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HomeMy WebLinkAboutMiscellaneous - 430 OSGOOD STREET 4/30/2018 430 OSGOOD STREET � BUHL'u"ING FILE � W r Date... ..`,! /....... NORTH Ott���c{•,'1'O TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ��SS�cHusf� This certifies that ........1."t...L.... . .. ...............................................,.............. has permission to perform U ...�. .-r ............F wiring in the building of �1.. .:. /�'' � rl. ................:... ' ................... x--30 - ,North Andover,Mass. Fe ..................... Lic.No....G7l>.. .............: : .........:. "-/S..... )arc.• f ELECTRICAL IN;i /S Check # 9'M 59 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 Wiresappointed pursuant to M.01 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. r Permits shall_be limited as to the time of ongoing construction activity,and maybedeemed_by-the,Inspector_of_Wires abandoned-and-invalid if-he—. or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the_permit application.` ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Secttons.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 certainpermits•and licenses concerning the use or development of real property.With limited exceptions,the Act automatically dxtends,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. ` ule 8—Permit/Date Closed: / I ***Note:Reapply for new permii$�!- ❑Permit Extension Act—PermitfDate Closed: Commonwealth of Massachusetts Official Use only )E' Permit No. �S �? Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /'p. -0 V-1)? City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of •s or her intention performtoopthe electrical work described below. Location Street&Number Owner or Tenant r,Q Telephone No. Owner's Address Su,w.Q— is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Buildingyvl,�-�p, '�L� Utility Authorization No. Existing Service mps / 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: V✓� r2> ` p� (N' .� Com lesion of the followingtable maybe waived by the Inspector of Wines. t 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 El o Emergency Lighting rnd. grind. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No. In Detection and InDetection Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons 1KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection 4 No.of Dryers Heating Appliances KN Security Systems: No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /.x-00 (When required by municipal policy.) Work to Start: /J.'Ca-0 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under theinns and penalties of perjury,that thein orm tion on this plication is true and complete. FIRM NAME: J f1 LIC.NO.: d,,17 �6 C Licensee: Signature 0,4 LIC.NO.: 20 (If applicable, entr�"ezem t" ' t e 'censy et tuber .) Bus.Tel.No.: Address: f– � Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent ,–d�– Signature Telephone No. PERMIT FEE: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: ?c — ^ Are Y9u an employer?Check the appropriate box: Type of project(required): 1.lrL1�I am a employer with 3 4. ❑ I am a general contractor and I 6. ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a'corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required] 13.0 Other Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: i J Policy#or Self-ins.Lic.#: Expiration Date: _,�- Job Site Address: ZY 3 0 S r,Ao v% City/State/Zip: IVn t�4694 P76 Attach a copy of the workers'compe strop 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 cern nder t e pains and penalties of perjury that the information provided above is true and correct Si ature: _ Date: Phone#: 01 �' �� Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License# [6.,10ther ui Issuing Authority or circle one g t3'( ) Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector ntact Person: Phone#: /(� 1 Information and Instructions Al,! 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 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 021.11 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass..gov/dia J w The Commonwealth of Massachusetts t City\Town of North Andover Cern 'cate o Ins ection In accordance with 780 CMR,Chapter 1 (The Sixth Edition of the Massachusetts State Building Code)and Chapter 304 of the Acts of 2004 (an Act to further enhance fire and life safety), this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to ANDOVER A111TO SCHOOL 430-09 430 OSGOOD ST Certificate Located at Expiration OCT 2009 Use Group AUTO SCHOOL Allowable Classification(s) _ Occupant Load Certificate of inspection is hereby issued by the undersigned to certify that the premise,_structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and-all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply urith conditions or,tampering with the contents of the certificate is strictly prohibited. Conditions of Temporary Use Name of Municipal Name of Municipal Gerald Brown Date of OCT 2008 Fire Chief Building Commissioner Inspection. Signature of Municipal Signature of Municipal Date of OCT 2008 Fire Chief Building Commissioner ���� Issuance Location (�✓ p��- No. �, G' vDate .MOAT1y,• TOWN OF NORTH ANDOVER 0 �..•e rya 4 ' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ��• TOTAL $ Check # 6/11J� 216 4 IK? - �Building Inspector COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER 1600 OSGOOD STREET Building 20 Suite 2-36 APPLICATION OF CERTIFICATE OF INSPECTION 2008 O Fee Required (Amount) $100.00 O No Fee Required Date: 2008 l / Accordance with the provisions of the Massachusetts State Building code, Section 108,15, 1 hereby apply for Certificate of Inspection for the below-named premises located at the following address: Street and Number Name of Premises � .r v r r �, 5c cc, Purpose for the Premise is used. �)Y 1 I)-eY s r 2C Licenses (s) or Permit(s) Required for the Premises by Other Governmental Agencies: Contact Person Ann Higgins Telephone 978-682-8785 License or Permit Agency —e CJ C C9 0 r r Certificate to be issued to Address Telephone Owner of Record of Bui ding ` Address cJ v Name of Present Holder of Certificate Al-lood-0-- Ao SC cs© Name of Agency, if any SIGNATURE OF PERSO O WH M C TIFICATE IT1 IS ISSUED OR HIS AUT RIZED AGENT DATE INSTRUCTIONS: 1) Make check payable to: Town of North Andover 2) Return this application with your check to: Building Dept„ 1600 Osgood Street, BLDG 20 STE 2-36 North Andover MA 01845 PLEASE NOTE: Application form with accompanying FEE must be submitted for each building or structure or part thereof to be certified. 3) Application and fee must be received before the certificate will be issued. 4) The building officials shall be notified within ten (10) days of any change in the above information. CERTIFICATE# EXPIRATION DATE: Application for Cl. revised 12/08 jmc �''e'-) INSPECTION REPORT FORM CLASSIFICATION PASSES INSPECTION YES NO DATED OWNER BUILDING NAME OR NO STREET LOCATION TYPE OF OCCUPANCY -Day Care Auditorium Restaurant Cafe Gym Apt School Common Victualer's Liquor Place of Assembly OPERABLE EXIT SIGN yes no LIGHTED EXIT SIGNS yes no NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STOREYS EMERGENCY LIGHTING SYSTEM dry cell wet cell operable SPRINKLER SYSTEM operable gage pressure_ es _ no_ ; Sh'!OKE DETECTOR operable_ _. Yes __—no VWRE ALARM SYSTEM expired date _ yes no ELECTRIC EQUIPMENT VIOLATIONS yes no FIRE RESISTANT CURTAINS OR DRAPERIES yes no �f EGRESSES LAWFULLY DESIGNATED unobstructed yes no HANDICAP ELEVATOR yes no STAIRS PROPERLY RAILED yes no HALLS AND STAIRWAYS LIGHTED yes no UTILITY ROOM –CLOSETS yes no RADIATOR GUARDS yes no COMPLIES HANDICAPPED PERSONS LAWS yes no HOW HEATED NO. FIREPLACES yes no BOILER ROOM CONDITION: ROOM LOAD IF APPLICABLE INSPECTOR: BRIAN LEA THE DATE OF INSPECTION Date..... .. :.a.�........ HORT1, 3r0et;�``- 0p� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAC14US This certifies that .................................... .... .............................. has permission to perform .................................... .. ................................... wiring in the building of...........................................:.. ........ I........................... at...............................3'�.. , .............forth Andover, ass. Fee; :...... ........ L c.Nd/.2�, ... .. . .. j ELECTRICAL INSPE R f Check # y 7608 lfOmmonweak of Maddac4u6ett9 Official Use Only 2epartment of, ire Servicee Permit No. 7&09 , Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 INFOR TION) Date: - S City or Town of: J� �}- VCS 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 L S 1. Owner or Tenant a Telephone No. Owner's Address G Is this permit in conjunction wittl a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 8 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 f Proposed Electrical Work: �r_ C6 4-L Completion ofthefollowing table inay be waivej by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil,-Susp.(Paddle)Fans No,of Total { Transformer KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool rnd e ElIrnd. ❑ Batter UnitsNo.of tg mg No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. :, Tonal No.of Alerting Devices r No. of Waste Disposers Heat Pump 1KW No.of Self-Contained Total """'"""'""""..................... Detection/Alerting Devices t No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No, of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No, of Water KNt No. of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent 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: (When required by municipal policy.) Work to Start: 1-14-01 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 BOND ❑ OTHER ❑ (Specify:) I certify, under the pain a d penalties of perjury that the information-on this application is true and complete. FIRM NAME: t S , G LIC.NO,: Licensee: v, Signature n - LIC.NO.:� �� (If applicable enter "exec pt"in the ice se nut ber line Bus.Tel.No.: Address: C Alt.Tel.No.:�Z60 Z *Per M.G.L. c. 147, s. 57-6.1,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does nol 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: $ pIbv Iv The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ' (�( C, f. Address: 2 (0 I�c�s2S � . Ci /State/Zi Z tY P , o �r � /�/ ��5� Phone #: a t I 2 �J �� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling � ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a 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. f I do hereby certify under the pains d penalties of perjury that the information provided above is true and correct. Si nature: � '!n"-j Date: -0 Phone#: 2 cl S� O 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#: rJ The Commonwealth of Massachusetts City\Town of North Andover 4 Renewal E!!:Yicate o Ins ection In accordance with 780 CMR,Chapter I(The Sixth Edition of the Massachusetts State Building Code)and Chapter 384 of the Acts of 2004(an Act to further enhance fire and life safety),this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to 430-09 ANDOVER AUTO SCHOOL-NORTH ANDOVER HIGH SCHOOL Certificate Located at 430 OSGOOD STREET Expiration OCT 2010 Use Group Allowable Classification(s) SCHOOL Occupant Load. 39 This temporary certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the ceitifficate,faihire to comply with conditions or,tampering with the contents of the certificate is strictly prohibited Conditions of Temporary Use Name of Municipal Name of Municipal Gerald Brown Date of OCTOBER 2009 Fire Chief Bunt Commissioner Inspection Signature of Municipal Signature of Municipal ^ Date of Fire Chief Building Commissioner '`� l�. `%�to.�.�ri Ince OCTOBER 2009 L Location No. Date D"1-- 491 NORTH TOWN OF NORTH ANDOVER o A ' Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �� Check # la 0 2 Building Inspec? r WN OF COMMONWEALTH OF MASSACHU ErTSTOSTREENORTHArvuvvv-fx 1600 OSGOOD Building 20 Suite 2-36 APPLICATION OF CERT7FICATE OFINSPECION 2008 ( ) Fee Required(Amount) 100.00 ( ) No Fee Required Date: October 6 2009I for co Sect on Accordance with the provisions of the Massachusetts State ua�'the fo�ow ng address: street 1 hereby apply Certificate of Inspection for the below-named premiseslocated Street and Number Os ood St . Name of premises North Andover Hi h School-Andover Auto School Purpose tnr the Premise is used. V Licenses(s) or Permit(s) Required for the Premises by Other Governmental Agencies: Contact Person A enc License or Permit r r Ce rti rcate to be issued o Telephone C �- Address 4 Owner of Record of Building , Address S Name of Present Holder of Certificate Name of Agency, if any --�-'i TITLE SIGNATURE R HIS AG�R IS ISSUED O TIFICATE DATE INSTRUCTIONS: Town of North Andover 1) Make check payable to: 1600 Osgood Street,BLDG 20 STE 2-36 North MA 0184 2) Return this application with your check to: Buildin De t. Andover PLEASE NOTE: in FEE must be submitted for each building or structure or part thereof to be certified. Application form with accompany gd before change in the above information. 3) Application and fee must e nobtiv—e within ten(10)days of any issued. 4) The building officials shall EXp1RAT10N CERTIFICATE# DATE: Application for Cl. revised 1/08 jmc CLASSIFICATION PASSES INSPECTION YES NO DATED OWNER BUILDING NAME OR NO STREET LOCATION TYPE OF OCCUPANCY -Day Care❑ Auditorium ❑ Restaurant ❑ CaM ❑ Gym ❑ Apt ❑ School ❑_ Common Victualer's ❑ Liquor ❑ Place of Assembly ❑ -- OPE ABLE EXIT SIGN yes ❑ no ❑ LIGHTED EXIT SIGNS yes ❑ no ❑ NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STOREYS EMERGENCY LIGHTING SYSTEM dry cell ❑ wet cell ❑ operable ❑ SPRINKLER SYSTEM operable ❑ page pressure yes q no D SMOKE DETECTOR operable ❑ yes ❑ no Q FIRE ALARM SYSTEM expired date yes Q no D ELECTRIC EQUIPMENT VIOLATIONS yes ❑ no ❑ FIRE RESISTANT CURTAINS OR DRAPERIES yes ❑ no ❑ ` EGRESSES(,.AWFULLY DESIGNATED unobstructed ❑ yes ❑ no ❑ •r' HANDICAP ELEVATOR yes ❑ no ❑ STAIRS PROPERLY RAILED yes ❑ no ❑ HALLS AND STAIRWAYS LIGHTED 1 no ❑ UTILITY ROOM—CLOSETS yes ❑ no ❑ RADIATOR GUARDS yes ❑ no ❑ COMPLIES HANDICAPPED PERSONS LAWS yes ❑ no ❑ HOW HEATED NO. FIREPLACES yes ❑ no ❑ BOILER ROOM CONDITION: ROOM LOAD IF APPLICABLE INSPECTOR. BRIAN LEA THE. U�- DATE OF INSPECTION