HomeMy WebLinkAboutMiscellaneous - 479 SALEM STREET 4/30/2018 479 SALEM STREET ' ��
2101038.0-0009-0000.0 I
i
I
,'
4. i�----
NOR7p
TOWN OF NORTH ANDOVER
F p
PERMIT FOR WIRING
• oma+ `..i
This certifies that ......................................... .......
has permission to perform ...U .....................Pd'^g .
wiring in the building o'....vic"
C ��2 e ...................................................
at................ ....................................................P Mass.
Fee. . ...... Lie.No.. . ..!. !�...... EAL ltaspwmR
Check # ! L
10898
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: in accordance with the provisions of M.G.L.c.143,�,3L,the a
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed-
bn the prescribed form.After a permit application has been accepted by an Inspector of Wiresappointed pursuant to M.01c. 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 shallbe limited as to the time of ongoing construction.activity,and maybe deemed bythe Inspector of_W.ires abandoned-aad.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 state d on the.permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sectipns.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.
ltaale 8—Permit/Date Closed: S **Note:.Reapply for new perm'
10
❑Permit Extension Act—Permit ate Closed:
Commonwealth of Massachusetts Official Use 0
Department of Fire Services
Permit No. log
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C;AR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Ins ector o Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 't" V,
Owner or Tenant }^C/ 1 sc. 4e S Telephone No.
Owner's Address S'ep-�
Is this permit in conjunction with a buildipermit? ,/� es El No F] (Check Appropriate Box)
Purpose of Building P,t�,c W'r"4-rYu�� 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 ofthefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- El
o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total
g Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Dr Heating Appliances KW Security Systems:*
y 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
3 OTHER:
Attach additional detail if desired, or as required by the Inspector of WYres.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: J 9 Z 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 El OTHER ❑ (Specify:)
I certify,under the aim and penaltiesnofperju tat the information on this application is true and complete.
FIRM NAME: . �Sr '! f LIC.NO.:
Licensee: S' Signature LIC.NO.: /., -
(If applicable,enter "exempt"i the licen a umbe Zine.) us.Te�No.: cy
Address: ( �I.�e�i y It.Te �
*Per M.G.L c. 147,s.57-61,security work requ' es Department of Public Safety"S"Licen e: ic.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 P
ERMIT FEE. $
Signature Telephone No.
r
i
^ ... • ,�JJJ.1l•111..rA.711-..'VF•l�-�--�(j.!.,�JJ.�-1.�//J'-'R.�lr�yed..l*�,®py� p^�j � 3JJ.�'L�,IC.f,�.l'f Jl�l.r.l��� M
. ��sset�--, _ �'a3IeH•�j � �e-�speetzo�txet�udz'ecT(��O.OQ)�j �
Inspectors'Commexts: '
(Xuspectoxs' zgeatuze�uorifiaTs} date
•�.JG'7-�-1�-t A-1Y47�[rt+�.�C.lolY t I
j )
nsp actors'cfl7oltn eJxfs;
fts�actors'gzgnafare•-)to initials) Date '
�.'asset�•-j � �'ailec�-j � ?Ze-xns�eefiou,xec�uixet�(��D.UD)�j �
rns.vectors,comments.
Clnspec$oxs' ignafuxe� oniffal�s) date
assed [ +aile --j e-uspecfionxequixet ( OAD) j
Is,�ectbxs'eoJanmeptfs.
(Xxtspectoxs',�zguatuze�xzo nzfiaTs) Date
Ssed--j � �'aiier�--j �- '�te�nspectzottxer�uit'ec�($50.00)�[ �
PC)dwre eoxammts:
�lus�lactors', ignafuxe 74oinitials) Date '
aOR T'AAGN AM rXO EE EPILED Oi7TAM IEFT ONRUR N TM MA.TO3E.M.EffED IS NOT
�5
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UV. 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): fA441_t�r�
Address: / 8 C U,$ Vim- ,
City/State/Zip: "yt2 --re N� Phone#: C& os--
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-time).*
have hired the sub-contractors 6. El New construction
2. 1 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. 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. 1 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.❑Roof repairs
insurance required.]t employees. [No workers' 13.0 Other "
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f 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: -t�/Ut 0 e w 14L1v' .7y C; a44
Policy#or Self-ins.Lic. #:)� Jf, Expiration Date:
Job Site Address: �X 7q �'u�/�y`� City/State/Zip: kt)l �d �
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
firie 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.
1 do hereby certi nder the d nalties ofperjury that the information provided above is true and correct.
Signature: Z
Date:
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#:
1
1
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."
i
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
h,
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
a
Please be sure that the affidavit is complete and printed legibly. Thebepartment 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 5-26-05
www.mass.govldia
.. .. _ sal.. !•. _ ..'+n'�F t y .,
Date.... .-.6- '. .....
_ HOR711
TOWN OF NORTH ANDOVER
O
MOM
'� A
PERMIT FOR WIRING
��SS�cMusE�
I 5E- U�C f
This certifies that b.................................C
.. .............-s........
has permission to perform ........., ILI/Z....
S �
wiring in the building of..........t-l..........�.�. ............:........................................
at....... ..�..9...t5/.. .� .......................North Andover,Mass.
8
c 4 O
Fee... `. Lic.No�3`3 C ..l..2.5!.�...�............. ........
ELECTRICAL INSPECTOR
Check
7616
Official Use Only
`! Permit No. 7"` l 1
V Kra 2,,par&"n1 of5 ire SerVicsd
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: (�-01
City or Town of: /I) • ,,�776 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) 79T Cc-ic.e . St
Owner or Tenant L�hC4 &V,-1- Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: `�[yg � Q�1
i S LJ 5-ren
e:
Completion o thefollow'rn table m be waived by the!ns ector of Wires.
0.0 Total
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA
} No.of Luminaire Outlets No.of Hot Tubs Generators KVA
A ove n- o.o mergencyLig rng
No.of Luminaires Swimming Pool rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
-Fo—.of Detection an
No.of Switches No.of Gas Burners Initiation Devices
No.of Air Cond.
Total No.of Alerting Devices
No.of Ranges Tons
Heat ump """um_e_r o_n_s_ _ o.o e - ontarne
No.of Waste Disposers Totals: � - Detection/Alerting Devices
Municipal Other
No.of Dishwashers Space/Area Heating KW Local❑ Connection El
Heating Appliances KW Security Systems:*
No.of Dryers g pp No.of Devices or Equivalent
No.of Water KW o.of No.or Data Wiring:
Hta:crs Signs - Ballcsts No of Devices or Equivalent
e ecommunrcatrons rang:
No. Hydromassage Bathtubs ] No.of Motors Total HP No.of Devices or E uivalent
r Attach additional detail if desired,or as required by the Inspector of Wires.
t Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:)
I certify,under thepains andpenalties of perjury,that the information on this application is true and complete.)S3 3 C-
r U�C25 LIC.NO.:
-�[ is LIC.NO.:/-3 Z
Licensee: Signatur
(lfopplicab/e,enter "exempt"in the license number line.) Bus.Tel.No.:
Address: 0 L 1 IJ I-0) �- ��t5 , >vH o3o P AIL Tel.No.:
* Department of Public Safety`S"License. Lic.No. �S C 0
- security work requires D
Per M.G.L.c. 147 s.57 61,s ty q p . ,
OW INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
NER S
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: $ �-
f
f
• C�h9M�NVDEtiLTN'd�-i;�a;;5;4��-f���`;',;' •,•
s�6G?.S'-i,gin sY5-frrt T�t;NF�I►.:'1: � ..
a3t!uu TN:Y_:CC:wE'P- '
j` ARTHUR W FIERCE
1 UPHAM ST
SALEFJ MA 1;3 _''r5-• 2SI6 •(C-
i C2�+ U C7J 3 07 O i4 7 7 1
h d.�\ ///Y� 'i>V/Jitiln.ytIl?r!�(/�• fG•.'YilldM�fftL'E�.
DEPARtMENT OF PUBLIC SAF'-7Y
y� ? Llcorrae: SEC SYS CERT.CLEARANCE
k:
Number: SS CC 00051.7 is
>3lrrr.tletc; 0B130/19dR
�plre�; CB/�G/2008 Tr.no: 97.7
ReetrlcleH: 00
AP'i NUR Vli PIERCE
1 UDMANI ST
SALEM ham, 1719?0
Goron'osloner
Zd WdTT:98 LOOZ 20 'ter B89sbL B2-6 'ON X"dJ SOdS I d 188 W0a-
^•; -"' ,t ::.'�•'r.'S:i't i^ .:-nc - _ •sx.:•t�:1r`�' _- L _ �ti=`yet'`
t;
COMMONWEALTH OF MASSACHUSETTS
OF ELECTRICIANS
REGISTERED SYSTEM TECHNICIN
ISSUES THIS LICENSE TO
y ARTHUR W PIERCE
1 UPHAM ST
SALEM MA 01970-2516\ .
1024 D 07/31/10 320257
-
-t Y
' . .'. ... ..,_ _,_, • , K� VdIIL/71lYItI/lPOLI/L G(.(p ..
DEPARTMENT OF PUBt fu SAF-QTY. 1
Licenser SEC SYS CERT.CLEARANGF ,
Number: SS CC
0605,17
Number:
i rt h da te: 08/30/1945
Expires: 08/30/2008 Tr.no: 97.0 n
Restricted: 00
ARTHUR W PIERCE
1!UPHAM ST
o SALEM, MA 01970 �C. +•—
Commissioner
. _� .�
Date. ................................
v.
f NORT",
TOWN OF NORTH ANDOVER
FO A
PERMIT FOR WIRING
VSs^cHusE�
This certifies that ... .�::...... .. ...................................................
has permission to perform .... .. ?. .............. :.:... �..., 1.....
i
wiring in the building of......f................_ ..........................................................
at... ?.��... ......................................................... .North Andover,Mass.
Fee.... �,.. .... Lic. Z-0
z• /........................
G/ �.'LECTRICAL INSPECTOR
Check # I -I
4785
SIN_ Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
1909 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/991 (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: 10/8/03
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) 479 Salem St
Owner or Tenant Doug and Kristine Alexander Telephone No. 978-683-9330
Owner's Address Same
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Residential Utility Authorization No.
Existing Service 200 Amps 120/240 Volts Overhead® Undgrd❑ No.of Meters 1
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Hot Tub and 3 receptacles on rear deck
Con: let"on qfthefollowing table may be waived by the Ins eetor Of Wires.
No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Tota
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool bore ❑ In-grnd. rnd. EJo.o Batte UUnitsnits cy �g ng
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o. Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
No.of Waste Disposers eat Pump umber Tons_ ., o.oSelf-Contained
p Totals: .. Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local ❑ umciPal ❑ Other
p g Connection
No.of Dryers Heating Appliances KW TecuriNo Jofbe,vmes or Equivalent
No.of WaterKW o.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications irmg:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the li-
censee 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:) Providence Mutual 7/04
(Expiration Date)
Estimated Value of Electrical Work: 800.00 (When required by municipal policy.)
Work to Start: 10/8/03 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: John Willey Signatu LIC.NO.: 37827E
(If applicable,enter"exempt"in the license number line) Bus.Tel.No.: 978-808-8623
Address: 174 Winona St Peabody,MA 01960 Alt.Tel.No.: 978-535-1428
OWNER'S INSURANCE WAIVER: I ain 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 PER11�IT FEE. $ 80 °a
Signature Telephone No.
a Location q 5 e idr '
No. Date
~ORT TOWN OF NORTH ANDOVER
O
F R
9
i ; ; Certificate of Occupancy $
�'�s'•"°'E<�' Building/Frame Permit Fee $
s�CHus
Foundation Permit Fee $
Other Permit Fee $
r TOTAL $ 3 y
Check # a5
6636
Building Inspector `
r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
�."' -tea'for,Qt"ic` Se tl► I y777777
BUILDING PERMIT NUMBER. DATE ISSUED: q 3 M
SIGNATURE: Z"
Qll���
Building Commissioner/I t of Buildings Date
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
0
-�� Map Number Parcel Number
W
1.3 Zoning Information: 1.4 Property Dimensions:
-R--3
Zon
-
Zonin District Proposed Use Lot Area(sf) Frontage 11
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided R red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
Name(Print Address for Service:
6 g-� - F33ca
Signa re Telephone
2.2 Owner of Record:
e O
Name.Print Address for Service:
t
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
r`'d thaEL Wad )SOR
Licensed Construction Supervisor: �
License Number��
7s o K r w �u e: 'T9
Address �
h c _ r Ex,,riration ate
Signature Telephone
�* 97s 373
3.2 Registered Home Improvement Contractor Not Applicable ❑
MtM CA C rl I .
Company Name
Registration Number r
7.5—r_5 f' " )
Address _r
I
?-e 3 7 Expiration Date
Si nature Telephone �/
SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check au applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
141 CA A/ fit/
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFVJ AAL USE 0NLY1
f'�zk3 3 �y��
Completed b permit applicant ,
1. Building �! c� (a) Building Permit Fee
1� 5Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)x (b)
4 Mechanical HVAC J y1
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGE NT QR CONTRACTOR APP IES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
ereby authorize to act on
My behalf,in all matters relative to work authorized by this building permit application.
-Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I
h as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name '
Si attue of Owner/A ent Date
I
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIIVMERS 1ST RD
2 3
SPAN
DfMENSIONS OF SILLS
DINIENSIONS 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
i
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 Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
u The Commonwealth of Massachusetts
' Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
5Workers'Compensation Insurance Affidavit
Name Please Print
Name:
Location:
city Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers'compensation for my employees working on this job.
Com an name:
Address G�
Ci j^ _ Phone#7 1-
Insurance.Co. c5'' Poliot#
Company name:
Address
City: Phone#
Insurance Co. Policy#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.:fine up to$1,500.00
and/or one years'imprisonment_as_vias_ciw 4xmakms-oSboJomointa-STOP]iVDW-ORDER:and_aline-d-(sl w)-ajiayagainsf Alp 1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/do hereby certify under the pains and penalties ofperjury that the f iibr ratiarr provx*d above is true and comict
Signature Date
Print name pbme#
Official use only do not write in this area to be completed by city or town official'
City or Town ---- -- Permit/Licensinq
Building Dept
Check if immediate response is required 0 Licensing Board
p Selectman's Office
Contact person: Phone# n Health Department
Ei Other
. MORTGAGE INSPECTION
BAY STATE SURVEYING ASSOC JOB #
IAT
100 CUMMINGS CENTER, SUITE#316J, BEVERLYIMA., 01915
LOCATION ......A1�au .tR........I:�1�; NOTES:
1)This Is a mortgage inapeetiori survey and not an
SCALE : I"=40 DATE :.Q&.T..! �.,,,,,J, S; Innmortgagetrum° t inspection therefore this plot plan is for
purposes only.
2)This survey is based on survey marks of others.
REFERENCE : ,�„Q,j �(=•y�`�• 1p
.:• F . 3)Bushes,shrubs,fences and tree lines do not
. ......
.`��i�:,X•,ayf� .�j...}�� .�� \.�-�.. necessarily indicate property lines.
R , 1 �ti?:C..S�F.••Q�. m „ 4)Whenever an offset is 1-a.or less,an instrument
survey is recommended to determine property
lines,and any possible encroachments.
To:�}lP., ,.MHIIy,T�y,�l..l�R ,QQNw.IQ 6)offsets shown are approximate,and are to be
The location of the building(s)as shown;either used only for the determfnation of zoning,Not to
complied with the local zoning setbacks at the time of be
construction or is exempt from violation enforcement action 0)In mused
Professional lopinion the sh PropertyIbuilding(s)are not
under Mass.G.L Title VII chapter 40A Section T
located In the special flood hazard tone,as
defined by H.U.D.MAP# Z S'O 0 9 g 6-Z- 93
0
M
N f�
o�
do
0
N
LOT
2o't
"t i. s f j
S :...
'-N;
,,�
Z-new
V i
Z 00
-5A L N\ ' T
Y i
t "
p0
TT
4: . -
, #�
i s.z ,
i
6`s
Ty.-
� ..
S
���
"_
'� �,
kr
E _._. �
s �I i .,,fir' -
}
d
� i
�i
I'II
p
f 7
`� ��+ _.»�...,t,- Cir ,.:,r.-.`�...��_. ��,.
S� 1
I
h
1j
1
P IC tµ
1
� �
1 � - '� ���S _. _'aim xil!'.rsea9r. �C L� _ _
{F{
f
6 ,�
yS�
{
� n
G
� .�s�
� -
�..w.. �,
�.
�,`rJ
v
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is eased to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION
r
APPLICANr PHONE7f�
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT(S)
STREET-'2 Q /epsl 7 ST.NUMBER
l *********** ►***** '**�'**********'*OFFICIAL USE
REC MENDATIONS O TOWN AGENTS:
CONSERVATION ADMINIS ATOR DATE APPROVED_ ®Z3E�_
-
DATE REJECTED
COMMENTS LA I_ �► / e �/ —
Wt� DN
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
D INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE. REJECTED
COMMENTS
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9\97 jm
NORTH
E over
Town of
0
o �
[� dover Mass.
� cocriic wicTc ,
ORATED P'Pa\,` C5
S H �
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
f �1 BUILDING INSPECTOR
THIS CERTIFIES THAT...... o .. .........`' ...��n sS Ti. '�......./..le.�`!4..!'............e.! '
. . .. .....:.......................
p► Foundation
has permission to erect.....�SY�G ......... buildings on ......Y. ../ c� �-�4
............ ........ !....../..�................. n/ Rough
rei�J pr+c N e2 O� / roll ON 1?* a0 d 4
to be occupied as...c.5.�.................1 ......................................................... ............J...................................................:..lie �himney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating tot a Inspection, Alteration and Construction of
Buildings in the Town of North Andover. 8 /(�, e7(0 = PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
................. .......................................... ................................................. Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina,
ti No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE smoke Det.
I
l
vocation
Date
i
NORTH
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 4
1SSACMUSEt Foundation Permit Fee $
Other Permit Fee $ ------
Sewer Connection Fee $
TOTAL $ ,/
7,"V/
N0. Andover Coll 6 Building Inspector
Div. Public Works
Y .'
PER3flT NO.� � � r APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
MAP dHO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK PAGE
ZONE I SUB DIV. LOT NO. 7 —
LOCATION PURPOSE OF BUILDING
OWNER'S NAME of NO. OF STORIES SIZE
OWNER'S ADDRESS CT�iA_m,p BASEMENT OR SLAB –
ARCHITECT'S NAME JK_,,._G n SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME •�X U `_ SPAN --
DISTANCE TO NEAREST BUILDING •I (J� lf7l DIMENSIONS OF SILLS
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES—SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
gap
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNE -
IS BUILDING ALTERATION IS BUILDING ONS ID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING,96NNECTED TO TOWN WATER -
BOARD OF APPEALS ACTION. IF ANY - IS BUILDI CONNECTED TO TOWN SEWER
IS BU DING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST -
SEE BOTHSIDES -
EST. BLDG. COST
PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST PE SQ FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS I - 12 --
SEPTIC PERMIT NO.
14 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
^ PLANS MUST BE FILED AND APPROVED BY BUILD! STEGT6
DATE F E
BOARD OF HEALTH
SIGNAT R .OWNER OR HO IZ ENT -
OWNER TEL.# y s'y 2
F E.E 6 CONTR.TEL.#
() CONTR.LIC. PLANNING BOARD
PERMIT GRANTED
? � 19
BOARD OF SELECTMEN
do
:r► BUt iNG INBPECTOR
n
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMI STORIES
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF .BUILDINGS. 'WITH PO CHES. GA-
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CO TRUCTION
2 FOUNDATION INTERIOR FINISH
CONCRETE _ 3 1 12 13
CONCRETE BL K. 'YtlNIE
BRICK OR STONE HA�RDW D _
PIERS PLASTER,
_ DRY WA _
UNFIN.
3 BASEMENT
AREA FULL FIN. B M AREA
1/' '/2 Y: �'/. FIN. ATTIC AREA
�...,
NO BM FIRE PLACES
HEAD ROOM MODERN KITCHEN ��C
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE
WOOD SHINGLES EARTH _
ASPHALT SIDING HARD\✓'D
ASBESTOS SIDING COMMON _
VERT. SIDING MPH. TILE _
STUCCO ON MASONRY
STUCCO ON,FRAME
BRICK ON MASONRY ATTIC STRS. 8 FLOOR _
BRICK ON FRAME I -
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR I-I POOR
ADEQUATE NONE
5 ROOF 10 PLUMBING -
GABLE I HIP BATH (3 FIX.
GAMBREL MANSARD TOILET RM. (2 FIX.(
FLAT SHED WATER CLOSET
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBIN
TAR 8 GRAVEL STALL SHO ER
ROLL ROOFING MODERN IXTURES
TILE Fu60R
TILE 6ADO
6 FRAMING I 1 HEATING
WOOD JOIST fPIPELESS FURNACE
FORCED HOT AIR FURN. �.
TIMBER BMS. &COLS. f STEAM
STEEL BMS. & COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G -
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
B•M'T 2nd _ ELECTRIC
1st -1-3rd 11 NO HEATING Y
� w
1 �.
s
j
t
Suggested Affidavit for Home Improvement Contractor Permit Application y
For Office Use Only NAME OF CITY/TOWN
Permit No.
Date j
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c.142A requires that the"reconstruction,alteration,renovation,repair,modernization,convet;ion,inprovement,removal,demolition,
or construction of an addition to any preexisting owner-occupied building containing at least one but riot more than four dwelling units...or
to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other
requirements.
Tpe of Work: Z0�.. Ty-\Q,yft– izze_4 1Yn" Est. Cost 0001a
Address of Work
Owner Name: AV4
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law
_Job under $1,000
—Building not owner-occupied
_Owner pulling own permit
_Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL
c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
,,,
Date Contractor Name Registration No.
OR:
Notwithstanding the ab o otice, I her f_lfoa perm t as the owner e above property:
a--
Dat Owner e
ml
■ M■■■ ■■■■M■M■■■■■■■■OM■ ■■■■■■■■■ ■■■■■■■■■■■■ ■■ ■■■l
■ ■M■MM h■M■MM■■■MMM■■MM■ ■■■■■■■■■■■■■■■■■■■■■ a ■
mmm
■ ■■MMM ■■■■�■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ �.. �� , . J; ■
■ ■ _ ■■ ■■ ■■■ ■■■■ ■■■■■■■■■■■■■■■■ ■
■ ' ■ - ■M■■■E■■ —OEM
■ ■ ■■■■■ ■■■■■■■■■■■ ■
■ ° ° � - • o ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■
■ ■ Q aQ ■� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■
■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■
M ■
E ■ ■ ■M■MMMMM■■■M■■M■M■M■M■MMMMM■■■■MEMO■■■ ■
M■■ ■ ■■■■■■■■■■■■■■■■■■■■■MM■■■M■■■■■■■■■■■■■■■■■■■■■�
■■■ M■■MEM■MM■ ■
■MMM■M■MM■■MMM■MM■■ M■MM■■■■■■■■
■ ■ M■MM , SOMEONEO ■ ■■■■MMMM■■■MMM ■MOM■■■
momm ME
■ ■■M ■■■■■, ■■■■■■H■■
MIMMOMM WINE ►'�, - .. ■M■■■■MINE
■■ ■■ ■ ■ MEMO■ ■■
M■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■EME
■ ■■ ■■ ■■ M■■M■■■■■■ ■■M■■M■M■■MM■■MM■■■M■■■■■M
MINE PM IMMMMMMMMMMMMMMMI
MME■ ■ ■ ■■MMM■■■MMMMMMSM■■■M■MMMM■■M■M■M
■■■MME■ �dmmmm■■■■■■■■■■■■■ ■■■■ ■■ ■ ■■■ ■■ ■ ■■■ ■■■■■
■■MM s e - ": MM 0!!! . : o MEN
- ■ ■■ ■■ ■■
■ ■■■■■■M WE■ ■ ■■■ ■ ■O■■ O ■■ ■■ MM■
MIMMUMM
MMM■MMMMM■■MMMM
■MMM■■■■ OII ■■ ■■MM■M■■■■ ■■■■■■■■■O
MMM■MMM■■■■■■■■ ■M■M■M■■ OM■MM■MM■■ MMM■■■■MM■
MMMM■M■M ®I r —,�: 1�. MM■MM■MEM
MINE■M■M■M ate' �� MM■MM■M■M
MUMMOMMMOMMMOMMEMS
O■■ ■■■■ ■■O ■ ■OM■ ■■ ■ ■■■M■M■■■■■■M■■■■■ ■■■■M■■■E
MINE■ ■M■■ ■E■ MmmmmmmmMME MINE ■M■■M■■■■■■MMMM■■■■■■M ■■■■■■■■■
■MOM N ■M■MM■ ■■ ■■■■M■MMMM■■■MM■■M■ M■■■■MN ■
■■■■ ''` °° ■■■■■■ ■■ MM■■■■■■ M ■■■■■M■■■M ■■■■■■O■■
,� ■
MMM■MMME■ ■MMM■■■ ■■ ■■■■ENEO�■■■■■■■■■■ ■■■■■■■■
■■M■MM■■■ ■■■MMM ■■ ■■MM■■MM■M■M■■M■■MMM ■■M■■■ M■
■■MMM■■■M ■■■M■■ ■■ ■■NEO■■M■MINE■■■■■■■■ MOON= ■■
■■■■■N■■■ ■M=■■■ ■■■ ■■MM■MMM■■MM■■MM■M■E ■■■■■■ ■■
■■■■■■MIN■ ■■ ■■■ IN■■ ■■■■■■■ ■MERE■ ■■
■■■■MM■■■ ■■■■■ ■■■ M,MMMIN ■■■■■■ ■■
■E■■M■E■■ NONE ■E■ i4 �i ■■■NMMINM ■■■■■■■■Mt
■M■■■MO■ NONE ■ a 090 ■ �r MOOMOO■ �
■■ MMM■■ OOMOM■■■M■■■ �_bes�s ■ MOON■■■
MEM ,1a EO ■N■■■■No - ■■■NM■ ■ ■MM ■
■■M ME ■OO ;� ME■NEN ■■ �:a'�■■■
MEMEM■M■ MMMMMMMMMMMMNMMM■■■OO ■■ ■ — ■M■■■MMM■
M■MEM■MM MMM■■MMMMM■■■MMMMMMMESMMMMNNMMIMMEMMMMMMMMI SAI ■ ■■■. M■MMEM■MMUMMUM ■i
NONE
MOSIMMOMME No MEMEME 0
EINE■■MINE. .......■.0.............. � ■■■■■■■E. EINE■■..
MOON■.... ■MEM■MMMMM■■MMMM■■■MOO■■ M■MMM■M■ ME■■E■
■■■■I
......._. ..............■......... ....... ..
MM■EENN E ■ENEN■■■EE■NNE■EEENEEEEM ......,. ..... .E.
MEN■MONEE MOROSENESS
a■EM■E■EM■EMMOMMOME
o
■■■■■■■M■■ ■ ■■ ■ ■ ■ ■■■e■M■■■■M■■■■EM ■
■■■■M■M■■M ► .. gyp ■■ ® ■ ■IN■■■■■■■■MM■■■■
■■■Et■■EMM■ ■ ■ ■M■■■M■■■■M■■■■■M■■■■M
■