection/Alertin Devices No.of Dishrs Space/Area Heating KW Local❑ Municipal ^ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water o.of No.of Devices or Equivalent Heaters KW of 'i s Ballasts. Data Wiring: No,of Devices n E uivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications icing: OTHER: __._ No.of Devices or E uivalent 00 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Wor4ctine .(When required by municipal policy.) Work to Start; requested in accordance with MEC Rule 10,and upon completion. 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 ❑ (Specify:) I cer[ify,under the pains and penalties of perjury,that the information on this application ' e and complete. FIRM NAME: Licensee: �� LIC.NO.: mature LIC.NO. (If applicable, enter 11mpf rn he license tuber line.) �-- Address: �C AZ . / Bus.Tel.No 04 *Per M.G.L c. 147,s.57-61,security work requires D !� Alt.Tel.No.: License: Lic.No.' OWNER'S INSURANCE WAVER: I am aware that the Licensee does not ehave'the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirem Owner/Agent ent I am the(check one) ❑ owner El owner's agent Signature Telephone No. PERMIT FEE: $ �. r- ,�, �IY-N�; ���J �� � �� �� � � �� D� r v i Ut , The Common wealth of Massachusetts k- ! Department of Industrial Accidents 8uX Office of Investigations 600 Washing ton Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insh. rance Affidavit Builders/Contractors/Electricians/plumbers A • Iiicant Information Please Print LeQibl Name(Business/Orsaniza6on/Individual); Address•_,�� l� 7 City/<State/Zip: Phone Are you an employer?Check the appropriate box: 1.❑ 1 am a employer with 4. Type of project(required): ❑ I am a genera[contractor and I employees(full and/or part-time).*. have hired the sub-contractors 6 ❑New construction • Llim:a.sole proprietorr or partner. listed on the attached sheet x 7• ❑Remodeling ship and have no employees These suit-contractors have 8. [�Demolition' working for me in any capacity, workers' comp.insurance. [No workers con ,insurance 5. 9, ❑Building addition P ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself.[No-workers'comp. c..1.52, §1(4),'and we have no insurance required.]t_ .employees. [No workers' 12.[]Roof repairs comp. insurance required.] 13.[].Other *Any trpplicant that checks bw tf I must also 1111 out the section below showing their workers'oompansetiori policy information t Hameownets who submit this atridavit indicating they are doing all work and than hire outside contractors must submit anew affidavit indicating each tCmtraetom that check this box must attached an additional sheet showing the raune of the sub-contractors and ultra worker`'comp.davit inicy in sting such. t am an employer that.isproviXing:workers'compensation insurance for my.employees• Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ` Expiration Date: a Job Site Address: City/state/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration datEe� 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. I do hereby c fy under the pa' nd p aloes of perjury.that the information provided ab a is date nd coned •� _ Date: Phone s �. t Official use only. Do not write is.this area,to be completed b3'city or town of ciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Cleric 4.Electrical Inspector S. 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 contact 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 deemed 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-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 cavy 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 yod 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 entertheir self-insraance'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 Hill be used as a reference number. in addition,an applicant ID 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 ofthe 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. Anew 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 bum 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. 9 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax 4 617-727-7744 www.mass.gov/dia Date. . 2 1. G.. . .. . ,AOR TIy °f °,'�'O o� TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SSACHUSE� Q t a This certifies that . . . .�. ��' ���`,/�i!ic r. „ . . „ . . . . . i has permission for gas installation . in the buildings of . .V./. . .3' C. .' .`. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . 'Y' �. . . . . .. North Andover, Mass. Fee. 3L... . . Lic. No.. 3.1.. .. .�. . . . . . . . . . . G4S INSPECTOR Check# / 114 / + U MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER V ,Mass. Date JAN. 21 2010 permit# �a Building Location 410 BEAR HILL RD. Owner's Name SAM AND GAYLE BROOKS Owner Tel# 508-451-2827 Type of Occupancy RESIDENCE New F-7 Renovation❑ Replacement❑ Plan Submitted: Ye[]No[] FIXTURES G w J -�• < 4+ �Z � w94 0 � U) x F S � z o a H a z z o F w o+ 00 w a W W 7 a a W ¢ V S 0 w z J Z z w w p > o V z Q w Q x .. F �• M z o z 0 2 Lu 0 0 Of 2 w � � A C¢7 a UU a > A a � O w SUB-BSMT BASEMENT 1ST FLOOR I 2ND FLOOR 3RD FLOOR 4TH FLOOR b 5TH FLOOR 6TH FLOOR 1 7TH FLOOR 8TH FLOOR 14TE TF__9111T7 Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 F Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter JACK COOMBS INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 13 If you have```c ecked yes,please indicate the type coverage by checking the appropriate box. A liability insurance policy❑✓ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above applic ' re true ur to th st of my knowledge and that all plumbing work and installations performed under the permit issued for thi appli ation II n mplian 'th all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws BY Type of License: lumber Signature o icen d Plumber or Gas Fitter Title •Gas fitter • -Master Licens Num r GF 3064-LP City/Town •-Journeyman APPROVED(OFFICE USE ONLY) Date. . .��: /a ... . . .. WORTH e? �' TOWN OF NORTH ANDOVER d PERMIT FOR GAS-INSTALLATION �,SS�CeHUSEt This certifies that . . . .b. . . . . '-{. :. . .�-�. . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . .9 . . . . `- �'� . . . . . . . in the building,", . !t !. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . !. ..�- .`".' . . � .�� :, North Andover, Mass. Fee-j� . . . . Lic. No�-'PG110 . / -`�'a �; r.-. . . . . . . . . . (/ GAS INSPECTOR Check# 7019 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town- owners Building Locatio. . '/M '00 Name: Type of occupancy: Commercial Educational: T industrial Institutional Residential i New:: Alteration: Renovation: Replacement:-— eplacement: Plans Submitted: Yes No'_ FIXTURES of z JU Y 1� y y O � y tri Q tl: O cc Q=i 2 O ui UJ U y O W cc z 0 LU> U W Z O }- i= O Z J t9 F W !- 11i Z >- CL CO "� ¢ <C m W O Z O y �= > Z Q O Wd t!� w ru Q O e 0 W Z Z tat SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3HO FLOOR t1 44 41H FLOOR I I 5 FLOOR F—FLOOR VH FLOOR I 8 FLOORI I 1 .. _ Check One Only Certificate# Insta474 I I I L I lling Company Name: : Y?.c;SGS. LITj �3ii'�r'f..S Corporation CitylTon: MA.teAddress - Partnership Business Tei: ��% =_ .�— !/u' Fax: FirrNCompany, Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: f I have a current liabilityinsurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes y` No If you have checked Yes'please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER:I am aware that the licensee dam 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. Check One Only Owner Agent Signature of Owner or Owner's Agent regarding this application are true and By checking this box❑;I hereby certify that all of the details and inforrrtion i have submitted(or enterer)rega 9 accurate to the best of my Knowledge and that all plumbing work and imstallatiops performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Csode and C 9 D the General Laws. type of License: ,. By' _Plumber , '` �✓ `J Gas Fitter Si"nature of Licensed Plumber/Gas Fitter Tide. Master Chy/Tmo Journeyman License Number: S V APPROVED OFFICE-USE ONLY) LP Installer FINAL INSPGC110 BELOW FOR OF IC-USE ONLY PROGRESS MSPFC'IZONIS) PI:1s: $ PERM VI*B APPLICATION FOR PERMITTO DO GAS 1117ING NAME d' TYIT OF lIlaLDINCi LOCATION )11 IWILDING SIC1U'C'I I.ICI?NSCi NIIMIMM: III"IMMIT GUNTIM❑ DKIT' (iAS F [TING INSPHCTIO1( :'t , ;?GNWEALT!# _ CON, NWEA T of MASSA-- _ GF fuASS,�_ USET u� fUSETTS jr _ „ l -d .m -;. �„" rix (IV pLUM6EF2S AN G 0LT } IN PLUMBERS AND GASFI� j LICENSED AS A MASTER PILfikll REGISTERED AS A PLUMBING UMB ISSUES THIS LICENSE Tp \ ISSUES THIS LICENSE To KEVIN M LEHANE KEVIN LEHANE BARROS COMPANIES INC 80 PERRY ST 80 PERRY ST r APT 205 PUTNAMco CT -06260-225 PUTNAM CT 06260-225 12868 225 t _ 05/01/10 2853 05/01/10 tiR.� c' :* a 441011 .sy (, 441012 C3NWEALTH OF rViASSACH-USETTS PLUMBERS NEPLIENSASaJOUYMANL MBEF ISSUES THIS LICENSE TQ KEVIN M LEHANE 80 PERRY ST APT 205 PUTNAM CT 06260-225`3 21619 05/01/10 441013 d r Date%...... �:.n .... Q f NORTH� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 13 CHUSEt This certifies that ......... :-r--q - has permission to perform ... :.. -' � wiring in the building of. ................................................. at....�IZ Z:.............lr_ ,��.................l...rt.:..�../. ,North Andover,Mass. Fee... .L::77.... Lic.No. .��` �,. -........... .1 t. ALI R ELECTRICNSPECTO Check # 3� Commonwealth of Massachusetts Official Use Only S Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1107] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: O C,'r 2W 'ZO 4 City or Town of: NORTH ANDOVER 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&Number) v $ 'L f ;LL- /- Owner or Tenanty Telephone No. Owner's Address 5Ml= Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) 4 Purpose of Building Utility Authorization No. Existing Service Amps / 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: 9 �-AE 0F Houst P06L. C'g.94AIA �G'f 201 tj etuj 6a AMP SJb PA')CL l Completion of the following table may be waived by the Iris ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp. (Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above . in- ❑ o.o mergency Lighting rnd• d. i Battery Units N��.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones No.of Switches (�j No.of.Gas Burners No.of Detection and 'Initiating DevicesNo.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number Tons - KW _ No.of Self-Contained Totals: Detection/AlertinQ Devices ' No.of Dishwashers Space/Area Heating KW al[I Loc Connec ion ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent ` 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. 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 Z BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. ' FIRM NAME: Z nJGI.E C- EL(:'-CTX T C- LIC.NO.:AJAA 3yZZ Licensee: 5A J Q fLo TA)&g:5745' Signature A LIC.NO.: L/27— (If applicable, enter"exempt"in the license number line.) Bus.Tel.No.:7i61-'1 C® 7oYS' Address: /O �UIJI?i=�- /��}� �n(QpVi•�- M�O 1�fD �-- *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt. No. 17Y 147S'7yvy} - 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 11 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � -� ` D Y� 13�-�. e�C �b_2�_a�QJ� �, ,, .... } The Commonwealth of Massachusetts De artment o P -f Industrial Accidents ,r Office of Investigations 600 Washington Street \ tlNp Boston MA 02111 www-mass-gov/dia Workers' Compensation Insurance.Affdavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name (Business/organizabon/individual): 2-0 G-�r Sry Address: fb City/State/Zip: Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. Type of project(required); ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors .6. New construction 2 [ I 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. [No workers' comp. insurance 5. ❑ We are a corporation and its 9' Budding addition required.) officers have exercised.their 10:❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I-❑ Plumbing repairs or additions myself. [No workers' comp. c. 1.52, §1.(4),and we have no insurance required.] t employees. [No workers' 12•Q Roof repairs comp. insurance required.] 13-El Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who subntit.this affidavit indicating they are;doilig a:l work and then hire outside contreciors nwsi 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 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. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Siartature: Date: d G t- 2- 1 20 o i' Phone#: 7 p S A 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 G.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonwealth for-any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-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 cavy workers' compensation insurance. If an LLC or LLP does have .. employees,a policy is required. Be advised that this afficlavit may 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 lave or if you are required to obtain a workers' compensation policy,please call the Department at the ntumber.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".lob 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 burnleaves 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 h Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 wwvv.mass.gov/dia ate. "0RTq TOWN OF NORTH ANDOVER 3? .! r o f o PERMIT FOR PLUMBING 4401 ,SSACMUS c� This certifies that . . . . . . . . . . . . r has permission to perform .. :':':'z `� '. . . . . . .11. . . . . . . . . . . . . . . plumbing in the buildings of_- . . .f� . . . . . . . . . . . . . at. . . . . .G. ... . . . !.. . . . . . , North Andover, Mass. Fee;. 7 -. . . .Lic. Nod?'/2�Y` :F! !?'fi??!� . . . . . . . . . . . PLUMBIN INSPECTOR Check it 780 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location 1;gn U.-I I �t', +� Owners Name Date CC (7- Permit#_ T an Type of Occu c f mount New Renovation Replacement Plans Submitted yes ❑ No ❑ FWTURES w o U � O U q ISB,KJOC 2 f M R-OZ 3M FL Qt 41H FLOCIR 51H I+IUQ2 6IH FIf. M 7M SIH IIDOR w (Print or type) Installing Company Name Vj ( `D(r*r1 r>/fjrV/y j Check one: Certificate 1— --_- n Corp. Address ��- l D G%�•2 � t 4 0 &/t- O t� --TPartner. Business elephone _ n Firm/Co. r Name of Licensed Plumber: Insurance Coverac"e: Indicate e type of insurance coverage by checking the appropriate box: Liability insurance policy Other��� type of indemnity rI Bond Insurance Waiver. I the undersig threened,have been made aware that the licensee of this application does not have any one of the above �� Z_ ignature Owner ❑ F1-red) 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 theMassac State Bing Code and Chapter 142 of the General Laws. By: igna�ure o i:.icens um er - Title Type of Plumb' License City/Town 6 c( icense um er APPROVED comcE usE orn.Y Master Joumeyman ❑ 11A is �v � n Date......................:,. ..... NORTH °ft"`° '•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 7► �O��no��,y� ,SSACMUS� k, This certifies that ... ......:.................................. .................................................. has permission to perform - r-t wiring in the building of --1 �s . .. ` ` '� . North Andover Mass. at..................................r� �....................... . Fee:3J.....�....... Lic.No.. �..�;.... t.................................. .... .. . '. :.:G J............... .. ..... ......... ..... ELEcrmcAL INSPECMR Check # i, 6 4 �ommorzwea�Ch a� a�lac�zrr�eJ�3 Official Use Only Pen-nitNo. _1 JeParfnwref o ,}ire �ervicas — BOARD OF FiRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev. 11!99 (lca'e blank) APPLICATION FOR PERMI ► TO PERFORM ELECT RiCAL WORK All %vork to be perfornicd in accordance with the Mass=husetts Elecirical Code(;NIEC),527 CMR 12.00 (PLE ISE PRINT IN INK OR TY„ r!- /+'r-n]?J11.•l7IOtb) Date: — ,2 �. city - of: N0QA AAJD©i/E R— To the Inspector of IY 1'es: By this application the undersigned eaves notice ofbis or her ilitention to perform the electrical work described below. Location (Street & Number) /Q 439Ao A b Owner or Tenant e�2oaK e� Telephone No. Owner's Address ..S/'q'/I1 �, • -Is this permit ill conjunction with a building permit? Yes ❑ No (Check Appropriate Boz 1'urlicise of Building Utility Authorization No. Existing Servicc Amps J bolts Overhead❑ Undgrd ❑ No. of Meters . NYeiv Seri- cc, Amps L Volts Overhead ❑ Undgrd ❑ No. ofbleters.' Number of Feeders and Ampacity Location and Nature bf Proposed Electrical Work: L { Ll� C-61i t Conr letion of the fiollowintable nzav be x•aired by the itr"ector orlvires. 4 . No. of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fates No.of Total a Transformers KVA No. of Lighting Outlets No.or llot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool o boti°e ❑ In- ❑ t o.of tnergenc} rg tong rrid. rn@. Batte Units No. of Receptacle Outlets No.of Oil Burners FIRE A.I,ARtiIS iNo.of'Cones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices + No. of Ranges No.ofAir'Cond. Total lYo,of Alerting Devices Tons a No:of Waste Disposers HeztYutnp i Nuniber Tons 1 W tNo. of Self-ContainedTotals: }— �Detection[Alertin�;)evices No. of DisInvaslters SpacelAren Heating KW Local ❑ blunicips! El Other � Connection _ No. of Dryers Henting AppliancesXW Security Systerns: No.of Devices or Equivalent No. of Water No.of No. of DataKiv aia;,'iriuy: Heaters Si_its Ballasts No.of Devices or E uiva.Ient No.Hydromassage Batlitubs No.of ilIotors Total HP Telecommunications Wiring: No.of Devices or E uivalent r OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURAINCE COVERAGE: Unless-waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurancc including"completed operation"coveia,e or its substantial equivalent. The undersigned certifies that such coverage is in force,and has e:diibited proof of same to the permit issuing office. CHECK ONE: INSURr1NCE BOND ❑ OTHER ❑-(Specify:) (Expiration Date) r.� i Work: .Z ur t T r.a'irlialed`'J aluc of Electrical r>lork: (,.r hen required by municipal policj'.) Work to Start: 7—Z!!�,-o 3 Inspections to be requested in accordance v6th IvIEC Rule 10, and upon completion. I ce1•tify, under the albs andpenalties ofperjrtry,that the infornt�`ot"_inrr 011 this vpplication is trite and complete. FIIZI I i`.ail ll: Kt cAA2 L �11/'4•r�4 EZeC, re- LIC.i-0.:. Q $ Licensee: I f q,o [.A /.q«E� Sibnature LIC.NO.: (if applicable. enter "arentpt•'in the license�minr_ber line,) Bus.Tel.NoJJTB`313•-3W Address: Z� �r2p S( 1'DFd2o 1�/.4- Alt.Tel.No.: M1'i`NER'S INSU = `NCE VV:11Y'ER: I am av-arc that the Licensee docs not have the liability insurance covera,e normally required by law. BV111Y siOnature below,I hereby waive this requirement. I am the(check otic)❑ o��ner ❑ o��n, . a rnt. Owner/_\gent Sibnaturc 1'cicphuncl'u. Pl-R 1IlT lL: S 3d-o TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. g s DATE ISSUED. S_ v M /V ic SIGNATURE: - -qBuildin Commissioner for of BuildingsDate SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O $ _ 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 R 'red Provided Required Provided 1.5. Flood Zone Information: v 1.7 Water Supply M.G.L.C.40. 54) 1.8 Sewerage Disposal System: i/ Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District; Yes No M 2.1 Owner of Record B�2l,�n� � Y�� ►�A sten�-�,j �-�� .'HA2 ��t..L.. 'R7�d t� Name(Print) �p Cy Address for Service: Signature Telephone Q 2.2 Owner of Record: Name Print Address for Service: O Z Signature Tele hone M SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ p'OV 4 Lqs P YA1 Licensed Construction Supervisor: + 1 Z%_ SY floLicense Number Po x b9'3 n��,vt� -� , t� oa�t9 � Address Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name 1 q 41 C crn Registration Number r 1 �a L y fl v �. 3 r Addr \ 0 40 Expiration Date Z Signature Tele hone V 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 bulding permit. Signed affidavit Attached Yes.......9 No.......❑ SECTION 5 Description of Proposed Work cher au applicable) New Construction Et Existing Building Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIALUSE,ONLY _ ; Completed by permit applicant r. 1. Building (a) Building Permit Fee Multiplier 2 Electrical 1 V (b) Estimated Total Cost of J069" '. Construction 3 Plumbing 32, Building Permit fee(a) x (b) 4 Mechanical HVAC /A/A" 5 Fire Protection 6 Total. -11+2+3.+4+5' _` 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 behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 9��'Q Y V�►S 1 UA ,ae r/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 SiNature of9tYr/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T VIBERS iST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS TEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH110NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I CERTIFY THAT THE EXISTING DWELLING IS LOCATED AS SHOWN HEREON AND THAT THE EXISTING DWELLING MEETS THE APPLICABLE SETBACKS REQUIREMENTS AND THE ZONING BY-LAW OF THE TOWN OF NORTH ANDOVER AND THAT IT DOES NOT LIE WITHIN THE HUD FLOOD HAZARD ZONE A AS DEFINED ON THE LATEST ;MLES-W. OD INSURANCE ATE MAP. of MgSsgcyG � JAMES NEVA�NIEVA P.L.S. #39399 39399 qQFESSI�NP� PREPARED FOR AND OWNED BY: u SAMUEL & GAYLE BROOKS 410 BEAR HILL ROAD NORTH ANDOVER, MASSACHUSETTS 01845 p� p TELEPHONE: (978) 258-7006 PLAN REFERENCE: " i PLAN #11095, RECORDED AT NORTHERN N18*14'40W DISTRICT ESSEX COUNTY 110.00' _ DEED REFERENCE: ► _ - -- -` -- - BOOK 7288, PAGE 171 _ ZONING REFERENCE: j W 64 BLOCK 102 t RESIDENTIAL (R-1) ; � � 45,224 FT.� 1.04 S i ASSESSORS MAP 64, BLOCK 102 + + � I BUILDING SETBACKS: 1 FRONT 25' 0' SIDE 10' ? � REAR 10' PROPOSED i PATIO � STARS 292' THIS SITE LIES WITHIN A + POOL WATERSHED DISTRICT. + DECK K � PFlOP06® ® PATIO � r i r � r i r .k ; EXISTTwNG sow i ion cc 2 STORY-WOOD FRAMED CONCRETE 0No.4110 N i RESIDENCE DRIVEWAY co N 1 + STEPS i ;+ C ONCREfE WALK + STEPSI r i I r i + � z I w � + I oI + IJt.IDIIVIG SETBACK LIE-Tt'f'ICALj PON L=144.13 54.11' ROD R=606.20' S11'50'56"E BEAR HILL ROAD Dunn McKenzie, Inc. PROPOSED POOL PLAN LAND SURVEYING AND CIVIL ENGINEERING 410 BEAR HILL ROAD 206 DEDHAM STREET, Rt.1A at Rt.115 NORTH ANDOVER, MASSACHUSETTS 01845 NORFOLK, MASSACHUSETTS 02056 (508) 384-3990 — FAX (508) 384-3905 staff@dunnmckenzie.com SCALE: 1"=30' MAY 19, 2008 PROJECT #4658 X275 °Y Date..laq—Alltve �10RTM °•,``°{'�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,s$ACMUSEt This certifies that ...... .. .a!..................................................................... has permission to perform .... ..... ................................................ wiring in the building of......./ �°... ....... .......................................... 1.at.........7.1 ..... .....ciJ..../,.l�........... . .. ,North Ando S. Fee:l: .............. Lic.No. ............. ........... .................... . ... ............. ` �� ELECTRICAL I C'COR Check # /%/ Commonwealth of Massachusetts Official Use On] Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR l .00 (PLEASE PRINT IN INK OR T P A IN ORMATION) Date: p City or Town of: t To the InspectoP ofWires: By this application the undersigned ives no' e of is or r intentio o erform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. _ M Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / 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: Installation of Security system Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecurityNo. ystems Devices or.E uivalent No.of WaterKW No.o No.o Heaters Signs Ballasts Data Wiring: No.of Devices or Ecluivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Estimated Value of El ctrica Work: , C (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under a ains hnapenatties of perjury, that the information on this application is true and complete. FIRM NAME: LIC.NO.: I 53-Ir Licensee: John $. Bdssett Signature LIC.NO.: 1533C (If applicable, enter"exempt"in the license number line.) Bus.Tel.No. 603 594 597$ Address: Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Li*see see 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 Signature Telephone No. PERMIT FEE: $