Loading...
HomeMy WebLinkAboutMiscellaneous - 42 WILD ROSE DRIVE 4/30/2018N J Q 0J 4e CfUMMU atUr# of .4JagSar UgrJt9 Bepartmettt of Public _afetu BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only Permit No. a,% Occupancy & Fee Checked 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12�0/1, (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 6 a 00* or Town of.-AO$TIL-AM-ME, To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) ya w it, 0 Ste, Owner or Tenant C Owner's Address S,4ry�L Is this permit in conjunction) with a bjuilding permit: Yes & No ❑ (Check Appropriate Box) Purpose of Building Re St ����I e I Utility Authorization No. Existing Service Amps _J Volts Overhead ❑ Undgrnd ❑ New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work In Sl*C�dSe�- +e -7 Total No. of Lighting Outlets No, of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures I Swirnming Pool P.bo•,e� In - No. grnd. L— grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets I No. of Oil Burners I Battery Units . of witch Outlets No. of Gas Burners FIRE ALARMS No. of Zones _ No. of Detection and Total No. of Ranpet; I No. of Air Cond. tons Initiating Devices Heat Total Total No. ofi Disposals No.of Pumps Tons KW No. of Sounaing Devices No. Self Contained No. r.f Dishwashers Space/Area Heating KW ction/Sounding Devices Detection/Sounding No. of Dryers Munici = ! Local _J Cor.,,act!on J I Beating D:jvicds KW No. of No. of Low Voltage No. of Wcta "caters KW I S gns E?Masts . YJiring ,_ No. Hydro Massage Tubs I �N:-. of Motors Total HP OTHER: # INSURANCE„COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a argent Liability Insurance Policy including Com leted Operations Coverage or its substantial equivalent. YES NO I have submitted valid proof of same to the Office. YES TNO = If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSq1rNCE J�, BOND - OTHER (Please Specify) /J (Expiration Date) Estimated Value of ectri al Work S 700 — Work to Start (Q Inspection Date Requested: Rough a Final Signed under the Penalties of perjury: ���3C,/ FIRM NAMEp �r j�� ie C, a^10 LIC. NO. 7 Licensee R 1C(! G I Zo 11' i' c Signature B M,n LIC. NO. SOS 37 2 O to I IP Address VST ��Ct'� S�l / m►T- Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) )tL_5 d� Telephone No. PERMIT FEE S �— (Signature of Owner or Agent) X-6565 —Tj - 2466 Date.ucojE. c .., NORTH TOWN NORTH, ORTH, ANDOVER EE Oy t /e - p PERMIT FOR 4M INSTALLATIOW / d This certifies that . � !�' zb // h7ecT/2I has permission for gO installation ...........................Q. in the buildings of .... !??!e: C'.'.��i?o....................... at.... . P"& — i1 a !K . ., ! e , ..... , North Andover, Mass, ZA 5c_.. . -s III - ITE: Applicant Applicant Lic. NoIP,53V .. CANARY: Building Dept. .......................... GASINSPECTOR PINK: Treasurer GOLD: File Safety Insurance Admhhhw PO Box 55098 Boston, MA 02205 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: ROBERT P CIPRO Property Address: 42 WILD ROSE DRIVE, NORTH ANDOVER, MA Policy Number: HMA 0304731 Claim Number: BOS00067616 Date of Loss: 2/16/2016 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Daniel Magee Claim Examiner Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3551 Fax: (617) 531-2758 Email: DanielMagee@Safetylnsurance.com 2/17/2016 Date 14 IS jl.z—... . M. • „y.�:pS:lup 7�.�....• 4 TOWN OF NORTH ANDOVER This certifies that. 0.6 j i-..'.9 .................... . has permission to perform ... e ,J QlrA-n r .................. . wiring in the building of .....lam ✓ ...................... at .... 4� ..1►,, `c .. 0?- P ...... , North.Andover, Mass. to .`-k'?. Lic. No. 044A . . l bJ - ELECTRICAL INSPECTOR Check # Xqjq I120 1 S Commonwealth of Massachusetts v Department of Fire Services w it 'aBOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. LF Occupancy and Fee Checked tev.1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ► 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) 7& - - 6 S 7 Owner or Tenant S ip� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No I& (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: of Recessed Luminaires of Luminaire Outlets of Luminaires of Receptacle Outlets of Switches of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs OTHER: Completion of the of Cell: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Abogrndve El. No. of Oil Burners No. of Gas Burners No. of Air Cond. T+ T. Space/Area Heating KW Heating Appliances KW No. of No. of c;R„Q - Ballasts o. of Motors Total HP table may be waived by the Inspector of Wires. :Generators �Jgting VA / ❑. o + mergency RaffPry Fnik ALARMS INo. of Zones o. o. of Alerting Devices o. of Self -Contained ❑1vlumcipai ❑Other P.P.rtinn No. of Devices or No. of Devices or ecommunicationi No. of Devices or Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: #t'p W,0 , U'0 (When required by municipal policy.) Work to Start: / a - / 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 tY undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE rV BOND El OTHER El (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. � eC -C, L [ LIC. NO.: (p� c4 lM Licensee: /Po &J g m- (a;,(e Signature ^ LTC. NO.: I C«a3 73VC (If applicable, enter "exempt" in t4 license number line) Bus. Tel. No.: 663 Address: �,`/ /�P�m Sf I a"xCl'/�CS �� C73(U Alt. Tel. No.: &0,3 K e -0 -1 - *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 cover ge normally required by law. y my s' re belo , reby waive this requirement. I am the (check one) ❑ owner owner's agent. Owner/A nt hone No.(0U3 �6 U 66)s -y PERMIT FEE. $ SigTelephone nature \ I _ ❑ 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. GL 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 I ` notification of completion of the work as required in M.G.L. c. 143, § 3L. 1. 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. 1 ❑ 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: s� Failed 0 Re- Inspection Required ($.) ❑ ,,k� // 1 spec rs Comrhen ; 1 14 A Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 No www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 0q3qS O --C City/State/Zip:'ActvLt-,, p S N D3103 Phone #: 6203;�y- -? ! 70 an employer? Check the appropriate box: Xreon I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑�1 am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ElI am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10;,�Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site !formation. isuran�e Company Name:_ ;VQ.tr ee� vtSGc �itc P olicy # or Self -ins. Lic. #: (7 r 9 3 3,,q Expiration Date: 3 ib Site Address: W>"l /�-f�e 1r — City/State/Zip: �p /Td"'�/UL�j'A M Itach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 I up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certi& under trains an ena ies of perjury that the information provided above is true and correct. a -7- '03 - 9- 6c)- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written" An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1877-MASSAFE evised 5-26-05 Fax # 617-727-7749 WWW mncc anv/din 1 Date/ :�// y 4. ......................... has permission for gas ' ttallation I.. ................. . 1 in the buildings f ... (b .. at .��.� ���,.... 1Niorth Andover Mass. FAe .. Lic. No..I: GAS INSPECTOR Check # 6 5 l 2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITT NG WORK CITY _ �►,oJy� MA DATE I — PERMIT # JOBSITE ADDRESS _ _yJ �A ro GOWNER ADDRESS Sa►»>, TELX7+ FAX J , TYPE OR OCCUPANCY TYPE COMMERCIAL (j EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: [ RENOVATION: Ej REPLACEMENT: PLANS SUBMITTED: YES F ---1I N00 APPLIANCES 1 FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER, CONVERSION BURNER :._ - I (� COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE�— GENERATOR GRILLE.-�- INFRARED HEATER LABORATORY COCKS _ —_ _ ,1 —TI MAKEUP AIR UNIT— OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER F__J OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IR OTHER TYPE INDEMNITY © BOND -�_I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 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 the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compjjance with aU Pertine t provi ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEiZ LICENSE #ISBN I SIGNATURE MP [Z"MGF [] JP DJ JGF Q LPGI 0 COR?ORATIONJ(## PARTNERSHIP [# LLCi# COMPANY NAME: _ _1 - ..Awl.y ADDRESS CITY —I STATE _yh fi ZIP STEL FAX CELL _EMAIL -_ H °z z 0 H U W P-4 � 1 � w of -j z 0 y W }F -I F-( a Z w a w Q W 5 o > a Pk w w N a o a a a � U ' �y J H a CL Q � w = w F- w W H °z 0 H U W A4 c7 I � 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors t 2. VJ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. E] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site :formation. isurance Company Name: olicy # or Self -ins. Lic. #: ib Site Expiration Date: City/State/Zip: Itach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 C. up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and pgpalties of perjury that the information provided above is trite and correct. zone #:��� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 2,-1-7-12, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The 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 evised 5 -26 -OS www_mass_gov/dia Theide Plumbing } l . If, w GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: GENERATOR kw �Ce� NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: cjjia��� ESIDENTI L COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: (-)j� *CONSERVATION APPROVAL � v � � �'✓ SIL. North Andover MIMAP December 5, 2012 Interstales Interstate Major Roads Roads Ci Easements 0 MVPC Boundary Parcels 1"=60ft N EMN, 9 Horizontal Datum: MA Slateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by theTown of North Andover. Additional data provided by the Executive Ofce of Environmental AffairsfMassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION Location, No. S Date AORT" TOWN OF NORTH ANDOVER Ot4t�o r1%p pL Certificate of Occupancy $41 -Building/Frame Permit Fee $ Eta' Foundation Permit Fee S cHUS ~ Other Permit Fee $ ,,*er Connection Fee $ WVater Connection Fee $ S� ,10 -3 TOTAL�� Q• D G ill Building Inspector ti. 53 Div. Public Works Locations ,No. Date a 91-4 °"T" TOWN OF NORTH ANDOVER --gificate of Occupancy $ •,Rr•,' C�; kjiding/Frame Permit Fee $ rs^c►+usE� Foundation Permit Fee $ „ OtKer Permit Fee $ ~� Sonnection Fee $ Water Connection Fee $ TOTAL �. 6 6+� 33 Building Inspector Div. Public Works ^7 Location-- ,No. ocation ,No. % ?_� Date TOWN OF NORTH ANDOVER Cegfficate'.Af Occupancy BuildinglFrarhe Permit Fee Foundation Permit Fee 'Other Permit Fee �L�ve��Mection Fee Water Connection Fee $ % #-ao- b0 i TOTAL $ ad Mzj4 Building Insp ctor 1j Div. Public'Works P Date. i NOR711 of -•'4a TOWN OF NORTH AND011 0 PERMIT FOR PLUMBAG ,SSACMUS� This certifies that ............ t has permission to perform .. ............................. plumbing in the buildings of ......./.`. �......................... at ... P P.F. ' ....... .... ,North Andover, Mass. Fee. .3p .... Lic. No..5. . .... ,....t-!'^.�'�..�......... 1 PLUMBING INSPECTOR Check # 17' >� 7378 MASSAGHUSETTS UNIFORM APPLICATION FOR.PERMIT TO DO PLUMBING (Pri to TT e) ass. Dat (tet �20 Perm' Building L cation r.Owner's ame v w Type of Occupancy New 0 Renovation 0 Replacemente Plans Submitted: Yes D No 0 B.P.•* �CFWFR A FIXTURES ccm-ri- 4. I stalling Company Name, .ddress ,usiness Telephone /D 6 2 9 3 ,�� .ame of Licensed Plumber or Gas l=itter 64 4 /0 ill -74 OZOV— Check on- g: 0 Corporation ❑ Partnership Certificate INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes No . 0 If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity 0 Bond 0 OWNER'S INSURNACE 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. Signature of Owner or -Owner's Agent Check one: Owner 0 Agent 0 iereby certify that all -of the details and-informatlon i have submitted entered) In above- applicatlon are 'true and accurate to the best of . y knowledge and that all plumbing work and installations performe nd r the pecmlY las for this application will be in compliance with-; I pertinent provisions of :the Massachusetts Slate Plumbing Code a t 142 of the erai Laws. By SI n ure of Licen ed lumber Tide P Aown Type of License: Waster (OFFICE US £ ONLY) License Number J �� ❑Journeyman IN ! ! • ...MIMNMM5M�.�.E.M- MIM .IN MIMMIMMINIMMEMM ME MINIM MIMMIMMINIMMMOM MEMMMMIM I stalling Company Name, .ddress ,usiness Telephone /D 6 2 9 3 ,�� .ame of Licensed Plumber or Gas l=itter 64 4 /0 ill -74 OZOV— Check on- g: 0 Corporation ❑ Partnership Certificate INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes No . 0 If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity 0 Bond 0 OWNER'S INSURNACE 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. Signature of Owner or -Owner's Agent Check one: Owner 0 Agent 0 iereby certify that all -of the details and-informatlon i have submitted entered) In above- applicatlon are 'true and accurate to the best of . y knowledge and that all plumbing work and installations performe nd r the pecmlY las for this application will be in compliance with-; I pertinent provisions of :the Massachusetts Slate Plumbing Code a t 142 of the erai Laws. By SI n ure of Licen ed lumber Tide P Aown Type of License: Waster (OFFICE US £ ONLY) License Number J �� ❑Journeyman W C 0 < < W F C Z 0 IK LL N W ,♦ a Z F 0 0 W W 0 W N_ a 1 7 1` 0 V� U _Z y ° I J � 3 W m z J WC f W f O < N J 3 W 20 0 i 0 W W 0 0 W W W J Z u u u LL Z Z 2 0 N_ N_ IFl1 K m O D D < N W W Z I u U. 0 J < K W i WW19 O W L"IL"13 i 3 0 0 O W u W 2 Z 0 u a Z ° J_ 7 m 0 v 1' C7 W i f < IL 1t I Z a a 00 W `1 WW 4 o W > W a U F 2 H 0 IY 0 D L OO U t7 2 W IL < 1 (Oj J J J u ! N j W (Q W W Q i ,A a M' p0 � Wy � Z Q W 0 Z ° < J % F M- 0 0 m W rc In rc 0 ¢ O Z W 0 N 0 F N W J Id OW W N D N G Z m a m O H d Q 0 z n� IJ Cj Q Z 0 0� g N VM 0 V W W Z 0 Z 0 2 N < a N 1- W T I.1 e K C F W C 0 < < W F C Z 0 IK LL N W ,♦ a Z F 0 0 W W 0 W N_ a 1 7 1` 0 V� U _Z y ° I J � 3 W m z J WC f W f O < N J 3 W 20 0 i 0 W W 0 0 W W W J Z u u u LL Z Z 2 0 N_ N_ IFl1 K m O D D < N W W Z I u U. 0 J < K W i WW19 O W L"IL"13 i 3 0 0 O W u W 2 Z 0 u a Z ° J_ 7 m 0 v 1' f 1t I Z a a m W `1 WW 4 o W > W a U F 2 H 0 IY 0 D L OO U t7 2 W IL < 1 (Oj J J J u ! N j W W W W Q l7 a a 0 0 W W a a W 0 0 m J J x LL 4 O N m W W V) d G 0 0 'b D z n >ON N mCN zm mmo DO NzZ "°c MX -1 D n 0�0 N°* p3m MX iNn mo -' azo mN3 �OZ -MN m�0 to N rr O_O -+c)r coo r • -� z�z =o -N Ma 0z In mm 10 m n O v Y G O H�m0<°Nm D D OvD NT 0 0 D V 0nA ZZ O m JO y CCAm?0DA H<TZ N` �Z 0 W (T1 0 0 CTmI N0 I(eZQ� Cy;- 'Zyo O Oym pNZ Dm OA7n Ov- n n o` A D A °yO 00000O ON O y T O Oy Cp rn� 7 N D Z Z Z p I^ D a; NCAD yO OT ND 0 Z �s DZ :o �NZ Oa O0 �Z c On N Z Az 3: 0 GONO N ? 0 z 0 I I I _ COv2vi Z 11J A D � � Lo .� Z^+90cmD=ymO O m- D Z D A O m 0 v r i /;yZA � � O D 0 + � 1m D D O Di DC p D yi DnS N O D D n O 0 ; O m�'m A Z Z ON n N y O D f1 y D 3 A T n� r T T o� (� m < y y m m= v T T O O; 2 A p p= Z p m T Z` ( N A m C T O n A A 1 n y Z m m N m Z Z= m W > ~ S y % Z v D D y m C D A G _� m N N D y= O A i 0 p 0 3 T O m N< A n 3 m A T N m Z , m C1 ti O N O N y O A D Z T A y C A G O N x C t C T ^ N m D A Z I I 0 �� O I I I Ia �ZD Al AA yrn °� �2 i O DD mli >e Zvz O A '.^' Z Z vi X C1 71-0 Z O C1 Z A I _ � �_ SII \—I I ISI--�I�',�-JI��� ,_ , I I ,., —�I�V�I1" � 0 0 'b D z n >ON N mCN zm mmo DO NzZ "°c MX -1 D n 0�0 N°* p3m MX iNn mo -' azo mN3 �OZ -MN m�0 to N rr O_O -+c)r coo r • -� z�z =o -N Ma 0z In mm 10 m n O v Y FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT ��,���`�1Z� , Phon LOCATION: Assessor's MaNumber Parcel Subdivision (Z � X6_2 e,,A AZ Lot(s) Street LOD � Q1 ) &,-, �"0 �_ St. Number A-2 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: 1� %AXL.-,_Ax4_ Date roved . rrA Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Food Inspector -Health Septic Inspector -Health/!, Comments Public Works - sewer/water connections - driveway permit Fire Department /t �r-s- Received by Building Inspector Irf 1 21 ! ''� `�E_DNG ;" ' ;ENT Date Approved Date Rejected Date Approved Date Rejected E117 C z 04 C S G) c �c� 110 CA 71 o � C m a a- 'z r to z a ITCX n o o p z C o a CD o o C7 T H � CO) o tTj D a z y T r D O '0. z CL r— 0 D IN, O O Q C 'k., y CD � v `D dcCDCL Q CD CD O CD � y. m M CCD D < D—' Qv O y z CD D < Z — y O CD m � O CD T z o CD D r CD E117 C cin ' o 04 �n w o c �c� 110 ?? w �O o � C" y m C O 0 Z 0 CD O as 0 W c CL co CN cc c 0 C40) y H ?�� = z •N O.Q y So 0 Ic .0 CO) =ami CD m y m a c * CD CO) CD fl'�m o m .► y � O .O N O -� O � O m = ��CA a o .0 o -a O y n �oCD 30- = y :� !� CL CD CD CL St CD 4y d y O. Ncr C• #4& m w y ay o h CD Im a . CD fC2 a 0 C7 O O w C O m = C m 0CD Co 3i y CD =i o®: ted: �'o a CL= = 0 O 0 �0 o = � co ��i cn o d cin ' o rn �n w o c �c� 110 ?? w � <JQ o � C" y m a a- 'z r to z a ITCX n o o p z C o a CD o o z tTj e ?�� = z •N O.Q y So 0 Ic .0 CO) =ami CD m y m a c * CD CO) CD fl'�m o m .► y � O .O N O -� O � O m = ��CA a o .0 o -a O y n �oCD 30- = y :� !� CL CD CD CL St CD 4y d y O. Ncr C• #4& m w y ay o h CD Im a . CD fC2 a 0 C7 O O w C O m = C m 0CD Co 3i y CD =i o®: ted: �'o a CL= = 0 O 0 �0 o = � co ��i cn o d cin ' o :° �n w o c �c� 110 ?? w � <JQ o � C" y ?? w a a- 'z r to z m w n o o p z C o a CD o o z 0 c CDpq • . CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number 165 THIS CERTIFIES THAT Date OCTOBER 29, 1993 THE BUILDING LOCATED ON 42 WILD ROSE DRIVE (Lot #3) - Type D MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 CAR GARAGE IN ACCORDANCE & DECK WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Toll Bros . , Inc , . •'�'4 3103 Philmont Ave., ADDRESS Huntington Valley, PA '?SA US Adding Inspector A n Tiz TI z z -n C O C4 _: 0z n'— co z CL r D O O a CD CL o`S O CCD O �0 0 z m En CDM D <a� —.0 M CO O z p CD � z � CA T 1CD O W _0 wy W O O y C7' C O y CD O �F CD CD y� CD CA y O CD 0 CD W f-` C O O z O CD 0 UP cc O C _ Cc CD cc O N C 0 a N cl FV e?�o 0 2 0 aoSm .� CO) a m C o C� cc�;a� m N ca � .d.► m N '11 CD CL = m O cc, y O -. O :E g!9! m zn CD ,o o .0 -� s,= 0 O N• O CD a =. O O N : �a3� N N _� cr CL W fl. ftt� wS ® N aN� S W ® . a, a . o O ® o co) moo. CO �. s mCCD ay � oma: oI dd: 0 o= A Ma m -I o� 0T.' o wQ �- o w �• �, �- r o; w G ►,y � n o\\ � a N o p- cp x d ro a�r� o 3 > �rx txrf H 0 Ad x c L Y Y a c > W _ 7E � Z U 2 L0 L 0 0 L < C 0 ¢ = W W N < Q 0 W r 3 z 3 0 r 0 r 0 W u W z z 0 u n 0 J 7 m m z L z 0 LI m J W L L L 0 1 e z 0 0 LL }Z W IL 0 w L m I I L 0' u 8 J m 1- q W m a Z r 0 L L < u Y m ,moww N) 0 Z 0 � � of � r � < I J I 0 , I I n W m u z J J Z W 1 LU O m • F H J W ul ce m m 3 0 0 m O U W W p r y F z N 0 m 0 L Y p 0 m m W u Z Z m u O W r m : x WW m m m m n Y r r L r W n < C Y p 0 0 r < e n m � 0_ I y `Cu N W r 0 7 m W W n u W 30 < !- r< tll L L W 0 N m $A L Q I � m I I q p� W W > 3 m z Q 0 Z W J 1- W O f Z0SF m Jgo l 0 a 0 J F m Z _ m W 0 0 , 0 eg o L¢ O 0 m U. O U W m r L p L 0 Z LL H d O W b m Z C W m< Z i n O N L Z m m y 0 2 m O H p, v r- o X W W o� ( F Z C 0 ~ ^4 �� Z v Z gIz- a J \ 1 I •. m Q Q - J n W O Z D 4J Z w F- m J o a W m r Z M W J W W m r 0 N I W N W ¢ Z 7; Z 7i 7: Z< an 2 0 w W w 0 0 Z < j. m J m m R u u u L p ! W< Z U u m r p Z Z Z 0 < a z z u U m W F N J 0 0< m o a o< G6 W a x c L Y Y a c > W _ 7E � Z U 2 L0 L 0 0 L < C 0 ¢ = W W N < Q 0 W r 3 z 3 0 r 0 r 0 W u W z z 0 u n 0 J 7 m m z L z 0 LI m J W L L L 0 1 e z 0 0 LL }Z W IL 0 w L m I I L 0' u 8 J m 1- q W m a Z r 0 L L < u m ,moww N) Z 0 � � of � r � < I J I 4 , I I n W u z J J Z W 1 LU O m • F H J W ul ce m r 3 0 0 m O U W 0 t p r y F N 0 m 0 L p 0 m m W u Z Z m f ; O 0 r m : Y WW m m m m n Y r r L W n 7W C Y p 0 0 r < e n m � � I y `Cu W r 0 7 m Wu W n W n u W 30 < !- r< tll L L W 0 ,moww N) of � 4 J J LU V F H J ul ce 3 0 0 O U U = 0 N mmN n Z mD NAn0n0n 11DO ZpD 10 0A A Wm(N00Znc0 x0ZZ() m .. 00 N�pNO A 0000 Tmm m m Z A Z Z O O _p ON N x- A 0; Z Z 2 r 3 n p 3 Z Z Z W L, 2 z pi 3 N N w 0 H; 3 �'•' H O D�o3 DDOZZ� << = 3 O A m Z 3 0 0 0 N 3 > Tp 2 mw Z Z n O 1111111 IIIIIlIIIIIIIl _ LLL _ I -LL I II o N 7C D N D n Z n 3 T T T C 0 v 2 V m O N py0n�j0� pm �0n AZ 0 OpmZZ Z> Z' m C r0 D r v 2> A r^i� Z Z N C Z A A V m A y ^ Z p Z CG 0' x N D �. Z ti m�7c T N C � � I I I I T Z m A m T A VIIIIH_MIL-- 1111111 I I IIIIIiI� IIII IIIII" �� D02 — 0-iN N y r N Zm mn D0 NZ2 X03 mm uCi D n opo Nod p3m • mx 2Nn u►oo ;az— mN3 vOm nma 10 c nco m N_z r- p -v ry OZ- Z q r 0 ANO ��D p Z -z-10 m A =o O T 4 o MD 0 in mm G1 M D0 .3 ti 4 J IIA Ih� 1. a i:: rn rh �It as v y .O C � — OD CO) CD CD CD 0 y � O 'v. O �« O cn O _� C � =z y � o n c Z v CD cn CCD O CD \ CD O CDCD O O O I CQ CD v CA®' CD Z loq cl) o r o d: CD -CD n. n o• o d = O -• rn Cr H r ao5m •a N CL Cl) CD Cl) O H C) a c7 =m Z m o -o col -i ,. m CL CD m CD N o=� _ Amo: -nl co '�'� p = ...r o Zc°ii:: -e G y, C2 C- 3 H ate..• 03 O i-� mm y CD 71 C') � c CD CD d 3 = i 7 03 y '� y m C c0 gyCD: y CD 1 CD 03 N CD y�'n V n•r M -0. G Cc, \ aCD OF a H � o r m ..:\ 0 ? m :Vj ny. sC CD 03 a -o• Cl) CAcl)� cnC/) -X cp z PO :5 n �, % r�r C ry Oil w--. Ilz O OGRw--' M n• O OAC �.y \•'�•-, O O z � O w • S ,� O ap O '.9 r" zCD� z IOZ to �• - O i].. n d o Omi 0 0 c