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HomeMy WebLinkAboutMiscellaneous - 47 PARK STREET 4/30/2018 47"PAR 11 K I STREET CF 210/071.0-0028-0000.0 l Office Use onlyi 7)� ubE LAIIiIIIIIIiIUEttjf IIf _ SScat#ustffS Permit No.EgZlrtMrnt Of 1jtlblir _%fttq Occupancy& Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 C&1R 12:00 31sa (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 �� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �t/ y� (%K or Town of NORTH ANDOV .R To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. / Location (Street & Number) LJ PA R K ` - 1 '1riC&SS V 1 1,� Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes _ No C (Check Appropriate Box) Purocse of Buildina_ Utility Authorization No. Existing Service Amos _l Voits Overhead Undgrnd No. of Meters New Service Amps Voits Overhead _ Undgrnd r No. of Meters Number of Feeders ana Ampacity Lccaticn and Nature of Proposed Electrical Work / -. H I No. of Transformers iotai No. of Lighting Outlets No. .,. of ':�s KVA bov No. of Lighting Fixtures Swimming Pact A gr.. e- crna. _ ` Generators KVA No. of Emergency Lighting No. of Receetacie Cutlets No. of Cil curners I Battery Units No. of Switch Outlets t No. of Gas Burners FIRE ALARMS No. of Zones total No. ct Air Cerc. No. Detection ana No. of Ranges � tans Initiating Devices No. of Disgosais I No.of yea: T1ons total •,No. of Sounein Devices 1e,t s :on_ KW 9 No. of Self Containea No. of Dishwashers SoaceiArea Heatiro KW CetecvonlSounaing Devices r, Local ; Munic:oai —other No. of Dryers Heating Oevices KW _ Connection No. at No. of Low Voltage No. of Water Heaters KW ! Signs Sailasts Wiring No. HVaro Massace uU No. of Motors Total -Hp OTHER: INSURANCE COVERAGE. Pursuant to the recu,rements of Massacnusers general Laws I have a current Liacinity Insurance Policy inclucing Com^• tec Ocerattens Coverage or its substantial ecuivaient. YES NO = I have suaminea valid -root of same to the Office. YES NO :: It you nave checxea YES. please incicate the type of coverage Dy checKing the aoppr/ nate Dox. INSURANCE fG BOND = OTHER - tP!ease Scec:`.�I (Excitation Datet Estimatea Value of E:ectncal WorK S Werx to Start Inscecuon Date Recuestec: Rougn Finai Signea unser the enalties of perjury: FIRM NAME _ IS — LIC. No. Licensee Signature LIC. NO. �0�T�141t/ S1 C �lfi: t f�} C�( _1 ass. ;el. No. _ Aggress Alt. Tei. No. OWNER'S INSURANCE WAIVER: I am aware that the L:censee goes not nave the insurance coverage or its suostantiai eauivalentt estte- ouirea by Massachusetts General Laws. ana that my signature on this :ermit a0ptication waives this requirement. Owner g (P!ease cnecx one) -eiecnone No. PERMIT FEE 5 22�_ j )Signature of Owner or Agent) %-a5;c5 t' Date.....// 1! . f a *� 573 NORT1i TOWN OF NORTH ANDOVER A PERMIT FOR WIRING r 'Ss CHUS� li 0,/ � ` 6 This certifies that `1 . <. .). ?.<.�tP...........:!.................../........................... C1 has permission to perform ......... ►tiJ......[� .. ..�.::.�........J 4�.......w.D................... wiringin the building of................................................................................... I at..................... .... .............I...- ,North Andover,Mass. Fee... Lic.No. ........................................................... ELECTRICAL INSPECTOR ' C S' YIQ�l9�109 15.00 RAID WHITE:Applicant CANARY:Building Dept. PINK:Treasurer N° 7 Date.................................. &ORTH, TOWN OF NORTH ANDOVER PERMIT FOR WIRING Ss�cHUS Thiscertifies that ............................................................................................. has permission to perform ...:........................................................ wiring in the building of:.............../.............:....1i .......................................... ate.....................:................................................ . .North Andover,Mass. Fee.: ................. Lic.No. . .... ............................................................... ELEcrRICALINSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer � TIE COWOIVWE4LTHOFhfAm ams Fl7s' Office Use only DEPARTMFVTOFPUBLICSAFM Permit No. 30 BOARDOFJWPREVEM70NRWUMT10MS527CMR1ZO ' Occupancy&Fees Checked APPUCATION FOR PERMIT TO PERFORM ELEO WCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL.INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to per"the electrical work described below. Location(Street&Number) tr`> Owner or Tenant 4212//—e,15�7 Owner's Address 4; (- Is this permit in conjunction with a building permit: Yes No M (Check Appropriate Box) Purpose of Building c...y"r",i"' r(/ �� Utility Authorization No. Existing Service Amps / Volts Overhead a Underground a No.of Meters New Service Amps / Volts Overhead M Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work t/ C�' 2,5" V4 i% ?7-777 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground around No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners �- No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP bTHER' l stiarxeCarmage Pt>fst>antbttrtegtmartatls�GataalLaws Iha%eaammtL bt'lityhast mxPoL,ynidigCat#AtC Ar.WcritssubskrtWe iv,&t YES NO I ha%esuhnftdVdl dpcoofofsarebtheOT=YES M NO IfyauhmcdxdwdYES pkmemdial6etheWcfwmaWbydtadatglhe bcx INSURANCE BOND OTI&R (PleaseSpeafy) L`� / �`� E*afime r,v Fstitn*dvalued 1ecfiW Wok$ /�y waI<ans�t � hspedwD*RwpesWd Rough Hail -% sigt�a r• �-- � •— _ FIRMNAME �i1 >✓ x// b BtskmTd% J /i�lUY217 OWNERS WSURANCEWAIVER;I.ama wftaftl dmnut $reitsuanecaemW" leglddatasmgLm dbyN4mmdxamCerealLaws aodiatmysigro mcnEasparniwaiAsftmw'mna . (Please check one) Owner Agent 6 Telephone No. PERMIT FEE$ Date..... �..�..../fi 1 1 NORTFr TOWN OF NORTH ANDOVER p PERMIT FOR WIRING a s CAU This certifies that .............................................. /�.......................................... has permission to perform 4 ?®©'0 ...................... ...................................+.......... wiring in the building of SS ........ .............................. ... .......... , a �7 *fc S7 ,North Andover,Mass. Fee.-�0-.0 ... Lic.No..# Q.tf.G6.............. ........ Pf ..... ELECTRICAL INSPFd7MR Check # 7 10750 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the Al Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed "I 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 notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and maybe_deemed_by-the.Inspector_of_Wires abandoned_and_invalid_ifhe—_. ._ 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. ffule 1—Permit)Date Closed: **Note:Reapply for new pemit Extension Act—Permit/Date Closed: v�\� a / C,ommonweakh o/Na66acha6ettd Official Use Only cc�7 Permit No. eLJepartment ol.}ire Seraice6 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 INFORMATION) Date: City or Town of: ld over To the Inspe for of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location Street&Number ( ) 'W 7 aA �' Owner or Tenant �CGvi; Fentress✓ Telephone No. Owner's Address f4v4e— Is this permit in conjunction with a building permit? Yes Zr No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ��� Q o R��i�a �s j err G�h r &Ti, Completion ofthe.following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 3 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 1:1In- El o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 3 No.of Gas Burners — No.of Detection and —Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number... er. ..T.ons KW .............. No.of Self-Contained .. ................................................ Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent y 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: Ir Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: psQ (When required by municipal policy.) Work to Start: 3�3/�12 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 pains and penalties of perjury,that the information on this application is true and complete.20 FIRM NAME: P C-cc' LIC.NO.:4404 Licensee: 64 l /`I Signature / LIC.NO.: It og i—t5 (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 7-n—ffk.02Z,1' Address: 4 rarriT rl:ncT At ft Olgo3 Alt.Tel.No.: *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 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 PERMIT FEE: $ Signature Telephone No. a 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 Legibly Name (Business/Organization/Individual): Aut A C1,cGG1014 Address: G�`•�iT y X01 City/State/Zip: aw 1i... ,w flta o4'd'3 Phone#: 78 �`- FZZB' 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 ,employees(full and/or part * have hired the sub-contractors 6. EJ New construction -time). 2._ I am a sole proprietor or partner- listed on the attached sheet. 7. -1 Remodeling ship and have no employees These sub-contractors have g, ❑Demolition ` working for me in any capacity. employees and have workers' 9. E]Building addition [No workers' comp. insurance comp.insurance. t required.] 5. ❑ We are a corporation and its l0J�lectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: x Policy#or Self-ins.Lic.M -7� Expiration Date: YJob Site.Address: L�7 �r 'f 1 City/State/Zip: A4 Ano1oVtr it ., Ot$'ys 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 imprisommnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t ains and penalties of perjury that the information provided above is true and correct. Si ature: Date: LI/2-A2 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.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 Revised 11-22-06 www.mass.gov/dia 9357 Dat TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 4 SSACMUS� This certifies that . . .QQ.!:.'�. . .. . . . . . . . . . . . . . . . . . has permission to r plumbing in the buildings of ./.�- k coq . . . at. . .Y.. ?. . . . . OP'4 Z. 4, 67,7.`�. . . . ., North Andover, Mass. Fee. . . . . . . . .Lic. No..l U31�rU. . . . . . . . . . . . . . . . . . . . .� . . . PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w",�—jo- f:j C ITY I!V o � . ! MA DATE] 3��"1� I PERMIT#JOBSITEADDRESS y �/9-✓'l , OWNER'S NAME1 K�1 ,J �1J �E�.�>P P OWNER ADDRESS � JM-�_ I TELT IFAX I I TYPE OR OCCUPANCY TYPE COMMERCIAL I I EDUCATIONAL (, RESIDENTIAL,14 PRINT CLEARLY NEW.( I RENOVATION:I ( REPLACEMENT: PLANS SUBMITTED: YES I NOI FIXTURES-1 FLOOR-' BSM 1 2 3 4 5 6 7 a 9 10 11 12 13 14 BATHTUB _l CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1 DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN i FOOD DISPOSER J i FLOOR IAREA DRAIN 7 I I INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ! SERVICE/MOP SINK I I TOILET URINAL - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES. WATER PIPING - - - - OTHER I _. e INSURANCE COVERAGE: — have a ctirrent liabilit hs0ratice policy.or its substantial equivalent which meets the regttirenients of MGL 0.142. YESKI NO I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC2aware OTHER TYPE OF INDEMNITY I BOND I. 1 OWNER'S INSURANCE:WAIVER:I 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 M!gi this requirdilent. CHECKONEGNLY: OWNER I AGENT I SIGNATURE OF OWNER OR AGENT I hereby certify that all of[lie details and information I have subrnitled of entered re'garding.thts application are true and accurate to the hest of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in cont fiance v,ilh all Pertinent provisi f the Massachusetts Slate Plumbing Code and Chapter 142 of lhg,Gerieral Laws. eA- i PLUMBER'S NAME (%}1nII^6'/il1:� �Jirn�`� LICENSE II I�a� ( SIGNATURE MP 1, JP I I CORPORATION(IiI ( J IPARTNERSHIPI I#� LLC 10 I COMPANY NAME it 1-19 L) P 1 nJ' C-- ADDRESS j I L,,l t C 0 i f' i CITY l�""�t`1 I STATE 1vI �ZIP,�1/�'t� �� TELL ,7j f ,P1 FAX S/t r"7-e CELL t1��yS�l EMAIL f!blit/10111,14 A)�0 I RO1t7GH PLUMBING INSPECTIONNOTE,S �:BELOVV FCL:O 1 � CE H75E:ONLY FINAL rNSPEC�TYON NOTES Yes No THIS APPLICATIOfi1 SQUES AS THE PERMIT E]: ❑ /I ! 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I'titsttaitttothisstaf►lfe anei/ ro�l�gistefiitecas`:.,ei�e�ypersoiiiitilleaerT�iceo€air.otlie'rtitideiitycontractci£iiite,, expii;�oriiilptied,.Qmlok Biu esrtl0,ivsirt�etiile�ias"fig iniiivitjcal,partiters�iip;,asuCiatioh;cpxpptIion Qiofier leIelitiCyt02ranjr l�0 0?liiora ri�tltefolzgaingeilg��ecliliia�oinFentcrprise,aiiilili�lialin�the;lega)iipresentatit��s:b�'a'leoeasederppfo}�el orlTte xeceivt;cor[rtisteeofatfiilciii`idiial,l►arGtersTiil,,assaciatibn:o>otltoriegal'elitit�;,�i>i�i'to��ulg;olvplayees,lfotvever:.fne otu+laro�ridtit�elliilglioiiseTtaving Eiotiltbrz tliau tiireeaapatfiuenls:aud��vlio r�sicfes tliereill;,orth�oe clisctljig'loll suoFA"t)tlier 1l() ant ofile enlplo}�spersonstocioaiiaiiltenulceconstructiaiiOrr air wori;on5uc11cite riilglioiis Itfrpil:tli�grolmdsorGnitdiilgollptlrfenautthereto,sha)lhiobbeesuse+ofsuch.eiliptoy�ntentb:cTeeuletl'tb be au entplo}�era'� 111GLc1laliicr.152° .5 6'also'slatestllat'`•`esol Rstjit-i !<Carlicensingngeticf�.sllttltivitliTiolTtlte sstiauceor tieival blffl lieC)I5 ba liertnit to oper:tle a btisiliessoi�t0:eonsfruct blinding-S in filo ColainfoiliYeattii ibi alit' p�IicaliF�iJ Tlas ttotprptlueeci ttccepfn6leeE�Icl'elice oTcaitip)initce lvltiUheilrstii iiuceot er�ge l;etlniretl'= At[dilionall° r. .1f�O��i1@pfei-15��25C(?jstates. �IeitherineconultomveaTtlutorari��ofifspoliticalsu6tliyision�sf11�1 OW917flto anycontractPor(ho perfomlatice ofp►ib)igieorl;ttt►til accepiab7eevidenceoft olnpliaucelvitlitlteinsurance l:e.�iltreinenfsofttiscliapterllattelleclipreeiitecltotIieco�itractingPutiiorit};" • Alijilic€ilils . ... . _.. .. . .... Please ft![oueEtlYi4ot�:ers':co1l);�eils�(iotz'a�iiTxtit�6ni-)ctai ni �7teclvit.f�lefiloteIt�f4�ypticsituationlii,iF necgssti4;snPplgsitb-aontra4or(s)natue(s),adI-e-Ss(d)•aItdPItollenutllb,04)atoluxvith isill�fa hch-cellilcale(s)of insttraiict-,L;ulifedl.iaUiiif}t Colnpatiies(I LG)or—MinitedUabiGtypiti dlihips(LT.Pj Svilit ilo eu1pZA��e?sotllerllintr;tite �iid1bers oi•pathiers;:ire iiot req;liredto Cary(tiyorl ereCUI11pe11SatI01l 1i1S11L'anCB. IfanL>;G orLLP sloes Bare emplo��2es,;ipolics►is required..B��dvised°thaEfhisiiffTclavifuiay,besitbmittecltothe�Departinentof 7ndushia) ACCMWifs-forconfimiatioilofillsluaitca.coverage. Ai basilre-tosignnil.d(I; 011* u41 cfammanwalib of ttsa�> s n orl�.tie. i. o. fleprtmcnt of Vublic %fctq Occupmq A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:000 pease blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK . All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date t`' M& or Town of NORTH ANDOVER To theIrl pector of Wires, The udersigned applies for a pqrpit to perform the ectrical work described below. � Location (Street & Number) 1; t •� Owner or Tenant - � �r/� ���/u/ S �{ " -; •es r' Owner's Address ����• !;. ;`+ Is this permit in conjunction with a building permit: Yes _ No (Check Appropriate B Purpose of Building Utility Authorization No. Existing Service�'.-r0 Amps 0 r ��O volts Overhead ' � Undgrnd � No. of Motors New New oAmps (ld I _Volts Overhead Unagrna r No. of Meters Number of Feeders and Am acit py Location and Nature of Proposed Electrical Work No. of Lighting Outlets I No. of Hoc --cs I No. of Transformers Total KVA ;k ` No. of Lighting Fixtures i Swimming Pcoi Abcve.— In- t— ti grno. _ grno. I Generators KVA .; No. of Emergency Lighting, No. of Receotacie Outlets I No. of Oil turners I Battery Units No. of Switch Outlets I No. or Gas Burr.ers FIRE ALARMS No. of Zones Totai No. of Detection and No. Of Ranges I No. cf Air Ccrc. :cns Initiating Devices Heal Tota, -ota, v No. of Disposals I No.of Rumcs :ons KW No. of Sounding Devices :'+. r No. of Self Contained a No. of Dishwashers I SoacerArea rieatmc K1•/ Ostection/Sounding Devices , No. of Dryers I Heating Cev,ces KW Local — Municipal e OtherConnection J , No. of - No. of Low Voltage i No. of Water Heaters KW I Signs ?a Pasts Wiring 4 � No. Hydro Massage Tubs No. of Motcrs Total HP r: OTHER: "y INSURANCE COVERAGE. Pursuant to the reawrements of MassacnLsers general Laws I have a current Liaoility Insurance Policy incluamg Come etec Ocerations Coverage or its substantial onuivaient. YES NO nave submitted valid proof of Same to the Office. YES = NO = It you have checked YES. please indicate the 3ypo Of coverage oy checking the appropriate box. > INSURANCE BOND = OTHER = (Please Scec:"/) Estimated Val f E!e cn� I work 5 111C �� ��b (Expiration 04101 C/l Work to Start Insoeciton Oate AacLes:ec: Rough - Final Signed under the Penalties of perjury: FIRM NA UC. NO. / - -� S;g azure �' UC. NO. Address v-G�trITF�i✓4�° Q� ( 1Y 1�4,'C�Ta�� p�f v! Sus. Tet. No. _G g 3 L' Alt. el. NO, JOIg OWNER'S INSURANCE WAIVER: 1 am aware that the L:censee Coes not nave the insurance coverage or its suoetanual equivalent as re- quirso by Massachusetts General laws, ano that my signature on :his -ermit apptication waives this requirement. Owner Agent (Please check oner b S'i Teieonone No. PERMIT FEF S (Signature of Owner or Agent) r t, a•6586� a Location 'e/ - �- No. /110 Date " T e' s i f NORTh TOWN OF NORTH ANDOVER 3 AL 0 a Certificate of Occupancy $ s+c►,us t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �1 // Building Inspecto%/ i° 11�G NORTH _ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACHUS� This certifies that .. --- ......... ..... ........................: .................... has permission to perform—..'d ..... .....fir.`... ........ wiring in the build' f..1 �'P—f .4%....... ....jnr 1, 011h ......at C .. � Andover,Mass.......... ........ .... ....................... Fee 4��............ Lic.N.k2fv ............................................................... fis ELECTRICAL INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUELDING PERMIT NUMBER: 14 , 9T I DATE ISSUED: X SIGNATURE: 44601-f Building Commissioner/Inspector of Buildings Date z SECTION I-SITE INFORMATION 7 0 1.1 Prop Addr 1.2 Assessor,s Map and Parcel Number: aI/ eve Map Number Parcel Number 1.3 Zoning Information:U 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage(ft) 1.6 BUILDING SETBACKS(ft) Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Repired Provided 1.7 Water Supply M.G.L.C.40. 54) 44 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: > Public 0 Private D t zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSE"/AUTHORIZED AGENT Historic District: Yes No M 2.1 Owner of Record -04;aW* 4-M'A� [:��WkSSIJ 4 Name(Print) Address for Service Sign= Telephone 2.2 Own6r of Record: NA PftlC- Za e Print Address for Service: &%� qqg'-&SIR4�) 111 Ainature (r- Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: D"Rwft 0 P.O.Box 637 License Number mn Address N&M Reaft MA > 01864 / �/S '7r 9,- Expiration Date ic Agnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Dh-rva—'Roeft Company Name —X P.O.Box 637 Registration r Noah Reading,MA Address 01864 7VC/- Expiration Date Sjg'nature Telephone G) � r SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) w Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi2ftrinit. Signed affidavit Attached Yes....... No.......❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: `t- - ����(,�t-rdr.� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Y3Sd Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ; 1, r6y—l ( A� "•-a � 0141er/Authorized Agent of subject property Herq6y autho i I IA& POoEi At 6 to act on ti ehalf, 11 m ers relative to work uthorized by building permit application. /Stgnature of Own Date SECTION 7b OWNER/AUTHORIZED EN DECLARATION 1, as Owner/Authorized Agent of subject property Duval RMft Hereby declare that the statements and information on tINAMP� plication are true and accurate,to the best of my knowledge ~ and belief North Reading, 01864 r Print N a ZI Signat6e of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS 1ST2ND 3RD SPAN DEV ENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH '9 own of t. 4Andover No. ' - LA dover, Mass., CMICMEWICK V Ids RATED O'P�\ �C 7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ....... .............. ................................... Foundation ............................................................................. has permission to erect........................................ buildings on ... ... .......... ................................ Rough tobe occupied a ................. ........................................................................................................................................... Chimney provided that the person ac ing this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provis ns 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 UNLESS CONSTRUCUON S ELECTRICAL INSPECTOR A 7L/-'� Rough ............................................................. ... ...... ........................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR ,. Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner RE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. Q North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of ermit Applicant oZ Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NOTICE Z W NOTICE n F TO = TO a EMPLOYEES EMPLOYEES o,�M Sve The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston,Massachusetts 02111 617-727-4900 — http://www.mass.govldia As required by Massachusetts General Law,Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD CT 06183 ADDRESS OF INSURANCE COMPANY (7PUU8-73OK535-4-05) 02-17-05 TO 02-17-06 POLICY NUMBER EFFECTIVE DATES ARGEROS INS AGCY INC 360 MAIN STREET READING MA 01867 �-- NAME OF INSURANCE AGENT ADDRESS PHONE# M-- DUVAL, KENNETH P DBA 184 PARK STREET o� DUVAL ROOFING NORTH READING MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE _ MEDICAL TREATMENT ^� The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably — connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 012916 W201= TO BE POSTED BY EMPLOYER s - rhe Common weallh of Massach uselts Department of IndaMialAccidena '� � � � � 11/1/iPODIlIn+8311g�110ttS 600 Washington Street Boston,tress 02111 Worker's'Compensation Insurance Affidavit MY /yC) p 1 am a homeowner performing all work myself. [] 1 am a sole>rroprictor and have no one worklag in any capacity am C) I am act employer providing workers'compensation for my employees woddng an this lob. coinaftfly name- P.O.Box 637 addCUIDRMOM MA 01 allyge 0 lam a stile proprietor,general contractor,or homeowner(circle one)snd have hired the contractors lisied below who have the following workers'compensation polices: addrrsr. "n about fi, �ttulfRiln�- tttllirs e coingany name;_ adstcer�._ _ insurnnee ro. Failure to secure toverser as reliind underStenon 21A of MGL 312 as Ind to tine Itaposition of estminal peaaltio ofs,fine ap to 51.500.00 Ammar wit sirs'latpriioament as well a ti"peoshles to the fast of a My wORK ORDER end rfine of 52011.011 a day sphin me. 1 end"2ad lb2l a NO of mit snermtat meY be forwarded to the Office of loveul2>ttieits of the OL4 for toveraga verifiesdon. I do hereby crnify ha Pat-it and pena6les of pertusy that the lofornmtion provided ebowr it tree and carreex S:�nata i Print minae tine, Offal■1 ase only do set write in this one in be eamploted by d!y or town ofiltiar city ar rs+rn: 00011 ieetttt It nQailding Nparinical Q t6cc1:it Immetaiote response is required pueessitig Boas OSeteetsea s Otnre QHta th Detnrtment cvotaet Ftrtuo: phone B. ...dm rias VIAS ✓/G— . eow—omu e-" o��ac�ivaeha r BOARD OF BUILDIN REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 058443 Birthdate: 12/10/1966 Expires: 12/1012005 Tr.no: 10052 Restricted: 00 j KENNETH P DUVAL PO BOX 190/72 NORTH ST N READING, MA 01864 Administrator f { i � �� �om�mzrnu�sea/� a��,aaoaclucael�a Board of Building Regulations and Standards HOME IM?ROVEMENT CONTRACTOR Reg istr`ation: 109288 Expiration: 9/9/2006 Type: DBA DUVAL ROOFING, Kenneth Duval 72 NORTH ST _ N.READING,MA 01864 `` Administrator