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Miscellaneous - 483 MASSACHUSETTS AVENUE 4/30/2018
483 MASSACHUSETTS AVENUE ((�� 210/045.G-0001-0000.0 r Date.......... .. ..... . ...... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUSEt This certifies that .............. .<. ........................... 12o has permission to perform ....................................................... wiring in the building of........ ..... . ................................. at....... .........MW ................ �- eE.............. /Njorth Andover,Mass. Fee.Y Lic. ,1T�n/R!. . ,,. BELE RICAL INSPECTOR Check # 8246 Commonwealth of Ylamac�ef Official Use Only 2.parto d of7lire Semicee Permit No. F Z 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 Code527 CMR 12.00 (PLEASE PRINT IN'INK OR TYPE LIN O TION) ?Date: Uc)� 6g City or Town of: p To the Inspecto f Wires: By this application the undersigned gives no ce of his or her iktention toperforin the electrical work described below. Location(Street&Number) YE2 ` ES Owner or Tenant 5- T6 v A 1700 Telephone No. - ✓3791-) Owner's Address 8T Is this permit in conjunction with a building rmV Yes V No ❑ (Check Appropriate Box) Purpose of Building S Ll't 1" Utility Authorization No. 67 Existing Service Amps / 1701ts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity l Location and Nature of Proposed Electrical Work: h �y Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal Trsformers RVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA AboveOrin- o.o Emergency Lighting grnNo.of Luminaires Swimming Pool d. rnd. El No. Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting in Devices No.of Waste Disposers eat Pump ._um er -`ons-__ o.oSelf-Contained Totals: - ` Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ municipal unicipa ❑ Other Connection Secure stems: No.of Dryers Heating Appliances KW Security S y No.of Devices or Equivalent No.of Water No.of No.of Heaters KW Si s Ballasts Data,Wiring: ofDevicesor Equivalent No.Hydromassage Bathtubs '>, No.of Motors Total HP Telecommunications Wn in No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of 1pectrical Work: -J- (When required by municipal policy.) Work to Start- Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee prow es proof of liability insurance including"complet operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhib' d proof of s o the e'.it iss mg office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHERrSpecify:) J `E %� I certify,under the pains an penalties of erjuy,t at thetionax1his application is true and completes FIRM NAME: V /¢ S' LIC.NO. 33 Licensee: 2 4,X J 'b4 Signature LIC.NO.: (If applicable, Ale lice a number line Bus.Tel.No. Address: lV � Alt.Tel.No.: I *Per M.G.L.c.147,s.57-61,security work a ire's 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ TOWN OF ANDOVER Commercial: Sewer Ejection Pump: $25.00 ELECTRICAL PERMIT FEEs a)including photovoltaic& Signs: $25.00 each ballast (Effective March 12,2003 generating Equip Per KVA $1.00 Smoke&Heat Detectors& ' 9 b)un-interruptible power systems, Initiating.Deviees: d0 per KVA$1.00 Residential:$1.00 each .; ;. c)batteries over 100 amp.hours,per Commercial: $60.00 up to 10 NO SE CABLE ON cell$1.00 devices over 10-$1.00 each OUTSIDE OF BUILDING Heat Devices: $1.00 each Space Heaters: Air Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each Hydro-Massage Bathtubs/Hot Sub-Panel:$25.00 Alarm Systems Security:(for fire 'I Tubs: $20.00 each Swimming Pools: systems see smoke/heat detectors) Lighting Fixtures $1.00 each Residential: Residential: $4e/ Commercial:up 0 10 Devices Lighting Outlets: $1.00 each Above Ground: $25.00 $60.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 $1.00 each $20 each Commercial Pool: $100.00 Carnival E ui menta $50.00 each Motors: (per hp or fractional part Switches: $1.00 each Ceiling Fans: $1.00 each thereof) $2.00 Temporary Service: Oil/Gas Burners: Must bave.Utility Authorization Number Commercial New Construction or Residential$20:00 each Residential$25.00 Alterations: Commercial$20.00 each Commercial $100.00 $100.00 per 1,000 Sq.Ft.of Office Furnishings:per circuit$10 Transformers: ;. Construction Space a capacitors,Per KVA $1.00 Commercial Service Change/ Blocs&F Partitions.00 e c h �ducts,conduit&conductors Repair: Outlets&Fixture: $1.00 each Ovens Built in/Counter To Units' (Associated w/Padmount Transformers)$25 Roust have Utility Authorization Number P c)each manhole$10.00 $100(first 100 amperes or fraction,one $10.00 each d)each handhold$5.00 meter) Panel Change/Circuit Breaker: e)per KVA$1.00 a) each additional 100 amperes Residential: $20.00 fl primary feeders,$25.00 each(over capacity or fraction.$30.00 Commercial: $25.00 600 volts,non-utility owned) b .each additional meter$25.00 Phone Jacks: See )vaults and equip. $25.00 each Commercial Temporary Service: data/telecommunications Washers: $15.00 each $100.00 Ranges$15.00 each Waste Disposals:$5.00 each Must have Utility Authorization Number Receptacle Outlets: $1.00 each Commercial Repair and/or Recessed Fixtures: $1.00 each Water Heaters:$30:00 each Maintenance Permit: (Blanket Re-inspection Fee: $25.00 Permit)up to 2 Electricians$150.00Repair to Service Resid *For Multi-Family& per air of Electricians over 2$50.00 $20.00 ential: Large Commercial Project Data/Telecommunication: Residential New Construction see Wiring Inspector for Residential: $1.00 per port (Dwelling): $220.00 Commercial: $30.00 up to 10 Must( hp amps have Utility Authorization Number � ( )with service u to 200 ) pricing: _devices over 10-$1.00 each Paul Kennedy 978 623-8306 Dishwashers &Disposals: for services over 200 ams see below (Office Hours 8 am to 10 am) $5.00 Each _ a)for each 100 amps capacity or Dryers: $15.00 Each fraction add$20.00 *Inspection Schedule: Emergency Lighting(Battery Units) b)each additional meter$10.00 1 ROUGH _$ 1.00 each unit c)each additional panel/sub panel Feeders or Sub-feeders: $25.00 I FINAL each 100 amp capacity of fractionResidential Additions/Alterations: I TRENCH (if applicable) thereof $220.00 maximum Residential: $5.00 each Residential Service Change or ADDITIONAL Commercial: $15.00 each Underground Service:� INSPECTIONS *$25.00(if Gas/Oil Burners: $40.00 applicable) Residential: $20.00 each Must have Utility Authorization Number Commercial$20.00 each a)one meter,up to 100 amp capacity $40.00 (revised 07/05) b)each additional 100 amp capacity or fraction$20.00 I* Location"0Q A-V No. /b Date C NORTIy TOWN OF NORTH ANDOVER � 9 x Certificate of Occupancy $ f, "us t�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # — 19347 Building Inspector TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXANIINATION 3?0a�S�•� ;6�tioL o Z. Permit ti0: � Date Received Datc Issued:k w—, �13,7ACH s���y IMPORTANT: applicant must complete all items on this page LOCATION 83 01 Ac #v c Print PROPERTY OWNER S"rxye4- 0' 4-GL/J-D/ Print !VIAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New BuildingOne family .- Addition - Two or more family - Industrial Alteration No. of units: Repair, replacement - Assessory Bldg Commercial Demolition El— Moving(relocation) Other J Others: '-. Foundation only DESCRIPTION OF WORK TO BE PREFORMED kCld/ 4 7— t2ao/zgyG 9// //V Identification Please Type or Print Clearly) OWNER: Name: s T/e,-l/ff— 12,4,a A-v lit/!} Phone: x --?q 5 ,— 9 p6 0 3 Al? 4-5 S VM Mig7-19 /i-tQ/0'rviol , Address: AlONTRACTOR Name: !�V /L. C(/� ✓l//�—� �/� S/G-l�/ Phone: ',5-9-08vol Address: Supervisor's Construction License: 0® 02 Exp. Date: 7 'a—ao IIon-tc Improv c►ncrrt License: -7 Exp. Dale: 7— -2. ^ O _ 1�ZC(-I 11 LC'T, ENGINEER Name: Phone: Address: Rcg. No. FEE SCHEDULE:BGLDLVG PER,V IT:510.00 PER$1200.00 OF THE TOTAL ESTIMATED COST BASED On 5125.00 PER S.F. Total Project Cost :$ i �O xl2.00--FEE:$ •� Check No.: /2( o Receipt No.:� i TYPE OF SEWERAGE DISPOSAL Swimming Pools _ Tanning.'Massage,,Body Art Public Sewer _ Tobacco Sales Food Packaging;'Sales Well — — _. Permanent Dumpster on Site _ Private(septic tank,etc. _ Electric ;deter location to project MOTE: Persons contracting with unregisterecl contractors do not have access to the guarana,./u1111 Signature of Agent/Owner v Signature of contractor Plans Submitted Plans Waived �_ � Certified Plot Plan Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE-REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION J iJ CON/IMENTS DATE REJECTED DATE APPROVED HEALTH j J CONINIENTS Zoning Board of Appeals: Variance. Petition No: Zoning Decision:receipt submitted yrs I'lannin�"Board Decision: Comments Conservation Decision: _Conmients \\ater�Q Sewer connection,Signature& Date Driveway Permit Temp Dumpster on site yes_noFire Department signature;date Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provide Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: N(YrES and D 1 rA—(For department use) LC`Ili \I.SI_P`:ICLS!il_PAk'I MLN 1':I','I l il•:.`.1.i> i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract j Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application .:j Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report In all cases if a variance P ors special permit was required the Town Clerks office must stamp the decision from the P Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:iVAIA rrouAL SERV WEN DEVAR FNIEv r:m,roRwws The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 www.nrass.gov/dia Workers' Compensation lusurance Affidavit: Builders/Contractors/Electricians/Plulontbers Applicant Information Please Print LeyIibly Name (Business/Organization/Individual): /Y P U-S Address: 6 Z LL S T City/State/Zip: V SJR . 01697 Phone #: �J 79• Are you an employer? Check the appropriate box: Type of project(required): 1..[r 1 am a employer with 4. ❑ 1 ,3m a general contractor and I 6. ❑ New construction art-time) ern to ees full and/or .* have hired the sub-contractors f p y ( p listed on the attached sheet # 7. El Remodeling 2. ❑ I am a sole proprietor or partner- . ship and have no employees These sub contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition o workers' comp insurance 5. ❑ We are a corporation and its officers have.exercised their 10.❑ Electrical repairs or additions required.] Plumbingrep airs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL I L❑ myself. [No workers'.comp. c. i52, §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#I must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check:this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Y an: an employer that is providing roorkers'.contpensation insurance for my employees. Below is the.policy and job site information_ _ Insurance Company Name: (> O� Expiration Policy#or Self-ins- Lic. #: � ` � ����xJ g� Date: Job Site Address: y d 3 � S City/State/Zi4 AIV a ytC.-p: �, 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 he,violator:-Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.fdr insuzance coverg verification. X do hereby certifiv under the pains and penalties of perjury that the information provided above is true and correct i - e: S afar Date: , Phone#: �7 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#: J 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 legalentity, 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)uame(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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required..Re 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 you;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.gov/dia l -�e Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 102467 Type: Private Corporation Expiration: 7/2/2008 NEW ENGLAND CUSTOM DESIGN, INC. — Val Lanza 226 LOW ELL ST. WILMINGTON, MA 01887 Update Address and return card.Mark reason for change. Address E] Renewal Employment ❑ Lost Card 'S-CA1 is 5OM-05/06-PC8490 BOARD OF BUILDING REGULATIONS + t License: CONSTRUCTION SUPERVISOR ! Number:.tS 008828 Pirthdate 04/20/1.951 Expires 04/20/2008 Tr.no: 21457 VALJ LANZA 34 BIXBY ST `.,; �i REVERE, MA 02151 Commissioner i I NORTiy Town o0f R0 " '1 ' . Andover No 110 -107 0 = d®ver, Mass., h: • ` J% e- o LA �. COCHICHEWICK ADRATED 1 S E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 9A (41a BUILDING INSPECTOR THISCERTIFIES THAT............. .. .............................................................................................. Foundation has permission to erect.................................... buildings on ......&(P.$.......�1.�l........1�4.��..................... Rough to be occupied as 6tq.............. t. {�4L...r�.�. Chimney provided that the person accepting this per shall in every respect confor the terms of the application on file in Final 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 le-r— PERMIT EXPIRES IN b MONTHS UNLESS p�� � T � y� ELECTRICAL INSPECTOR V 1 V LESS CONSTR V C � � Tl1C -TS_ Rough .......... .... ..... ..........44w�jiService SPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. '.'his is a legally binding contract. Make sure yi;u i ead this Agreement and understand it bef:to signing it. Do not sign this contract f there are any blank spaces. IOTICE: All home improvement contractors and subcontractors, unless specifically exemp!ad by Massacl:::.setts Law, must be registered with the Commonwealth of Massachusetts. All inquiries about registr }ion should b directed to: D'RECTOR-HC_:ZE IMPROVEMENT CONTRACTOR REGIS ,,..,_TION One Ashburton Place,Room 1301 Boston, Massachusetts 02108 Telephone:#617 727-8598 his Agreement is made on 20 ( �i y by and between Nzt2ngland Custa,:n Design, Inc. (herinafter, ontractor") and owner ye /t , _ hereinafter, "Owner"), of _. /� �t/G ity / Town 4)o /-•7"�i ,4.�'L4 �r1�/�'r State lam` Zip __3 HPhone_ °.7�' )b Address ("The Premises") ' � tl-e LWPhone ew England Custom Design, Inc. Salesperson _ ? c';'« Roofing will be applied only on slope roof surfaces below,over present roofing shingles unless specified under REMARKS. wa z MATERIAL, 67.',j.G... .!79.7 ? . .(/y.C........ J.0... .. .. Color O u Main Roof......!e-4.............Bay Windpws...,1V4� /.E......Extensions....��"./�/:F............................. a O ............................................. v� O Porches: Front........ ..E'5...... Side........... . 5... . . . . . Rear.. .........�ttdl.'1..�.............. Other Ro;fs ... .�%?............ NOTE:Roof board e lacement Cost �4' P rS�per foot OR �f. per 4 x 8'sheet of inch CDX Plywood. :EMARKS / EXTRAS: Missing.or defective l,;nber is not included in any category of we:,k unless specified under-RE-Nr KKs. e....:.'..:r.. ...'�`.... 4'x.... 7 v?^/. 'Z c•/y. �...... <.... r'��.,b....tt1�.�.1.::?�e!..�i.1/..v.!J.:f'. •.... .u.S.l�.1..�.... X'%,!: ...1.F.+�._1.�.....7d:.. \ J �7 +sadk:...) !Cff�.... .x!.`f.J..I ...ah�I:�� .r...../ 1....... .��.... ?'YJ '!.5 ....✓.mss!.. , e... 0< !¢x/. `........................ e' .....:t.7.e :..... .......55U.'ax..12 : ...........................�...... If....... ...c .... C.lYf/ lrt/1c �'i l�....�.r...�.......'�,J! .c./ � - �... .....-..... .. ,... .. ............................... ...............................................................:........................................... .. . ................................................................................................................ The Contractor agrees to perform in a god and workmanlike manner all work detailed above. CASHPRICE $........ ... Lp:....................•........ NOTE: All Roofing Customers DOWNPAYMENT $........... New England Custom Design,Inc.will not be held PAYABLE ON START OF WORK $...... P responsible for dust and debris falling in attic area ................................. PAYABLE ONCOMPLETION $.......3.2.9 ' during roof installation. Please remove or cover valuables. DATE:............. ... ...............................................................20 C94r........ RIGHT TO CANCEL he Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of the Contractor,which may be his nain office or branch thereof,provided that the Owner notifies the Contractor in writing at his main-office or branch by ordinary mail posted, ty telegram sent or by delivery,not later than midnight of the third business day following the signing of this Agreement. See attached Notice if Cancellation. A cancellation fee representing 30%of the contract price will be in effect if cancellation is requested after the legally allotted ime has elapsed. -he Owner hereby certifies that he has read this Agreement,that the terms and conditions and the meaning thereof have been explained to him, nd that he fully understands them and that there is no understanding between the parties,verbal or otherwise,than that which is contained in %his Agreement,and agrees that the said Contractor is not responsible nor bound by any representations not contained in this Agreement,made ty any of its agents,unless the same be reduced to writing and signed by the Contractor. �TTENT ON HOMEOWN R: DO NOT SIGN THIS CONTRACT—IF T ERE A ANY BLANK SPACES. It'� � ;11 tr1 )wner's Signature Da (ew England Custom Design, c. Date )wner's Signature datet Location •` ,y� No. Date NpRTIy TOWN OF NORTH ANDOVER Oi �•u .•,1•C f � Certificate of Occupancy $ r �'7S�•no•W. Building/Frame Permit Fee $ s•►c Nus Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # c�U 17978 �� `Builaing Inspectov TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .r 4 r^-�a��-rT*^` - ' _ .....'. pF '�""�a7� oh�ll�i7.�4,` �: � 'fi $k�,;�� ott � ` C & �• f o, BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/1for of Buildings Date SECTION i-SITE INFORMATION z 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O ©SFS O O v /yo,<-� a�)yl/�6V/Yt n Map Number Parcel Number 1.3 Zoning Information: 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 Rapired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT 2.1 Owner of Record Name(Print) Address for Service Signature Telephone 1 2.2 Owner of Record: Name Print Address for Service: o Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0� o ,rte >-' �/16G jr S% �T' License Number Mn Ad rens. \1 J Expiration Date Signature Telephone ic 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number r Address _r Expiration Date ^z Signature Telephone !1/ t SECTION 4-WORKERS COMPENSATION(XG.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 all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify t A ,v,' Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL (ISI;+ ffNLY' 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 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 57—VE T,9-L1,4PbV'0 as Owner/Authorized Agent of subject property Hereby authorize . W Gk1rr-1J1 to act on �1� O My behalf, 11 matters lative to ork authorized by this building permit application ' Si nature of Owmer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I> P/ )/h aser/Authorized Agent of subject g .l property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print m / Signature of Owner/A crit Date InNO. OF STORIES SIZE BASEMENT OR SLAB �,k SIZE OF FLOOR TEVIBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Z u u F' Department of Industrial Accidents Office of Investigations ,w Boston, Mass. 02911 50 Workers'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 FJI am an employer providing workers' compensation for rry employees working on this job. Company name. Address City Phone# Insurance:Co. Policv# Company name: Address 6-b Phone#- 0 0 0 Insurance Co. U �7�°�'A�- G� � Policy# /nes'7o Z Failure to secure coverage as required under Section 25A or MGL 152,can lead to the imposition of criminal penalties af.a fine up to$1.500:00 and/or one gears'irriprisonment_as cepe as -daMI)P.AORK9RDER_ d_afine cfIAIJO0.OD)-ajdaY me: F understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage veriricalion. M1 I do hereby the pains ofpegwy that the information provided above is true and correct r Signature / ` pate' 2 O� � S Print name Phoma.# Lt/O o� Official use only do not write in this area to be completed by city or town official' City or Town Eurnit Licensing !] a QCheck if immediate Building Dept response is required l] Licensing'Board p Selectman's Office Contact person: Phone# Health Department Other I I i Official Use Only Permit No. aent"`e°`r°�due Sa�et�y Occupancy&Fee Checked ' BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 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 To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number Owner or Tenant 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 Voits Overhead ❑ Undgmd ❑ No.of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool gmd ❑ grnd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners" FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di sal No. Pumps Tons KW. No.of Sounding Devices . No./of Seif Contained No.of Dishwashers Sp ace/Area Healing KW Detection/Sounding Devices ❑ Municipal ❑ Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Sion Bailases Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws 1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC.NO. Licensee Signature LIC.NO. Bus.Tel No. Address Alt Tel.No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ (Signature of Owner or Agent) 0�e tpomnmzo�tu�ea�� a� ac�zuGe 6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Numbef_C$ 082039 Birthdate: 12/30/1977 Expires;12/30/2005 Tr.no: 82039 Rest6cted::M.::' DANA M GRIFFIN_ ! 28 HIGGINS ST APT4- ALLSTON, MA 02134: Administrator 00-35.000 d enclosed space (MGL C.112 S.601.) 1A-Masonry only 1 G-1&2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DIG SAFE CALL CENTER: (888)3447233 NATIONAL GRANGE MUTUAL INSURED INSURANCE COMPANY 55 West Street, Keene;NH 03431 Telephone: 1-888-646-7736 CONTRACTORS POLICY DECLARATIONS Named Insured and Mailing Address DANIEL T GRIFFIN DBA Policy Number: MPS70532 MASTER SERVICES Account Number: CACK73458 411 NUTTING ROAD JAFFREY, NH 03452 Agent: COURNOYER-HILL INS AGENCY -INC Producer Code: 280677 AGENT PHONE : 603-532-4131 POLICYHOLDER INFORMATION Named Insureds Business: CARPENTRY RESIDENTIAL Entity: INDIVIDUAL Policy Term: 12 Effective: 03/02/04 (12:01 A.M. Standard Time at the address Expiration: 03/02/05 of the Named Insured stated above) In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. See the attached schedules for Description of Premises, Property Coverage, Optional Coverages, Forms and Endorsements applying to this policy and Mortgagee Schedule if applicable. BUSINESSOWNERS LIABILITY COVERAGE LIMITS OF INSURANCE Liability & Medical Expenses - each occurrence S 500 ,000 Personal and Advertising Injury Limit $ 500 , 000 Products-Completed Operations Aggregate Limit S 1100,01000 General-Aggregate Limit__, 0 0 0 ,0 0 0 Fire Legal"Liability- any one fire or explosion S 500 , 000 Medical Expense Limit- per person $ 10 , 000 Business Liability and Medical Expense: Except for Fire Legal Liability, each paid claim for the above cover- ages reduces the amount of insurance we provide during the applicable annual period. Please refer to section DA. of the Businessowners Liability Coverage Form. For policies subject to premium audit: Annual Audit Applies. Estimated Annual Premium: S 528 TOTAL PREMIUM AND CHARGES $ 528 Countersigned: By_ (� 1_\ 64-5470(9/00) 12/22/03 RENEWAL MC _. I A 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) i Signatu a of Permit Applicant f�2S�`U5 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the office of the Building Inspector Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............................................................................................. has permission to perform ......... fiakc-A4 ................ ..............I............................ 71ring:in the building of.............. ............................ ........... at......... .............. ................ .............. North Andover,Mass. Fee..................... Lic.No. -5- 3 .. ............. ELECTRICAL Check # 5566 COAM0ArREALTHOl+'A5SACHUSE7TS Office Use only DEPAIZr7WEU0FPUBLICS4MY Permit No. BOARDOFFREPREVEMON_ REGULAHONS527CMR12.V Occupancy&Fees Checked APPLICATTONFOR PERNRT TOIPERFORMELE=CAL WORT ALL WORK TO BE PERFORMED IN ACCORDANCE W Vrk MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 3L Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electricalescribed below. Location(Street&Number) 0 3 Owner or Tenant Owner's Address cJ A)" Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box) Purpose of Building S���, �{ Utility Authorization No. Existing Service Amps / Volts Overhead Underground No.of Meters New Service Amps� Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 1J I ne T ,S✓ h .02o I$v No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures I Swimming Pool Above Below Generators KVA round ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons I _ No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW N9.of Sounding Devices No:of Self Contained Deiection/Sounding Devices No.of Dryers Heating Devices. KW Local . Municipal Other Connections No.of Water,deaters KW No.of No.of a Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP THER• �nanceCovaage Pt>r�a>anttotbetequiof� Ws aveaointaIlabEtyh>armwAblicyinchxkqgCompl2 GDNc ageoritssubstanfialecNivalent YF5 NO avesubmitledvalidploofof totbe0l�YES FyoubawcliedodYFS,ptmkidicaiethe ofoovaageby wig the ��„a SURANCE BOND r7 OrIHER M (P1easBSpacify) J !J EMmaled Value ofFlecUical Wotk$ xktoS A h>SpectimDateRequested Rough Final red urderMPeralliescfpejtuy. 'MNAME v✓ '� � Z G C LcffwNo. V�3? see Zbp SignahuE LicmseNo t / Business Tel No. Alt Tel No. 'NER'SINSURANCEWAIVER Iama datheli=sedoesnothavetheinstuanxcc)vaageoritsai)stmtalegtuvalentasmquaudbyMassachusksCxl�Lam that my signalule on this pennit application waives this u :ase check one) Owner ® Agent Telephone No. PERNUT FEE$ Signature 5T Owner—or Agent i u w The Commonwealth of Massachusetts r . ; d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation insurance Afdavit Name Please Print Name: `, t Location: City Phone # I am a homeowner performing all work myself. s 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. Company name: Address City: Phone#: Insurance Co. Policv# Company name: Address .� Ilk City: Phone#: 1 Insurance Co. Policv# Failure to secure coverage as required.under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment-as-well-as_civil,penaltiesinlhefnrmnfa..S?OP.WORKORDFR..and_afine-of.($1DO..OD)_a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify under the pains and penalties of perjury that the infonnation provided above is true and correct. Signature Date Print name P.hone.# Official use only do not write in tHis area to be completed by city or town official' � City or Town Permit/Licensing _ Building Dept ❑Check if immediate9response is required Licensing Board Selectman's Office +. Contact person: - �'. Phone'#, ii Health.Department� Other i TRE COMMOATREALTHOFMASSACHUSETTS Office Use only DEPARTAfl 0FPUX1CSAFMY Permit No. J~�� BOARDOFFMPREVBMONRWULAHONS527CMRI2.VO Occupancy&Fees Checked 0 APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WO 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 / O7 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) C t ; Sv Owner or Tenant Owner's Address I S/! -1 . Is this permit in conjunction with a building permit: Yes No [ET (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps I Volts Overhead Underground No. of Meters New Service Amps olts Overhead Underground No.of Meters ders and Ampacity ature of Proposed Electrical Work W I fte -R) ,CW utlets No.of Hot Tubs No.of Transformers Total KVA fixturesSwimming Pool Above Below Generators KVA round ground F1 i e Outlets No.of Oil Burners No.of Emergency Lighting Battery Units tlets O No.of Gas Burners No.of Air Cond. Total FIRE ALARMS No.of Zones n] es No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices '�'���' hers Space Area Heating KW Nq.of Sounding Devices Noyof Self Contained ��.�.� Deti cWon/Sounding Devices Heating Devices. KW Local MJ Municipal Other Connections Jeaters KW No.of No.of Signs Mlasis sage Tubs No.of Motors Total HP PtusuvxrotheregtlaerrraltsofMassxtrusc4ts ws hisuru>�Pblicyirlch�dargComplete_OE94disCo veragecrilssubslan0a ffM alat YES NO validproofo totheOffim YES IfyouhaNeched®dYES,pleaseindicaielhe ofoDvaageby tangthe �� JRANCE BOND � OTEM (Please Specify) J y! � 16r EstaiWl Vahle ofElectiical Wodc$ ctoStart hTccti nDaeRecpestcd Rough Feral d underTr Penalties Of peliulY:- 7,.--'b4 1I NAME ✓ d � (C /`6 C /f �/ Iic�No. 32e SL Signattue LianseNo BusirmTeiNo. �'J�-`ej-Te7 Alt Tel.No. ER'SINSURANCEWAMi;I I am awarldiatdrLicmsedoesnothavetheinstuarlcecovetageorilssubstanbalegurvalentasreWredbyMassachusetlsGme dLaws t mysi9mmon thispennitappfiration waives this mgaffemEnt >e check one) Owner ® Agent Telephone No. PERMIT FEES Signature ot Uwner or gen o � � N° 261 9 Date......... U r10R71� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 41 �SStCHU ZI f This certifies that ..............................................`.... .............................C:...... has permission to perform ...h.' �c����f........1�.�.Mv`�.......................... i9 wiring in the building of................................................................................... at....... ........ X5.5....:-.:Q:J.e::... ............. .Nord AndoverWMagi- Fee.7 d:..�J... Lic.No�.S�J , EL RICAL INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Official Use Only Permit No. ' low oLJcr�cu lmc•nl a�_ti,r_,lvricc•.t Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev' 11199) tleaveblankl APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CMR 112.(X) (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: (3�'a a� W City or Town of: \\J. ��r\c�Due. To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below, Location(Street&Number) L,55 %( ', Owner or Tenant \ \w O Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes r No ( (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead[ ] Undgrd❑ No.of Meters New Service Amps Volts Overhead I:--� Undgrd❑ No.of Meters Numkr of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following ruble may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp. (Paddle)Fans Total of Trraa nss fformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA Na of Lighting Fixtures Swimming pool Above In No.o Emergency Lighting g g g grid. gmd. ❑ Battery Units No.of Receptacle Outlets No:of Oil Burners FIRE ALARMS No.of Zones No:of Switches"`' ` ''' No.'of Gas Burners' �. No,o Detection and Initiating Devices No.of Ranges Total g No.of Air Cond. Tons No.of Alerting Devices No. Heat Pump Number __Tga�_ __ KW No.No.of Self-Contained of Waste Disposers Totals: Detection/Alerting Devices No.of Dishwashers S a e/Area Heatin Municipal p g � KW Local❑ Connection Other Securityystems: N+b.of Dryers Heating Appliances KW No. f Devices or Equivalent No.of Water No.of No.of Data Wiring Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP 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 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:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expir- .ation Date) Work to Start:-.---- - ----- - - -inspections to be requested-in accordance-with MEC Rule 10,and upon completion. /certify,"under ili'e pains and penalties of penury tharthe"injnrniation on this application is true and complete. R."Collins Electric ' Inc. FIRM NAME LIC.NO.: R ' onald Collins _ rr Licensee: Signatu (If applicable•enter'exempt'in the license number line.) Bus.Tel.No.: 7 R 1—2 4 5-6 5 9 9 Address: P.O. Box 294 Wakefield, MA 01880 Alt.Tel.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 agerr[ Owner/Agent Signature Telephone No PFR.AfIT FFF• R9Q, �6 Location I-fP? 72. No. 4�� Date HQRT1y TOWN OF NORTH ANDOVER F 9 ' Certificate of Occupancy $ ��'�s'••• Est' Building/Frame Permit Fee $ A � s�cHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 14150 �'--Building In5p'ector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: icU SIGNATURE: Building Commisiioner/InEL=tor of Buildings Date z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O Map Number Parcel Number 1.3 Zoning Information: 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 Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of R rd Name rin) - Address for Service: Signature Telephone 2.2 Owner of Record: I Name Print Address for Service: O rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: ®� O License Number Address Z/— � Expiration Date �ature Telephone 3.2 Registered /ome Improveme Contractor Not Applicable ❑ v Company Name M Registration Number r r Address Expiration Date /1 nature Telephone YI SECTION 4-WORKERS COMPENSATION(KG.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 all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ,❑ Demolition ❑ Other ❑ Specify Brief Description of Proop^oseed,Work: SECTION,6-ESTIMATED GONSTRUETIONwCOSTS* - - Item Estimated Cost(Dollar)to be t4FICTAL USE,QNLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee(8)X (b) 4 Mechanical HVAC 5 Fire Protection ` 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, letze /T li�t� as Owner/Authorized Agent of subject property Hereby authorize !C- 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, ��' ��r� S 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 a of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORT#1 o of over No. " / 24 -_ o over, Mass. -:h* COCMICMEWICK V ORATED OPat-`y S H ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System It 4 BUILDING INSPECTOR THISCERTIFIES THAT. .................. .............................................................................................. ............................... Foundation 3oil, has permission to erec buildings on . ............................................ Rough t0 be OCCUpled aS Chimney .... ........................................................................................... 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 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 PERMIT EXPIRES IN 6 MONTHS Final ` UNLESS CONSTRUCTION STAR S ELECTRICAL INSPECTOR Rough ............................................................Y..... ........................................... Service B LDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathingor D Wall To Be Done Until Inspected and roved b the Building Inspector. FIRE DEPARTMENT p pp y 9 p Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phone aam a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity fTJ<am an employer providing workers' compensation for my e'mp ,yees working on this job. Company name: Address J S Ci G /� /� Phone#: 441, cre"," 0�1(1� Insurance Co. Policy# '71 9l.)C-->c7761 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 a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the forth of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cer*under the at ns a d penalties of perjury at th ' formation provided above is true and correct. Signature Date .41 �0 Printname Phone# �7 Official use only do not write in this area to be co pleted by city.or town official' Building Dept ❑Check if immediate response is required Building Dept p Licensing Board p Selectman's Office Contact person. - Phone A Health Department Other FORM WORKMAN'S COMPENSATION i lq44 . I. .41t�. 3 ii 'I a HOME TiMPROVEMENT CONTRACTOR RPgiStrat _ ion 106478 TYPI - PRIVATE CORPORATION Expiration 07128100 SILVERIO CONSTRUCTION CO. IN -If& John L. Silverio . IDDLESEX AVE_ SUITE # .l'9 ADMINISTRATOR WILMINGTON MA Oi887 1 + -- ;/rie"(�orrrirraa'�r� o��ivGaaaactiubP,�b 4 , BOARD OF BUILDING REGULATIONS License CONSTRUCTION SUPERVISOR Number CS 005387 i Birthdate s04108�11947 i @ , Tr.no: 20750 Restricted Tp 00 < I JOHNI SiLVm6 30 EN08;CIR READINO, 'MA 01867 Administrator 8 I I PER4lT oZi6 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. V/ PAGE 1 MAP i-402V LOT NO. OQ� 2 RECORD OF OWNERSHIP IDATE BOOK PAGE ZONE '7 SUB DIV. LOT NO. FI : LOCATION �� PURPOSE OF BUILDING OWNER'S NAME J ^ �%y�� NO. OF STORIES ' SIZE OWNER'S ADD ES f/A w(••(•[mac/ BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME ' SPAN -- DISTANCE TO NEAREST OUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION _ SEE BOTH SIDES LAND COST �4 Q EST. BLDG. COST C P6,2e .= PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 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 BUILDING INSPECTOR DATE L D BUILDING INSPECTOR SIGNATURE OF OWNER 9 AUTHORIZED AG F E E 12.ig OWNER TEL.# PERMIT GRANTE i-_ CONTR.TEL # i�,23 19 - CONTR.LIC.# �Z �" H.I.C.# CJ BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILYsiouIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA. APARTMENTS I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BIL K. PINE _ BRICK OR STONE RDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 1/1 1/3 % FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDI!J'D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MAS NRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. &COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS A01 B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING 14ORTjy TO" Of . _ Andover L No. 126 � m * i _ dover, Mass., 19 �� s ,� AJr 9A.000HICME WICK`yY 1` TE6 P, BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... .. ' .... ......../'400 .. . ... .... ......... Foundation has permission to e'eet.. . .................. buildings on .............. .. ........ ........... ... .. .....�...... r.... Rough tobe occupied as........................ .... ... •. ........................................................................................ Chimney provided that the person accepting this it shall in every ect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws re ating 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 Be%I�NVIPKSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Location 7 t�3 A SS A No. S� I Date / MaRTM TOWN OF NORTH ANDOVER 3? i. • "OOL F ,� 9 # Certificate of Occupancy $ � acMust� Building/Frame Permit Fee $ 6 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �_ 16437 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. Qo/ DATE ISSUED: SIGNATURE: Building Commissioner/1for of Buildings Date Z SECTION 1-SITE INFORMATION' Q 1.1 Property Address: 1.2 Assessors Map and Parcel Number: -183 /*YK5. , y F- •�� — Q-,��v� Map Number Parcel Number 1.3 Zoning Information'. 1.4 Property Dimensions: V ' Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required 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 (� i �\ 57-EYE a-/ 141-) E&/ ;PAzM Jy► > .4?3 Name(Print) Address for Service: 9 79- - 3990 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 1. 5 Qe2.0 3 9 O 28 14/66-M--5 -57-• AP7-1 hL 5737),MI} G -/3y License Number mn ess OZ ` 30_ OS r 617 - Expiration Date Signature 11 Telephone j 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number r Address Expiration Date ^z Signature Telephone P1 A + 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.......0 No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building X Repair(s) Alterations(s) X Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 23,9-/W # / RE-)DI (SE F4AM,31,V4 4-645CM1644_ /=1X7VRF=S /A/ C-k/sT7W;5- 4 064 77 4415 , A►214) 5 b0< ,7'ALu , ViNf�� �'.1X�2i�6 6fR AGE 34-IY #2 lREP44c6 f�M8/NG ,F E46:�R/CALL 254(72AES -A-bb SftIVF-� nrEw 5#J5rM.0 cX P341N i ✓IAIYL FGdaei�/G SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL>GTSE ONi,'Y Completed by permit applicant 1. Building �S (a) Building Permit Fee r� Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby 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, 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIhv1BERS 1ST 2ND 3RD r SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DiMENSIONS OF GIRDERS IIEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BU11,13ING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE '(DNATIONAL GRANGE MUTUAL INSURED INSURANCE COMPANY 55 West Street, Keene, NH 03431 Telephone: 1-888-646-7736 CONTRACTORS POLICY DECLARATIONS Named Insured and Mailing Address DANIEL T GRIFFIN DBA Policy Number: MPS70532 MASTER SERVICES Account Number: CACK73458 411 NUTTING ROAD JAFFREY, NH 03452 Agent: COURNOYER-HILL INS AGENCY INC Producer Code: 280677 AGENT PHONE : 603-532-4131 POLICYHOLDER INFORMATION Named Insureds Business: CARPENTRY RESIDENTIAL Entity: INDIVIDUAL Policy Term: 12 Effective: 03/02/03 (12:01 A.M. Standard Time at the address Expiration: 03/02/04 of the Named Insured stated above) In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. See the attached schedules for Description of Premises, Property Coverage, Optional Coverages, Forms and Endorsements applying to this policy and Mortgagee Schedule if applicable. BUSINESSOWNERS LIABILITY COVERAGE LIMITS OF INSURANCE Liability &Medical Expenses - each occurrence S 500 , 000 Personal and Advertising Injury Limit 5 500 , 000 Products-Completed Operations Aggregate Limit 5 11000 , 000 General Aggregate Limit S 11000 , 000 Fire Legal Liability - any one fire or explosion $ 500 , 000 Medical Expense Limit - per person $ 10 , 000 Business Liability and Medical Expense: Except for Fire Legal Liability, each paid claim for the above cover- ages reduces the amount of insurance we provide during the applicable annual period. Please refer to section DA. of the Businessowners Liability Coverage Form. For policies.,subject to premium audit: Annual Audit Applies. Estimated Annual Premium: S 469 TOTAL PREMIUM AND CHARGES $ 469 Countersigned: By: 64-5470 (9100) 03/13/03 NEW BUSINESS BM . ✓/ze-Pomrmzauuea� a�✓�aa�ar/uraelta BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number:.CS 082039 x' Birthdate,12/30/1977 Expires 1,2/30/2005 Tr.no: 82039 Restricted:,,00_ DANA M GRIFFIN 28 HIGGINS ST APT 4 C.�ra h ALLSTON, MA 02134Administrator 00-35,000 cf enclosed space (MGL CA 12 S.60L) 1A-Masonry only 1 G-1&2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. i DIG SAFE CALL CENTER: (888)344-7233 2-15-03 REV 3-14-03-13 S 13i2d 0 � I � I LC DPW HV LC I 3DR � J K Y L E KEVIN MR SERVICES 411 NUTTING ROAD 1/2 - - 0 JAFFREY.NEW HAMPSHIRE 03452 ` i /ln) 2-T 5-03 REV 3-72-03 41 69 y T ' LC 30 i 3 DR LC 3 Fo O 2 D R 3DRW i 3o'Z \' CLO 5 E T sTEv MaURE Ery I--A ' LADING MASTER SERVICES 71211= T-lol ,1 ! 411 NUTTING ROAD JAFFREY,NEW HAMPSH!RF 01,65- NO K T11 Town of. Andover 0 TO 9pft&70 0 3 0 �-o cHIL A dover, Mass., C W C '�ATED BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D THIS CERTIFIES THAT....v-/'O ...5-/,Ovqr 4- MAV ovo W'0 PP A 414) 0 BUILDING INSPECTOR .......................................................................................................................................................... Foundation has permission to erect... 1........ buildings on .... ........ Az....... .......... Rough to be occupied as.... .... P, Chimney .!Q...........BA"11"11k. .........IV............ .....$4 ..... ........................... provided that the person accepting this permit *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-La relating to thXI spection, Alteration and Construction of Buildings in the Town of North Andover. 4 ,5 (0 7) 1(P 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 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 Date.G� . . . . . . . . . . ",O R7:94, TOWN OF NORTH ANDOVER — 3? .�� ....•.°oma ° p PERMIT FOR PLUMBING SSACMUS� II n / This certifies that : .�1... . .7. . . . .1. .~. (�. . . . . . . . . has permission to perform plumbing in the buildings of . . .��.�.�.� `1!�. ° . . . . . . . . . . . . . . . at . . .y. . ?. . .tw-l. s.S . �!f/. -,`. . . . . . . . . . . . North Andover, Mass. Fee. Li c. No. 3 C. . . _, . . .i L -),i-1 . . . . . . . . . f PLUMBING INSPECTOR Check # S 5635 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS C� c Date L C ` y Building Location ��6 ) � �f Gi� �y�pners Name .�� ✓V/( � I Permit# / Amount (' •/ Type of Occupancy New Renovation ® Replacement o/ Plans Submitted Yes El No El FIXTURES Cr En Cn ' A SUB—BRa BASRAM IST:FLOM a i 22 HfM 3M HOCK 41H RaR 5MWUR 6TH HIM 7IH FiOCR SIH Imm (Print,or type) TCheck one: Certificate Installing Company Name Corp. Address Jyy "jl Partner. Business Telephone � _ IlFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ��� Other type of indemnity E] Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner p Agent p I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and lati performed under Permit ed forthiplication will be in compliance with all pertinent provisions of the M „ t�e Plumbin a and C ter 14 a General-Laws. By: mpatureoT Licensear Type of Plumbing License Title - ,�,/ City/Town icens nm er Master � Joumeyman ®• APPROVED(OFFICE USE ONLY Date... ...3G...�...3 t NORTH, 4, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACHUSEt This certifies that .......��. ...>..c:t....=....!.P C.....!n..� .......................... has permission to perform ...... 4 . �?.. dv!�'^.. �P � '`�l�'°./. ............. ....... wiring in the building of.........� �>..1�.... �:1. ....................................... 141) �.SS ... ,..cJ. ,orth Andover,Mass at........ .. ���................... ..... , Fee..;U. /�5 3- � e/ -��! LECTRICAL INbA' CTOR Check # 4584 ThECOMMONWEALTHOFMASSgCHUSETTS Office Use only DEPAXrMWOFPUB IICSAFETY 4BOARDOFFIREP Permit No. S� s REVEMO N� ONS527CNIRl2 .•GYl Occupancy&Fees Checked APPLICAHONFOR PERAff TO PERFORMELECTRICAI, W ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �j(jjp3 Town of North Andover To th Inspector of Wires: The undersigned applies for a permit to perform the electrical w rk described below. Location (Street&Number) !�3 Owner or Tenant TPS e / h J Owner's Address Is this permit in conjunction with a building permit: es No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amp Volts Overhead ID Underground g No. of Meters � New Service Amps / Volts Overhead Under found --�- g No.of Meters Number of Feeders and Ampacity Location and Natu ye of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total No.of Lighting Fixtures Swimming Pool Above BelowKVA Generators und KVA ' roround 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 No.of DryersDetection/Sounding Devices Heating Devices KW Local Municipal Other No.of Water Heaters' KW No.of No.of ID Connections Signs Bailasis No.Hydro MassageSfubs No.of Motors Total HP OTHER• I inurm=C0VW,W,110=10 themWmn""aWdmM;fffdLaws haveaa miLdihtyhm W=PblicymdxkgtP CoWrdWoritsmb lapvalet YES NO haw stlixrmtedvalid sanletOdleOffce YES Fou have dlacWYES,Please m&*the typeOfmve�ageby hedarlgthe x �J VSURANCE ' BOND � MIER �� / ✓orktO Start EstQnated VahleofEk tial Wolk$ igtedunderthe fpgjwy. —� n Roug11 /T� F RMNAMEE - /U HiQ E ec d"C c (Q (A IicumINo. �3 Sim �� � t'C��� 'v Q{�%✓-( Bi>sinessTe].No. Ii�VNII2'SINSURANCEW Iama Alt Tel No. A� thatthelxa>sedoesnothavetheu>stUMMOoverageoritssuhuifialequivalalaswquiredbyNi%sachus,-mGer)eralLaws J that rrysig>ahneonlhispemritapphcation waives thisrDqum=t lease check one) Owner F-1 Agent 0 Telephone No. PERMIT FEE$ ✓.5 igna ure or Ownul or gen