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HomeMy WebLinkAboutMiscellaneous - 46 CIDERPRESS WAY 4/30/2018 i <, f BUILDINGFILE Date..... NonrH TOWN OF NORTH ANDOVER PERMIT FOR WIRING gBACMUS� .�j�. This certifies that .................&....../....../ /�r Z . . ...................................... ....................................... has permission to perform ......../v. ...4 .Po................................................ wiring in the building of.....,.MT!�.q. (f5, /� D.................... .. .................................I.............. a' ........ � L "2'`�!P�I�....�.,�.5.........� ,North Andover, ass. ............. .......... ............ hh,,nn Fee ' Lic.No.,Yt1 �I� c........ ................ .................... ... R Check# .............................:......... / ELECTRICAL INSPECTO1 1 ` -A v Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. 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), 52 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: J0 �� 3 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)_ Le!f h f' Owner or Tenant /1/l �`flc�/bl.�y$� ��Nl p Telephone No. 1087-26A,§— Owner's 087-26A,§—Owner's Address 6,--G,4� PQ--Z ,ti� < <A� �4.�y�cj✓L�-v� AA Is this permit in conjunction with a building permit? Yes Pl-- No ❑ (Check Appropriate Box) Purpose of BuildingE4 ��=,�1,�/ 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: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires 7i- No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets -6 No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting O rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of SwitchesLibNo.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alertin Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: " " " """.......'""""""""""" Detection/Alerting Devices LK No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of DryersHeating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters -Signs Ballasts No.of Devices or Equivalent 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 YYires. Estimated Value of Electrical Work: l�,c70(0 d (When required by municipal policy.) Work to Start: p Inspections to be requested in accordance with AMC Rule 10,and upon completion. INSURANCE CO 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 covera in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the aims andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.:� , � Licensee: t'�-t-C.� rte, &eft>4 ���ignature LIC.NO.: � Z? S-0 flfapplicable enter "exempt"in the license nz ber line.) Bus.Tel.No.• — CCDD Address: ,+� ��-✓ ,vi., Alt.Tel.No.: `� ��O bj?` *Per M.G.L.c. f 47,s.57-61,security work requires Departmenttof Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. 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 electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the V 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 may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 151 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass N Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed❑'f Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS EC ON: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comm nts: Inspectors Signature: - Date: FINAL INSP C ON: Pass 0 V Failed Re-Inspection Required($.) ❑ Inspectors Comme ts• _- Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflnlustrialAccWnts 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 Legibly Name(Business/Organization/Individual): (n.�✓Vl f�(�f i1.t l C— Address: 'a: 1�,1h.-tit [��� 4-✓ O3 3lk!E; T City/State/Zip: e, Phone#: �/ _)4- _�) 7 S--C)kh Are you employer?Check the appropriate box: Type of project(required): 1. am as employer with 1O 4. ❑ I am a general contractor and 1 6. A�ew construction employees(full and/or part-time).* have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet. 7• FJ Remodeling ship aud'have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. 9 ' y p ty. El 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 ire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Iam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name:. lk.ti/OJ.cam_ Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: LeGS City/State/Zip: J00. e�—�j�k,T O. Attach a copy of the workers'compensation policy declaration age(showing the policy number and expiration date). ` Failure to secure coverage as required-under Section 25A ofMGL 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 maybe forwarded to the Office of 'Investigations of the DIA.for insurance coverage verification. I do hereby cerfifv under the pains and penalties of perjury that the information provided above is true and Correct Simafore: Date: o Lam' Phone 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.PIumbing Inspector 6.Other - - Contact Person: Phone#: s v 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 ofhire,• express or implied,oral or.written." An em ployeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more Of the foregoing engaged in a j oint 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 bean 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 carry workers'compensation insurance. If an LLC or LLP does have I employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial ` Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the 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 pemzithicense number which will be used as a reference number. In addition,an applicant • that most 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 Cowmonwealtla of Mossohj�setts Department offadusIdal.Accidents Office ol`Westig,010.1m 600 Washington Street Boston MA 021 1,Z TO,#617-727-4900 ext 406 or-1-877-MASSAFF, Revised 5-26-05 FaY,#617-727;7749 XVWW_mace an-gIrlia J20 1 Date • y1�'K'D.s ' b a s • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .AJ,r has permission to perform . .)c/,p �,► <.!Ln.t..� plumbing in the buildings of. Iv'e-A-. .h L �. at . �f� ,.%tCt '14�� ,�/ �, , , North Andover, Mass. Fee 5� . Lic. No. ,/6-/5'.7 . . .. . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# ��' -2`17- Pi-1 714113 v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY U �1 MA DATEL.. PERMIT# /���� JOBSITE ADDRESS r OWNER'S NAME POWNER ADDRESS r 0 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Q RESIDENTIALa PRINT CLEARLY NEW: 0," RENOVATION:El REPLACEMENT: ® PLANS SUBMITTED: YES EQ NOR FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE f f _I 1 ._ ! I _. _._..... J ! __..__..._...1 iL.2 L.1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM 1EDICATED GRAY WATER SYSTEM DICATED WATER RECYCLE SYSTEM HWASHER _._-7=--=--1 ----___l 'NKING FOUNTAIN I .. __--( _-.-fI .-.._-_S __1 _._._._ __..._i 1 I _ E _ _ .._J __.... 1 )D DISPOSER i . I .__.___ .___.__I i _f _._._.._i __._..__J -_J _ � _...--I _ _._I .. __.J I )OR IAREA DRAIN i 1 ._..__1 __j IL _ _.....___ j-­__J1 4TERCEPTOR(INTERIOR) KITCHEN SINK J __.{ 4 _._� ___._..J ... _._! I _-_ ._1 ....__.__J LAVATORY ROOF DRAIN SHOWER STALL _f i -_-_. _—_I __ f _._._J i ...._._I -- ___-i SERVICE/MOP SINK TOILET URINAL ) -_-___-- _-------_J _..___J==== WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i i WATER PIPING ( I i - i . f __ € i _.__f _J1 _I OTHER ____ = _J __..__._.l ? { i _._....-_( ._-_..._J ...__..._! ► ._._..__I _ I _ I �ll �J ........__. .._ .�._.....-._ ___ _._.{ ...__. � 'I ..____.._i ......---I ----�j ... I atom _ I .__.J _._I _ i ___.._1 __..____I f _._.__..J _..____.I ._.. -._f ....._.J I .- . _.-_► _ .'. __I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES dNO IF YOU CHECKED YES,PLEASE INDICATE�THEPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ( BONDi 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. N CHECK ONE ONLY: OWNER J AGENT N SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 compliance with all P rtine t pr i io o he Massachusetts State Plumbing Code and Chapter 142 of a General Laws. PLUMBER'S NAME (LICENSE SIGNATURE IMP Eff JP D CORPORATION 0# j PARTNERSHIP O# LLC E COMPANY NAME (,� _ ADDRESS I "" - - c CITY �G-_��d/y� STATE ZIP TEL FAX _. j CELL [ - f.`.t . AIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES 0 I,S Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ' M l ' The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberg Applicant Information Please Print Le ibl Name(Business/Organization/Individual): kell� 7r Address: City/State/Zip: FO_// X6&76 Phone#: �63 0 53-413 'F Are y, an employer?Check the appropriate box: Type of project(required): 1. I am a employer with T 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.EJI am a sole proprietor or partner- listed on the attached sheet. F1 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.F1 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. I Homeowners who submit this affidavit indicating they lire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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 certunder the pains and penaIt'es ofjury that the information provided above is true and correct. Si ature: Date: Phone#: 665 —8-S 3 —131 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#: r 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 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 ofl dustrial Accidents OfAce of Investigatitons 600 Washington Sire.et Boston.,NIA,02111 Tel,#617-7274900 ext 406 or 1-877-MASSAF& Revised 5-26-05 Fax#617-727-7749 wvvw.mass.�ov1dia f Date...... ...�� .�...................... � �►ORT�y o�' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88�cMusE This certifies that ..'......1... .C ......../............... ........................................... has permission for gas installation ..... P.. ...... ..o................... in the buildings of..... . .d!. .......Z. �........................... � 1 at.... c�..... ..!.f: ...I �.-�..... ��' ..., North Andover, Mass. Fee./&—. Lic. No./ ...... ........................................................ GAS INSPECMR Check#2/17 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYMA DATE / PERMIT# '. JOBSITE ADDRESS OWNER'S NAME h„ __- -- GOWNER ADDRESS L E FAX TYPE OR OCCUPANCY TYPE COMMERCIAL F,711 EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:[� REPLACEMENT:® PLANS SUBMITTED: YES Q NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _s _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN FOOL HEATER ROOM/SPACE HEATER I _ ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER OTHER ........ I INSURANCE COVERAGE I-,lave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J_ NO _I I.T YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND 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 I 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 compliance with all Pertinegitf he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. RA4j PLUMBER-GASFITTER NAME LICENSE# / SIGNATURE MP[dMGF El JP 0 JGF[__( LPGI© CORPORATION[ #©PARTNERSHIP 0# �LLC[3# COMPANY NAME:1 A�tiT-� �� ADDRESS CITY L _ STATE ZIP TEL FAX I CELL EMAIL 1� ROUGH GAS INSPE TION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION OTES 1;r. S /j r1f WYes NoAfa I/J/W,/ ; S l THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ mt a FEE: $ PERMIT# PLAN REVIEW NOTES F A � The Commonwealth of.Massachuseas Department of Industrigl Accidents Office ofInvestigations 600 Washington Street Boston,MA 02.111 www.mass gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual):gal Address: City/State/Zip: e ti 2)6 e6� Phone#: 9 Are yzu an employer?Check the appropriate box: Type of.project(required): 1. `Y I am a employer with- 4. ❑ I am a general contractor and 1 6 ` El Now construction employees(full and/orpAtime).X 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, E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.E] I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers'. comp.insurance required.] 1311 other !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 anew 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 workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: ExpirationDate: 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 requireduader 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 maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Ido hereby certlo under the pains andpe Id s of jury that the information provided above is true and correct. Simafore: !���?� Date: /0 Phone#: [Of7felalse only. Do notwrite in this area,to be completed by city or town official.own: Permit/License# sgAuthority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.PIumbing Inspector 6.Other - - - M,,,,o . r A 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 ofhire,• - 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 floes have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be,returned to the city or town that the application for the 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 -P-lease be sure that-the affidavit-is-complete-and-printed legibly. TheDepattihbiit 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 whichwill 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(ifnecessary)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 maybe 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 homeowner 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: �`hc Goxnx�on�eaXt11,o:��iassachu.,sPtts ' Dopazmextt ofladwtdat,A,cczdants Ofaice ofWe8tigatiou 600 Washingtm Street Boston?MA,02111 Tel,#617-727-490.t0c r-406 o1-877`, FMASS F RPVICPA 5-96-05 Fax# 17-727 7749 1 is . . COMMONWEALTH OF MASSACHUSETTS PLUMBERS AS A MASTERS I.L MPCU: JJCENED T ISSUES.THE ABOVE LICENSE TO: "llCki'AE.L. 41 KEL..LEK Zhm iN 20 KENNEDY 0-0:7G_:. GOr...: RE'L H A M' Ll _ c 1�1 ILGi T 1 F ' 9 COMMONWEALTH OF MASSACHUSETTS " PLUMBERS AND GASFITTERS. LICENSED AS AWASTER PLUMPER t ISSLIES.THE ABOVE LICENSE TO: - M1CHAEL. W KEt.LEFz. ._ 2 0 KENN.EDY OR, - 4 PELHOt , W11 0,50 76-=2605 .15357 No pYM M,S ACIN15tt49 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 247-14 on 9/18/2013 Date: March 19, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 46 Ciderpress Way MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Meetinghouse Commons, LLC 76 Great Pond Road North Andover,MA 01845 Building Inspector Fee: PrePaid $100.00 Receipt: 26874 Check : 3826 E NORTH q F a 01ro r� 'rf r 'tS# 4r.o r'519 SS^CINSE CERTIFICATE OF USE & OCCUPANCY . TOWN OF NORTH ANDOVER Building Permit Number 247-14 on 9/18/2013 Date: March 19, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 46 Ciderpress Way MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Meetinghouse Commons,LLC 76 Great Pond Road North Andover,MA 01845 u Building Inspector Fee: PrePaid $100.00 Receipt: 26874 Check : 3826 1 NORTH Town of 2 �._ � EAndover No. 14 +� a4l Ct h ver, Mass ICK �'►• U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System lik THIS CERTIFIES THAT .........����'T.L!.:��„l'�,n��s'fi...�G?.�?`r'.!�rr��ls'..�;<< ................................. BUILDING INSPECTOR �� C�•`�F�,. miffs Foundation has permission to erect .......................... buildings on ......................... ......... to be occupied as / ��N ��`�� Chimney p' ................................................................................................................................... provided that the person accepting.this permit shall-in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and J Construction of Buildings in the Town of North Andover. 1 PLUM G INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. RoughFinal PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Service .................... ........................................ .................... a 0/ BUILDING INSPECTOR GASINSPEC Occupancy Permit Required to Occupy Building Rough � Final/Qli 3/11P�/Y74/ Display in a Conspicuous Place on the Premises - Do Not Remove No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No.,Det. r SEE REVERSE SIDE � c10RT1i Town of ndover ; : - "t No. 1 114 * t h ver, M oL > Mass, COC MIc"RWICK ��• S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System lik THIS CERTIFIES THAT r �-'�C.:Y�.l�.�!r:S�...��.�rr��ls' •f•(C BUILDING INSPECTOR Foundation_ has permission to erect g y� c!.�.�`: /��ff1..��. 7hY,/,.5 � l� .......................... buildings ............... ..... ............................. ? C3 � !y to be occupied as / � iVa ...................................................... chimney - ............................................................................. provided that the person accepting this permit shail in every respect conform to the terms of the application Final -.311 17 / on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and J Construction of Buildings in the Town of North Andover. PLUfd,G INSPECTOR Rough Ok 9 VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 04��- PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS ou Service BUILDING INSPECTOR GAS INSPE`� Occupancy Permit Required to Occupy Building Rough A, 3� �� Display in a Conspicuous Place on the Premises - Do Not Remove Final)�lI No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No3 t. Smoke Det. F_ SEE REVERSE SIDE �,( 2--r9-/' j of NO ora A o APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION y T O'P OGMK twKw y' �9SSAcHUs���� BUILDING PERMIT#' -7- y ADDRESS/LOCATION OF PROPERTY: G CI Map ,Q L Parcel 31 Lot Number rrV4 SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: 311 3 I3/�4/ j CLOSING DATE ON PROPERTY: 511, FIVE 5 DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETE ITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20 0 WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: L L G Address: AJ ,1`�• 1 ROUTING M TOWN ENGINEER, SITE PLANDRIVE-WAY REVIEW [ U 'ol 1413 CONSERVATION 2�7--1114 PLANNING DPW-WATER METER L`1 SEWER CONNECTION L( . DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST D c PW SIGNATURE File:Application for OC form revised Jan 2007/2011 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 190,500.00 m $ - $ 2,286.00 Plumbing Fee $ 285.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 285.75 Total fees collected $ 2,957.50 46 Ciderpress Way 247-14 on 9/18/2013 Single Family Townhouse Ili i tAORTH Town of tAndover No. Lt 10 VW h ver, Mass COc lic"IWICK y7• �d A�agTEO ►'PP,`�(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT %J 'T.L!.�a,4:.L�.���s'�:... G?. i.�. �r� s BUILDING INSPECTOR has permission to erect buildings on 7� ...... , ........� ...``Ll Foundation fir Rough .-- to be occu led as �N '�0 Chimney p' .......................... ................. .................... ........................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough _ Service ................... ............................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until-Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE MAP 104Cf ' LT30 ✓ NOTES: / 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A / MAP 104C LOT 29 PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT NESSEX COUNTY SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, MASSACHUSETTS"; SCALE: 1" = 80'; DATE: JULY 20, 2001 BY THIS GREENBELT BELT ASSOC., INC. OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY 14.09' NORTH DISTRICT REGISTRY OF DEEDS. / 2) THE INTENT OF THIS PLAN IS 70 SHOW THE AS-BUILT LOCATION 14.64' OF THE FOUNDATION ONLY. " 13'24 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR �Ta6 UMjT FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP MAP 104C S�3 T�?S U FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY �9fK A41/T / "? PANEL NUMBER 250098 0007 C, MAP REVISED: 6/2/83. LOT 28 / ` .Sq j / ) 4 THE CONCRETE FOUNDATION SHOWN HEREON HAVE BEEN INSTALLED Cy^� SUBSTANTIALLY IN ACCORDANCE WITH THE 40B SITE PLAN AS lOtNi APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD. I HEREBY CERTIFY THAT THE LOCATION OF-THE TOWNHOUSE UNIT / ' >A� \ NUMBERS 24-26 FOUNDATION SHOWN HEREON IS THE RESULT OF A �-4 { �� FIELD SURVEY BY THIS OFFICE MADE ON APRIL 23, 2012. i G FRANCHERR >' `� `�`i� ' \\ Na 38118 � � \\ LICENSED LAND SURVEYOR DATE >/ /� ^ >� A` ��- CERTIFIED FOUNDATION PLAN AL \ AL GRAPHIC SCALE MEETINGHOUSE COMMONSDERPRESSWLANE HOUSE UNITS 20-23 0 25 50 100 NORTH ANDOVER, MASSACHUSETTS AIL111b �--� PREPARED FOR MEETINGHOUSE COMMONS, LLC o0 oyo / (IN FEET) 121 CARTER FIELD ROAD J �o� / /1 //1 \` 1 inch m 50 fL NORTH ANDOVER, MASSACHUSETTS A 2 44 Ston Road,Suit*Ona Salam,Naw Nompshim 03078 5 t, Z r� \ (803)893-0720 t m / / \ MHF Design Coneuttonta, Ina. ENGINEERS•PLANNERS•SURVEYORS �J If \ � SCALE: 1" 50' DATE: APRIL 24, 2012 DRAWING AL (1 B�i40 NOt \ NO. DESCRIPTION BY DATE DRAWN BY: I CHECKED BY: PROJECT NO. NAME REVISIONS __ CMF 250508 2505CFP.DWG • i t "Oassachusai?s -De rrr e,it o ;tet;= _ "•_ tliiC..y4i C=57 Board of Building PegulaIi0315 311G Standards COiNtrurtiun 5upeni or iczrse: CS-055417 THOMAS D ZAHgRUIK0 J r' 115 CARTERFIELD RD N ANDOVER Mk 01845 Commissio p; 04105/2014 4 t -------------- i I Z'tans Subm-id Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL ubIic er TanninglMassage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT -= COMMENTSg (tvv 1 �_ CONSERVATION Reviewed on 7 `� J Si nature COMMENTS M "i01 l l �� � 01 CC HEALTH Reviewed on Signature COMMENTS j L Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: 2 2' 1'-� Comments Water & Sewer Con nection/si nature&_Dates Drivewa Permit ` DPW'gown Engineer: Signature: Located 384 Os iood Street FIRE.DEPARTMENT -Tem pDuster ori site. . es ,/ . no Located at-124 Main Street- Fire Department signature/date COMMENTS IZ