HomeMy WebLinkAboutMiscellaneous - 49 ELMWOOD STREET 4/30/2018 (2) 49 ELMWOOD STREET
210/003.0-0012-0000.0
Date. v. . . ... ..
,aOFTN
i OF�..ao
o= °� TOWN OF NORTH ANDOVER
e p
' PERMIT FOR GAS INSTALLATION
•' h
�9SSACMUSE�t
This certifies that . . . . . .DeG n. . . . . ��. . . . . . .
has permission for gas installation J/ I/X'." . . .
in the buildings of . . f�c,r<.r.t P S,x. . . . . . . . . . . . . . . . . . . . . . . . . .
at . . �l. .4 :Lx . . . . . . . . : ., North Andover, Mass.
Fee. .'�.`. Lic. No.. ?.v�F.? . C 1_✓. .1{. -�. . . . . . .
�GASINSPECTOR
Check#
7 `' 04
dt
MASSACHUSETTS UNIFORM APPLICATON FOR PERMrr TO DO GAS FITTIlVG
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
�
Building Locations �7 / �'� W Uy�y T Permit# LO C�
N Aly oy L)-96Z Amount$ (�Z
Owner's Name � �F S
New❑ Renovation. Replacement ❑ Plans Submitted ❑
x W ri
U
w w a p o H x x
0. w H 4 z z 4 x
w W Q W o a °o w
zcw7 Q w Q F F w p > w w V J
a w > w O z a x Q O O w O vi x
eeee4444 O w LT3 p C9 .� U C >
SUB -BASEM ENT
B A S E M ENT'
1ST. F L 0 0 R
2ND. FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8.TH . •FLOOR
(Print or type) Check one: Certificate Installing Company
Name NN r �2 LV/�'d,Q �1J ❑ Corp.
Address G� '"'ewl -
❑ Partner.
BusinessTe' ep one90, ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter �sz;-
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy �� ._ Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent
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 installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State G Code and Chapter 142 Gen
p eral Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title ❑ Plumber -Z__�4 ?
City/Town ❑ Gas Fitter License Nrim5er
❑ Master
APPROVED(OFFICE USE ONLY) 1-7 Journeyman
v,.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. Type of project(required):
❑ 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 ?• ❑Remodeling
* ship and have no employees These sub-contractors have
working for me in any capacity. workers' comp.insurance. . E]Demolition
9'
[No workers'comp. insurance 5. El We are a corporation and its [1 Building addition
required.] officers have exercised their 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no
insurance required.] t 12.❑Roof repairs
q ] employees. [No workers'
comp.insurance required.] 13.❑Other
`AnY applicant that checks box#1 must also ii?o_!the section below shoe;Lng;.heir workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature:
Phone#:
Official use only. Do not write in this area, to be completed by city or town officiaL
Cite 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#:
.i
Information as d 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 orother 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 apartoxents 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 notbecause of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants ,
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town ma4 the application for the permit or license is being requested,not the Depa=--nt.of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. .
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street �
Boston,MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Fax it 617-72.7-7749
Revised 5-26-05
vvrw.mass._gov/dia
Date. /.,/.�v . . .
NORTH TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS�
�c �n <
This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ./.
has permission to perform . . t`G .. . C. . . . .�?�` L. .r. . /. . . . . . .
plumbing in the buildings of . .//c. . .`. .` .
�. . . . . . . . . . . . . . . . . Noct ndover, Mass.
Fee. U . Lic. No..� �-- �. . . . . . .
7PLUMBING INSPKTOR
Check # Y
8594
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Print)
NORTH ANDOVER,MASSACHUSETTS
Building Location DatePermit#_ JVj 5/
Amount 30 �--
Owner
New ❑ Renovation ❑ Replacement ® Plans Submitted Yes No
1.
El
FIXTURES
rr
r
]ST IIDQt
ZQ EL"
am IIDQZ
4M BDM
Rap.
ORROM
7M E10M
MHELOW
(Print or type) Check one: Certificate
Installing Company Name J p � ?j Corp.
rP
Address -C,41 Ale
Partner.
Business Telephone 2 um/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurar=coverage by checking the appropriate box:
Liability insurance policy , Other type of indemnity ❑ Bond
Insurance Waiver: L the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 4 Agent ❑
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 installations performed under permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuse�ts/Sta Iamb esd-*apter.142 of the General Laws.
By: rgnaurre o/rcens r lum=i
Title
Type of Plumbing License
Z 3917
APPROVED(OFFICE USE ONLY
City/ rcense amour - Master Journeyman
�f 1�
lj
1
B-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Appficant Information
Please Pr'nt Legibly
Name (Business�/Or�ganizato7n✓diGviddu'a)� � d
Address:
City/State/Zip: ZA, Phone#:
Are you an employer?Check the appropriate boa:
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. New construction
2.Z-I-am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
' working for me in any capacity. workers' comp.insurance.
o workers' comp. insurance 5. 9. Building addition
[N p. ❑ We area corporation and its
srequired.] officers have exercised their 10. Electrical repairs or additions
3.[]
.❑ I am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers'
comp.insurance required.] 13.[1 Other
*Any applicaut that checks box#1 must also fin out the section below shelving W�
^L R'o'ir:�;aa GvWj,:.a."u.'.t10n 17Q::C)'S221D.Z"atiDn.
T r4omeo vu s who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees Below,is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of
the workers compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Sienature• / ZDate J7
Phone#:
Official use only. Do not write in this area, to be completed by city or town off ciaL
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
t
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity;or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)mame(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 cid or tiorTn that the application for the pernait or l cense is being requested,not the Dep&rtment 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. he Department has Provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would lilce 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 gf Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-8 77-MASSA-FE
Revised 5-26-05 Fax#617-72.7-7749
u=wu,.rnass..gov/dia
Leq))BayStateGas
A NiSource Company
May 24, 2006
Hennesy Maurice Account Number: 9353520087
49 Elmwood St
North Andover MA Ol 845
Dear Hennesy Maurice:
This follow-up letter is to inform you that your gas H/H-W/H located at 49 Elmwood St has been
tagged due to a violation of state safety regulations. It is unsafe to use until the following condition
has been corrected.
Boiler and water heater under water flood
The Masachusetts code pertaining to the installation of gas appliances and gas piping, established
under Chapter 737 Acts of 1960,requires that the condition be remedied.
If you have questions or would like to discuss this issue, please call 978-687-1105 and ask for the
Service supervisor.
Please disregard this notice if the condition has been corrected.
Sincerely,
Service or Meter Department
Bay State Gas Company
CRR: CRR#
CAcisupdatedletters\236 05/24/06
55 Marston Street P.O. Box 869 Lawrence. MA 01841-2312 978-687-1105 Fax:978-688-1875
Date...
......................
&ORT#1
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
SS MUS
This certifies that .......J.14
has permission to perform ........../X..#.......5rekt-c-r ..........................
wiring in the building of...........A(4F 4.75�K....................................
at...4
..... .........5.27................... ,North Andover,Mass.
FeeC.lt/. ........... Lic.No/ 3,6
.............
.............................
A—
ELECTRICAL INSPE R
Check #
W) 2
Permit No.
BQARDOFF=PREVF M0NR9=A1X M527aARtL0
Occupancy R No Checked nue—.ammo
A.PPUCAU0N FOR PU;Mff M PUU0 M EUCMC U- WORK
ALL WORK TO BE FBMRMBD 1N ACCORDANCE WrrH THE MASSACHUSSrS ELECTRICAL CODE,527 CMB 12:00 _
ti (PLEASE PRINT IN INK OR TYPE ALL INFORMATION ) Data
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location(Street 3 Number) � G��IC✓O� 0 J-
Owner or Tenantme G�/t/�Glss
Owner's Address S-057/7
is this permit in conjunction with a building permit; Yea[:3 No 13-(-Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service /moi Am V/OVolts Overhear! U::undC3
und No.of Meters
New Service 0V Ampa�dolts Overhead UNo.of Meters _
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work .D v " �/ 2 757 77777 G 7–
No.of Ughdrg Outlet. Na of Har Tube No.of Transaxrears Total
No.of Lighthig Fixture Swirnating Pool Above Below Oerrentars KVA
KVA
around 11111d
No.of Receptacle Outlet No.of OU Burners No.of Ere rveuep t.iahtins Battery Units
No.of Switch Outlet
® No.of am Burners s :
No.of Rargas No.of Air Coed. TOW FIRE ALARMS Na of Zones
Toes
Na of Disposals No.of Had Total Total Na of Detection red
Ton KW leidedeg D"Joes,
No.of Dishwashers Speer Area Heeling KW
No.of Sounding Devices
No.of SaU CoWa6ead
No.of Dryers Heeling Devices KW LoDelectlaafflottaft Dakar
Municipal � OU
No.of Water Haters KW Ne.of No.of Connections
sine Ballasts
No.Hydra Massage Tuba No.of bloom Tote)HP
OTHER.
VKUr aeCbvesaga PMWlDhe+JaartebdQmllm a
IhmaaaQrtI.WifthumPbfthidrBt7�r>yle� orihXbft laWjVd t 7'o NO 0
IhnestnitbdvafiipoddslmeofeOIDm YM � ><�arhatedtedoDdYBg,
dmd %ftEr- M4D
Pkai***egVC( MVby
MRAP�B [3 OOM
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EdnftVab c(EhadWWc&$
*edurtds PtrftCfp dW.. � ,—
FT<tMNAMt3 1.io=Na
1 . C [icaseNo 3 9�1)Is
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Owt�'SIl�AJRAi� ianaweedirtllreiicais:dosaotltaretbeirsmroea�►a•�or�s�yirlecfivaletffi0;*dbyMmmft el cnwLm
andlhetrrtys�sttaeonthbprnr»<applcsdQmwaheafisrequierrst
(Please check one) Owner C3 Agent aignum us vwuw or Agm ,,11
Telephone No. PBRIb1M F13H! /UV
r
12.1t.�-u2
10
r
DateS./G. . ..... .
Y. NpNTM
Of1'Yp
of �` T WNI OF NORTH ANDOVER
9 PERiOT FOR GAS INSTALLATION
�,SSACHUSES
This certifies that . . .LA-. . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . . . . . . . , . . , ,
in the buildings of . . 9(q.�%t " . . .. . . . . . . . . . . . . . . . . . . . . . . . • •
at VIFte- c o cf
. . North Andover,r Mass.
Fee. . . -. . Lic. No../ . . . . . . . . . . �'��� . . . . . .
GAS INSPECTOR
Check#
5590
MASSACHUSETTS UNUMM APPUCAMN FOR PERK TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations 7/ �00Ocj 57 Permit# JU
Amount$ ��
Owner's Name �v r i C Q l� tiesu
Ne�u w� Renovation ❑ Replacement ❑ Plans Submitted ❑
� a
w �a o U F x x
z c P; z o z w
w a o c x 6
Gz w lux,w �" U Ix
z Da z a o °o z °o w
O 7 A C7 a U 0 A a F O
SUB -BASEM ENT
B A S E M ENT
0
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
or tyge) ,lL�� n� / ' Check one: Certificate Installing Company
Name
(�� r ,416/i q / %�!?9'
Address 6 ST ❑ Partner.
Business Telephone Y28 Z Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1No❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 1:1Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
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 installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Signature of Licensed Plumber Or Gas Fitter
Title ❑ Plumber PL
City/Town ❑ Gas Fitter License Number
Master
APPROVED(OFFICE USE ONLY) ❑ Journeyman
Date . . . . . . . .
TOWN OF NORTH ANDOVER
7,
'PERMIT FOR PLUMBING
S US
. . . . . . . . . . . . . . . . . . . .
This certifies that . . . . .
has permission to perform . . . . . . . . . .
plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . .
at�J. . . . . .
. . . . . . . . . . North Andover, Mass.
Fee le No.. \" I
Lic. . . . . . . .
8 4§PECTOR
L U M�BI*NG"I
Check
6980
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
(�7� Date
Building Location c , Owners Name Permit#
Amount
Type of Occupancy
New ri Renovation Replacement 9 Plans Submitted Yes ❑ No ❑
FIXTURES
z
�, a o ff a w
o Z Z a
W x
d U d0
d H U W
SLRlM
>aASEVEqr
M HBM
HIM
—SRI FLOOR
61HHADOR
7THHADOR
s>HH-IDCR
(Print or type) Go Check one: Certificate
Installing Company Name V` Corp.
Address fe ay 772- Partner.
747177 "'"'0 41 �G ?
Msmess ge ep one co 9j/ Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate h type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ 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 Agent
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 installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
BY Signature OT Licenseaum er
Type of Plumbing License
Title I
O
City/Town 4_cze lNum e—G r Master Journeyman ❑
APPROVED(OFFICE USE ONLY
D .. . . .. .. . .. . .A
. . ..... .
NORTH
01 '14,
6,6
6
OF NORTH ANDOVER
0
• PERMIT FOR GAS INSTALLATION
�1SSACMUSEt
This certifies that J.
. . . . . . . . . . . . . . . .
has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . .
ter,. . . . . . . . t . . .1-010
in the buildings7of . . . . . . . . . . . . . . . . . . . . . . .
atNorth Andover, Mass.
. . . . . . . . . . . . . . . . . . . .
Fee . . . Lic. No.. . . . . .. . . . . . . . . . .
GAS INSPEv
Check#
-S92
(IASSACHL SETTS UNIFORMAPPUCATON FOR PERM TO DO GAS FrrMG
(Type or print) Date �j c
NORTH ANDOVER,MASSACHUSETTS
Buildin Locations
� � I'" `� fT Permit#
Amount$
Owner's name
New Renova ton Replacement Plans Submitted
J
J
Z F
0
�p rn
Z a4 O• O O F
SUB •BASEM ENT
BASEM ENT
]ST. FLOOR
7,ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . F L 0 0 R
7TH . FLOOR
8TH . FLOOR
(Print or type)Zf,7 Cliffil one: Certificate Installing Company
Name Corp.
ir Address �nx ?2 2 Partner.
Business" e ep one 7d' l 2'5- PP Firm/Co.
Name of Licensed Plumber or Gas Fitter �"i9MIf s L,-O Call le
INSURANCE COVERAGE- Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1NoD
If you have checked yes,please in 'cate the type coverage by checking the appropriate box. D
Liability insurance policy Other type of indemnity Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
i `tereby 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,kIl plumbing work,Ind installations performed under Permit Issued for this application will be in
,cmpliance with,Ill pertinent provisions of the Missach tts State Gas Code and Chapter 142 of the General Laws.
Signature of Le nsed Plumber Or Gas Fitter
By: Plumber 9 7 i'
CitvTtlrTcwn Gas Fitter Ltcc . um er
• . Master
APPROVED ICE r,sE C�,I , Journeyman
�_F
Location
No. Date
4
t
NORTFTOWN OF NORTH ANDOVER
_ _ O
F e
9
a y
Certificate of Occupancy $
Building/Frame/Frame Permit Fee $
s+cNust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ I
ods
Check #
17058
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATf2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING r�
;.n.,
BUILDING PERMIT NUMBER. �� DATE ISSUED. /a aroma
SIGNATURE:
Building Com-missioner/Inspector of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
1z
Map Number ,'Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area s 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 ❑ 1 Zone outside Flood Zone 0 Municipal 0 On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIPIAUTIIORIZED AGENT
2.1 Owner of Record
Na (Print) Address for Sernce
r Z 712 3
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 tensed Construction Supervisor: Not Applicable ❑
m� Ax�-�
Licensed Con ion upervisor. e `D 10,331 1 License Number
Address7171,
j
16KVa AAC�'k;�� �Z?i-e,) S6 Expira on Date =
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date Y
Signature Telephone
SECTION 4-WORKERS COMPENSATION(MLG.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) ❑ Alteratior*s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be �F prC ,L USE ONiy
Completed by permit a licant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of / p
Construction ! /
3 Plumbing Building Permit fee(e)X (b)
4 Mechanical HVAC /60
5 Fire Protection
6 Total 1+2+3+4+5 j) Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1> 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
1, 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 �GG
Avaw,ti o
Print Name
,Atk y
Si ature of Owner/A ent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS 1 ST2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIN ENSIONS 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
NORT�y
ovm Of "-. Andover
No. y� O r :.. - 0
, �y. L A K E dover, Mass.,
COC MIC ME WICK y�'
RATED
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT... .�..� n .............................OIL 14 ~.y......Ss... ................................................ ............. Foundation
��
haspermission to erect...V� .Y.�............. buildings on .....................................................................................1 �........ Rough
to be occupied as .. Ali.....C".A.0. ................I............. Chimney
. . . . . . . .. . . .
provided that the person accepting is permit shall in every respect con orm to the terms of the application on file in Final
this office, and to the provisions of the Codes and By- ws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. 311A i mo f s PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PSE 5 6 M�yO S ELECTRICAL INSPECTOR
UNLESS CONS U ®ASB STARTS Rough
.. .. .A..C.. . ...... .... .. ................. Service
BUILDING INSPECTOR
Final
Occupancy Permit Required t® 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.
. ........ . .
COMMOnwMahof
M' 01. of t
Irafrra real
600 WasFeingm Stan
j3ost^ XX 0111
Workers'Cotnpstsssm )$atuac:a AfSda�t
�eo�°� .pgibtY
A,.. rr e nrr trIF®RM��aN
Location= -
--�
Telel,hont
City: l
M lam a homeowner performing ail work myseL,
?atr sola to rietor and have no one working in my ca achy
vi workers' compensation for my employees workiag on this job
0 I am at;employer pro dim , .
company Name:
Address:'
Telephone t
City:_
III Policy*:
JI
Insurance company:
Ci
contrac:crckited beiaw who baJe;
I am(circle out) sok proprietor,general contractor or homeoW�ner and have hire�t'ne tbe fol�o`vitsg
workers' compensation policieg�
C;ompeny Name:
Addre;s:
Telepbone.M
Insursace Campamy. Policy '.
Company Name:–
Address-
Telephone#:
City. —
insursace.Company: Policy
Attach additional sheet if necessary
raiiurt to secure:coverage as required under Srctior.25A of MGL 15B can lead to the urapositicn of criuunal penalties of a fine u_l to i,SGUA
arzd.ar one years' imprisotunent is well as civil penalties in the forts of a STOP wO1u ORDER and a fine of 5100.00 a dsy agar-ns'm:, i
undersand that a copy of tbis smternent may be forwarded to the Office of Investigations of the DIA for coverage Verdication.
1 do hereby certify render the pains andpen s ofperjury that the information above is true and correct..
Signature; id "r A-ya Date:
?rit:t Name;
Ofticlai Use ONLY-Do not write is this area
c 6ui�ding�eDartme<nt '
City or�', r1 Parmn,'License#: r. i tensing 3oar>r
3 Se�eCimer s Office
n ieaitr,i�e.anmesnt �
�II c Check if immediate response is requires 0 Other__
Castricone Mooring & Siding
• REPAIRS FREE ESTIMATES
Telephone (978) 682-4266
MARIO CASTRICONE
31 Court Street,North Andover,Mass. 01845
I/we,the owner(s)of the premises mentioned below, hereby contract with and authorize you as contractor,to furnish all necessary
materials, labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and
conditions, orwrises below describe
Owner's Name. .. 1 � ..... .. .:... ........... ..............
Job Address.....<..... ...`.���' .1�� ..... .........................................................City . : ...l ... ate .........State �............................
SPECIFICATIONS
v� .. .. .�'lC . .
. A. :.: ................... .:,...f ,. .................
�97 �.
. ..........
1 ............ .1. f/f }n�
............ .j........ .%..�/ ..•...�....../..�.7....... .. .. ",J,(�J.} .... ..1.. ........................................
... ......... .. ........ . ... ....�.....X.....Lt....................................................... J411
................................................. .....� JL/.T7: ....... ..... .............. ................ i •• .. ...........................................
. . ... ... . . .
'.. ...............:r..... .....�, .. ............................................................................................................
t.. ................................................................................................................................... .... ........................................ ...............
............................................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................:.................................................... .
t ......................................................................... ................................. ......... ..�............................
........,........................................... ...//... ................................................................................. ..................................
Materials and labor to cost$ . ..l.��........................... Payable.........................................on .... ........ ................and balance in..........
monthly installments of$.........................................each, payable on ........................................day of each and every month thereafter until paid
in full(..............%charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
Contractor will do all of said work in a good workmanlike manner.
Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation and
completion as requested by the contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpa
immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s),all reasonable costs,attorney fees and expenses,
addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor;and also that the obligations hereof shall bind and apply to their heirs,successors or estab
of the parties.
The undersigned warrant(s)that he is(they are)the owner(s)of the above mentioned premises and that legal title thereto stands of record in his(their)name(:
PROVISO:This contract shall be void and of no effort if credit approved of owner(s)is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is tt
contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signi
by all parties.
Cover attic storage cleaning not included.
Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read ai
the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements ai
understandings of said parties are contained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in operation. _
IN WITNESS WHEREOF, the parties have hereunto signed their names this............." .L....day of.. ..`.........
Accepted:
Signed
... ................
O ner
(OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT)
Signed......................................................................................
f Owner
Per...... . .................... .. ............................................... Signed......................................................................................
Representative