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;'"',;';�.��o� TOWN OF NORTH ANDOVER
03?
p PERMIT FOR WIRING
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Thiscertifies that ...................�......�.....1,�!................................................................................
has permission to perform ........ ....... c.+.. .'k?..............................................
wiring in the building of..........
at ..........'.,. ..... ��......./�f I /�/�. ,North Andover,Mass.
... ........... .................................
Fee....j .................Lic.No14:1b......ly.....4, ft �
ELECTRICALINSPECTOR
Check# —�
1 _ Q—
Commonwealth of Massachusetts Official Use Only
- Department ofFire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07]
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Al, Al&4ekC
City or Town of: NORTH ANDOVER To the Inspector of Wires.
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conj unction with a building permit? Yes No ❑ (Check Appropriate]Box)
w Purpose of Building F L Utility Authorization No.
- Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires /Z No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No,of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- F1 No.of Emergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: """""""""""".............. Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KWNo.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
101, Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of pectrical Work: (When required by municipal policy.)
Work to Start: 7 .r Inspections to be requested in accordance with MEC Rule 10,and upon completion.
C
INSURANCE VE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such cover 1s m force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
Icertify,under thepains and enalties ofperjury,that the information on this application is true and complete.
FIRM NAME: " • Li d B j LIC.NO.: /W 79
Licensee: U 5 Signature LTC.NO.: y-r
(If applicable,enter "exemp/' zn the lic nse w ber line.) Bus.Tel.No.• Jd
Address: U /tt• ,aAlt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑ Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass n Failed 2 Re-Inspection Required($.) ❑ •
n
Inspectors Comments: r
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 151 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Sign re: Date:
r
ROUGH INECTION:
Pass IN Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date: 77G-
FINAL INSPECTION:
Pass M V Failed ❑' Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date: 16 f f
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
. The Commonwealth o.f Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: /CJ A(I !? o
City/State/Zip: r-51e&� /l/ Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
I aTaoam a employer with ./) . employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $. L;�Remo deling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. _
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ,
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: ffl'led 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 MGL c. 152,§25A is a criminal violation punishable by 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 viola to y.7A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifica'
I do hereby c ti nder ze ains and penalties of perjury that the information provided above is true and correct.
Signature: Date: - Z
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
A
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its`political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
E
COMMONWEALTH OF MASq
° ® HUSETTS
� � • •
B DARD
ISSUES EIECTHIcl
THfr FOLLOWING
REISTEREl3 LICENSE j
MASTERA
:ILECTRICIA
FORBES ELECTRIC
flRBEj
CUR"T L F Z
10 NORTH''ENO RD `
TOWNSEND , �:>.
16 44 A 01469 llz5
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COMMONWEALTH OF MASSACHUSETTS
BOARD'OF
LET TRI C I ANS
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<> S I S.0 E.S ;:TH E F 0 L L OW I N'G%`L`I C" NSE
AS A
E. JOURNEYMAN, ELECTR
.Cl1RT FORBES °
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10 NORTH'`END`RD W
UNSEND .. MA` 01469 1125'
37854:E 0773111.6 : 99369
Well 1.1 J
Ao r-
Date...'Y.P.M.............
OF NORTH,�O TOWN OF NORTH ANDOVER
° 9 PERMIT FOR PLUMBING
gs�CHUS�
This certifies that....... .......�'''?.'' ............................,.f...............................................
has permission to perform..................................... Jr9` .....
..........
plumbing in the buildings of.............t :P..j ........................................................
at.....�........ J.. .....�.-..��-�
...... . . . . North Andover, Mass.
Fee — Lic. o. + .................................................................................
7 ..
7 PLUMBING INSPECTOR
Check#
1 q6 `(; V-Y , 2Z-11
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY /\/�/- MA DATE V PERMIT#
JOBSITE ADDRESSC OWNER'S
OWNER ADDRESS TEI�,� l �FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ Q
FIXTURES Z FLOOR BsM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM 3
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER 06 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY `
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 8'NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 9�—' 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F-1AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Per-nent pro ision f the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
� I-
MP JP ElCORPORATION``k# />a 9 PARTNERSHIP El# LLC❑#
COMPANY NAME�G /�,(`a ,[ y �� ADDRESS
CITY STAT�� ZIP ��� TEL
CELL
Date.............:�1...:. 5.............
NORTh
o� TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
,S`SACMUtP
J /,�'1✓. �jLI(�Iivt
This certifies that ....................................................................................................................
1 - eP��A
has permission for gas installation .. U �(��[_.
..................................................................... ...
inthe buildings of................ e..Ir�...�.........................................................................
�/..�at.............-a .... ...... 1. )('�-.. 4 ....., North Andover, Mass.
Fee ` .. Lic. No2(j/" .. .. .. .. ......................................
GAS INSPECTOR
Check# �
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r1 fy
l
CIT MA MA DATE �� PERMIT# _
JOBSITE ADDRESS.,," NER'S NAM
_..... _. / �.....
G OWNER ADDRESS .�-� TEL ��G� i J_ FAX;
` TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL <z RESIDENTIAL ��
PRINT
CLEARLY NEW.r�RENOVATION:;„ REPLACEMENT: ..3 PLANS SUBMITTED: YES NO"-'
APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
�..,
BOOSTER
, I E
CONVERSION BURNER _.
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE __ . �_ _ �
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS ;
MAKEUP AIR UNIT
u
OVEN
,
f
r
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT _ _.....;:. .
f.
TEST
L 4T
UNIT HEATER _. _..
UNVENTED ROOM HEATER = r�
3
WATER HEATER.
OTHER
y
INSURANCE COVERAGE
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .`� OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent pr vision of the
Massachusetts State Plumbing Code nd Ch ter 142 of the General Laws
PLUMBER GASFITTER NAM �/ .� � . LICENSE#M/ spa SIGNATURE
MP MGF: JP m_ JGF� LPGI CORPORATION? # "PARTNERSHIP
# LLC= -#
COMPANY NAM l DDRESS
CITY 17
��/��� STATE ZIP 454�TEL
_, ..
FAX CELL) MAIL...! .e, �, a�,� �.r� - . \/�G, .-..... _
11
`�� ',Q�� I� ��"� �,1� SSS
The Commonwealth of Massachusetts
z Department of IndustrialAccidents
1 Congress Street, Suite 100
' Boston,MA 02114-2017
- ��;��•`t www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Le 'bl
Name(Business/Organization/Individual): "
Address: J
City/State/Zip: Phone#: 9` U�GG� v
Are you an employer?Check the appropriate m5r Type of project(required):
1.❑I am.a.employer with employees(full and/or part-time).* 7. []New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 F1 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.❑Roof repairs
• These sub-contractors have employees and have workers'comp.insLuance.#
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other
oyees .[No workers'comp.insurance required.]
152,§1(4),and we have no.empl
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
I 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 state whether or not those entities have
employees. If the sub-coniraciors have employees,'they must provide their workers'comp.policy number.
I am an employer tfzat is pFoviding workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verificatio
I do he y certif uy er the pa' a altiof peijwy that the information provided abov is tru and correct.
tore: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written." '
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
r .
COMMONWEALTH OF MASSACHUSETTS. 1
bi •l k"q 901 2gusl
F
PLUMBERs'� ASF ITTERS,,:;
ISSUES THE FOLLOWING LICENSE
LICENSED:=AS A JOURNEYMAN PLUMBE
THOMAS H PRICONE
LLI
71 PHEASANT 'RUN D:R W
CHESTER N.H 03036-4187 J
20166 05/01/16. 225990 I
Date.
"�R'M TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSAC14US� �f / f
�fl� �3 C 1.��
This certifies that �t� . . . . . . . . . . . . . . . . . . . . . . . . . . .
�( t ) <C 1
has permission to perform . . . . �. . .': . . . . . . . . . . . .
plumbing in the buildings of . . Y ` �. . . . . . . . . . . . . . . . . . . . . . .
at. . North Andover, Mass.
Fee. . . .'.'. . .Lic. No. ?51. 3. . . . . . . j ti ,. . . . . . . .
^� J PLUMBING INSPECTOR
Check # J c'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: /rf /. 7KDQl/�r�C MA. Date: 3 Q Permit# -3 ?9
Building Location:--5-4 Owners Name:
I
I Type of Occupancy: Commercial ❑ Educational
❑ industrial ❑ Institutional ❑ Residential
New: ❑ Alteration. ❑ Renovation: ❑ Replacement: U Plans Submitted: Yes ❑ No
FIXTURES
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SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
S 1FLOOR
6 FLOOR
7 FLOOR
8 k HFLOOR
Installing Company Name:/� l//�f� ! /yJ,�j�t/� /� � �} Check One Only Certificate #
p r"�6n�� ' [[corporation
Addres
s ,lli�r�n� �/ City/Town: /�J�T�// / State: i�
f Zip Code: pl ❑ Partnership
Business Tel: Ov4y'-f pv3 Cell j7) �,-5ZZ;?q Fax:
' ❑ Firm/Company
Name of Licensed Plumber:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes Rl""No
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A 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 tf
I Massachusetts General Laws, and that my signature on this permit application waives this requirement_
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of rr
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of th General Laws.
By Ty
pe of License:
Title lumber Signature of L" nsed Plumber
City/Town
i APPROVED OFFICE USE ONLY ❑Journeyman License Number: 3
C1-1 us
Town of Andover
Massachusetts
(Office Hours 8:00 A.M. to 10:00 A.M.)
Gas & Plumbing Fees
Effective March 12,2003
❑NEw-New Construction and Additions ❑ RENOVATION= Plumbing within the existing system
❑ REPLACEMENT:Removal and replacement of a fixture to the existing piping
`1ALL TENANT FIT-UPS ARE CONSIDERED "NEW"
PE tTINJBING FEES
New Domestic Construction—up to 3 Units $100 plus $5 per fixture DNEW�
1�Iet�r Domestic Construction —4 units or more $200 plus $5 per fixture DNEW
Renovation(Domestic) $50 plus $5 per fixture DREN
Re lacement (Domestic) ExistingFixtures ONL IT $1 Q plus $2 per fixture DREP
Backflow Preventer(far boilers) $10 plus $2 per fixture DREP
Backflow Preventer for irri ation systems) $25.00 DBAK
New Commercial/Industrial $200 plus $5 per fixture CNEW
Comrnercial —Renovation $100 plus $5 per fixture CREN
Commercial Replacement— Existing Fixtures ONLY $50 plus $5 per fixture CREP
Backflow Preventer(for boilers) $50 plus $5 er fixture CREP
Backflow Preventer (for irrigation systems) $25.00 CBAK
Re-ins ection Fee $25.00 -INSP
GAS FEES-
New Domestic Construction —up to 3 Units $75 plus $5 pera liance DNEW
New Domestic Construction—4 units or more $150 plus $S pera Bance DNEW
Renovation (Domestic) $50 plus $5 pera liance DREN
Replacement (Domestic) Existing Appliances ONLY $20 plus $2 per appliance DREP
Gas Boiler/Furnace/ Conversion Burner (Domestic) $50 plus $5 pera liance DREN
New Commercial/Industrial $150 plus $5 pera liance CN-EW
Commercial—Renovation $100 plus $S peT appliance CREN
Commercial Replacement— Existing Fixtures ONLY 5 !us $5 erappliance CREP
Gas Boiler/Furnace/ Conversion Burner (Commercial) +1_110 plus $S pera liance CREN
MISCELLANEOUS
Gas Log/Fire Place $50 plus $5 pera liance DREN
Gas Stove/Heater $50 plus $5 pera liance DREN
Utility/Bar Sinks $10 plus $2 per fixture DREP
'
Capped Sewer Lines $25.00 SCAP
f Re-inspection Fee $25.00 INSP
'These fees are used if the permit is for this wnj-lif, Cpiy. r� t.:e p .-
e ,^ ;t i:iClu`;eS otherplurrlbiiib wOri�� tfe
fee charged will be the FLxture fee which appears under renovation, replacement or new work ($2.00 or
$5.00)
' S v ue I
Location
No, Z Date "Z•Z — G
4
Of NORTq TOWN OF NORTH ANDOVER
I 0 p Certificate of Occupancy $
Building/Frame Permit Fee $
k �s�;yy� '•
b " Foundation Permit Fee $
s�cMust
f � 49ther-Permit Fee $
v _i Sewer Connection Fee $
fWater Connection Fee $
v
TOTAL $
C/`` Building Inspector
`•
95411 Div. Public Works
�6
PERMIT NO. —el V APPLICATION FOR PERMIT TO BUILD NORTH ANDOVER, MASS. ao/ PAGE 1
MAP 440. O C LOT NO. f� 2 RECORD OF OWNERSHIP DATE BOOK 'PAGE
ZONE Ccs I SUB DIV. LOT NO. FI
LOCATIONO / PURPOSE OF BUILDING — I
OWNER'S NAME NO. OF STORIES SIZE
OWNER'S ADDRESS �/{ „ BASEMENT OR SLAB
ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME SPAN --
DISTANCE TO NEAREST BUILDING 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
LAND COST
SEE BOTH SIDES EST. BLDG. COST I+ 0 6
r v
F,G$E 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PEh SQ. FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
•ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS /J
PLANS MUST BEFILEDAND APPROVED BY BUILDING INSPECTOR
DATE FILED
SUILDINO INSPECTOR
SIGNATURE OF OWNER OR AUTHORIZED AGENT
FEE OWNER TEL.#
PERMIT GRANTED CONTR.TEL.#
�•I rITZ 19 <� L/ Q
CONTR.LIC.b
• H.I.C.u 1 Q 33 17
/#I-
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY STORIES 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 RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE 3 1 2 13
CONCRETE BL'K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT
AREA FULL FIN. B M AREA _
'/. 1/2 1/1 FIN. ATTIC AREA _
NO 8 M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WAILS I 9 FLOORS
CLAPBOARDS 8 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDI4'D _
ASBESTOS SIDING COMMON
VERT. SIDING ASPH.TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. & FLOOR (-
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIOR If POOR
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE HIP BATH (3 FIX.(
GAMBQEL 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 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. d COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS r,
OIL
B'M'T 2nd _ ELECTRIC
1st I-j-,dl NO HEATING dl