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HomeMy WebLinkAboutMiscellaneous - 53 CHESTNUT STREET 4/30/2018 J53 CHESTNUT STREET 210/060.044-0000;0 ` -- I I� I i I Date..../Z......././............... ...... 3? NORrH�tiooc TOWN OF NORTH ANDOVER 0 1- 2 i, PERMIT FOR WIRING sSA C This certifies that ..........� ........... ..................... ......2�.... has pennission to perform, ............... ........................... wiring in the building of......... ...2�.......��ae2. ....!,................................................... 7 ort n over,Mass. at ..... .......S............................. Lic. N AV ................ .1z Fee... .. o/K7.7 ...... x. . .......... ELECTRICAL INSPECTOR Check it 12947—/ t Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank 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 INMK OR TYPE ALL)NFORMATION) Date: 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 J� ��ry 1 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service+�� Amps )�'/ c�`�°Volts Overhead Undgrd❑ No.of Meters New Service G Amps 4�0/ '�M-4�Volts OverheadrX1 Und rd No.of Meters r Number of Feeders and Ampacity j Location and Nature of Proposed Electrical Work: 'alv;ct5- Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires t j No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets S No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches �c� 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 KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: ' Attach additional detail if desired,or as required by the Inspector of Wires. ' Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE �C]' BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperiury,that the information on thisplication is true and complete. FIRM NAME: _�dn-,n�R�S �'� `r= te`Com\ LIC.NO.: Licensee: Signature LIC.NO.:C (If applicable ter " empt"in the license nu ber line.) Bus.Tel.N0.• �� I Address: VC) tc l* ! A. Alt.Tel.No.:-5'c—?R' q-23 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 E&--"IT FEE:$ /D 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 R1 Failed [N Re-Inspection Required($.)❑ Inspectors Comments: r _l Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: Z DEB WEINHOLD —TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 3 i The Commonwealth of Massachusetts F Department of IndustrialAceldents I Congress Street, Suite 100 Boston,MA 021142017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl c, Name(Business/Organization/Individual): Cry�—C��, C � \ Address: PO City/State/Zip: S�It5iv.\ O 0yPhone#: Are you an employer?Checkthe appropriate box: Type of project(required): 1. I am a employer with 7 employees(full and/or part-time).* 7. E]New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] ❑ 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FJ Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL G. 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. 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 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 that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: '- S Policy#or Self-ins.Lie.#: Expiration 5 Date: /� Job Site Address: -53 S�' � City/State/Zip - i�Y` �Gc3� 6)-)-,:l <z) 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 verification. I do hereby certify a - dtazwlties ofpefjury that the information provided above is true and correct. Si nature: Date: Phone#: l I ) 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#: f 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 fbi 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-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia I 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 forin.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 constmction activity,and may be_deemed.by-thednspector_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 beguming on August 15,2008 and extending1hrough August 15,2012. r✓ Rule 8—Permit/Date Closed: �1� tet% ***Dote:R 'ply for new permit Permit Extension Act—Permit/Date Closed: OV Date.... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING T�kg certifies that .......................... .................. has permission. to perform—,<L-4— ............. wiring in the building of..... ............. ...... ........................ orth Andover,.Mass. ► F,IA6 .. Lic.N,,,P ..............a,'k ELECTRICAL INSPE Check # 8377 Commonwealth of Massachusetts Official Use Only Permit No. O r2 Department of Fire Services /,� Occupancy and Fee Checked �.7 • BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) 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: 9" Z 1i- 6 E3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or er intept, to perform the electrical work described below. Location(Street&Number) Jt'3 C h.0 S r� S Owner or Tenant M r S Telephone No. Owner's Address S3 C-ke s ti Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building ejA+ Utility Authorization No. Existing Service t ev Amps l Z v /Z'41- 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 thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 1 Swimming Pool Above ElIn-d. Elo.o Battery Units Units cy rg rng rnd. rn No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g ' No.of Waste Disposers He Pump Number_ Tons KW No.of Self-Contained Totals: ....... ...................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other `► Connection Heating Appliances Security Systems:* No.of Dryers � g pp �' No.of Water KWD No.of No.of No.of Devices or Equivalent Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent- No. uivalentNo.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent rS 4-er 3 Attach additional detai7 if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:'�? - Z L1-06 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 'JK BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties of perjury that the information on this application is true and complete. FIRM NAME: c -t e��`vA ,"c �Zry i c-C LIC.NO.: 1 Z 3 M >Z Licensee: A- trv,r ��c-� Signature LIC.NO.: 12 3 A A (If applicabl ente empt"in,the license number line) 0`� Address: K 9bX IZ4. 4)4rvi�cv,. FORS N14 o3C611� Bus.Tel.No.: X05 -QZ8 3 1 Alt.Tel.No.-: 3"1:118- 9? *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 Signature Telephone No. PERMIT FEE: ,( I ' 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): <<-2 VC JV I' �-r�r,. c.•c Address: 7© 6bx I z (, City/State/Zip: `�mJ ' o VO b--z qt 1 Y Phone #: (o 0 3 4 2 3 0 3 Are you an employer? Check the appropriate Vox: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.�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. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions '+ myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs ilsurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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. 1 Insurdnce Company Name: Polity#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). r ailure 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 bf up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' under the pains a d peva ' s of perjury that the information provided above is true and correct. Sign e: 61 9~Z (4- o g Date: Phone#: (PO - 9 Z W Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Date. . . . . Tly • 3=Orya�.ao ,a.,tipL TOWN OF NORTH ANDOVER O 9 41 - PERMIT FOR GAS INSTALLATION h �9SSACHUSEt4 This certifies that . . .(= .- Qct . . .c. ..` . ... . . . . . :�` has permission for gas installation--- /�: �Z- in the buildings of . . . . . . . . . . . . . a . . . . . . . . . . . . . . . . . . . . . . at —3 . . . . . . . . . . . . . . . . . . ., North Andover, Mass. Fee. .L Lic. N04o.�' - . GAS INSPECTOR Check# /�3 6532 MASSACHUSETTS UNIFORM APPLICATON FOR PERK Ur TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS �� —� Building Locations �� Permit#� D3 Owner's Name Amount$ r — New Renovation D Replacement D Plans Submitted rnw ;D W GW x z v w m a w �" o A > w w m w [- x z d a N F o > x >o x 3 a d e o °o w SU B -BASEM ENT G 'a U > O a E. O BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD . FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type)� Name Check one: Certificate Installing Company Af"���C iJ,00,`,4..)���r�.g/oma e Corp. Address ' Partner. Busin ss Telephone_ _ �. Firm/Co. Name of Licensed Plumber�or Gas Fitter i INSURANCE COVERAGE 1 have a current liability Insurance,policy or it's substantial equivalent. YesChecVM e: NoIfyou have checked Yes,please indicate the type coverage by checking the appropriate boLiabili Liability policy � Other type of indemnityD Bond13 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. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13 i hereby certify that all of the details and information 1 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 . compliance w' P d under Permit Issued for this application P with all pertinent provisions of the Massachusetts State , Code 4umber r 1 2-of the General will be in i By: Sig ure of Licen ar Gas Fitter Title P13 Plumber City/Town, Gas Fitter 9 (cense NUMber Master _ APPROVED(OFFICE USE ONLY) Journeyman Date. /71 NORTH TOWN OF NORTH ANDOVER _ s PERMIT FOR PLUMBING • s � s 'fir,+O+.:.°••��`4h �.. 3SAC NUSE� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. has permission to perform . 1nf�t'.1."i"� ���*f�^,,-?� . . �. T plumbing in the buildings of �.r . . . . . . at . . . . .0P.5'�.NV. . . . . , North Andover, Mass. Feel/Oi4.P.Lic. No.. . .K.�. ?. . . PLUMBING INSPECT Check # 1L� 7836 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date q 1171'e Building Location irt,t Owners Name Permit#__ Amount Type of Occu anc New Renovation ri Replacement E2- Plans Submi ed Yes No ❑ FIXTURES z C) H U D Wun Ln Gr W w R, Z G U W A � A � M FLOC12 2MNU FIfJC[2 3M FLOCK 41H KDM SM FLOCR 61H FIaR _ 7MFLM 9M FLCIC[t (Print or type) Check one: Certificate Installing Company Name _ l 1 f �l�'L/Z�--� Corp. Address +� v +ted (/ � El Partner. Business elephone 1- 7-7 ?s[ Firm/Co. Name of Licensed Plumber Insurance Coverage: Indicate the type of Insurance coverage by checking the appropriate box: Liability insurance policy LrJJ�' Other type of indemnity ❑ Bond F1 Insurance Waiver. I, the undersigned,have been made aware that the lic three insurance ensee of this application does not have any one of the above Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I ha submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work aI s VSperform unde ermit Is d for this application will be in compliance with all pertinent provisions of the M ac lumb g Co and C er 142 of the General Laws. By: SignaLure ol LicensezjrLwjnt)e-r- Title Type of Plumbing License City/Town kens um er APPROVED(OFFICE USE ONLY Master Journeyman ❑ Location ��� �`r Jos /'U U� No. 31711 Date �r 3 NORT1y TOWN OF NORTH ANDOVER Certificate of Occupancy $ s i a s'••.°•t<� Building/Frame Permit Fee $ V �cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # fv /,7 17849 r `� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING t 11 NMI BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commission" for of Bui ngS Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number _W 1.3 Zoning Information: 1.4 Property Dimensions: , Zoning DiAiic­t Proposed Use Lot Areas Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided RequijjET 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 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District Yes—No m 2.1 Owner of Record / Name(Print) ` Address for Service Signature Telephone 2.2 Owner of Record: x Name Print Address for Service: Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Li Constructi n Supe Not Applicable ❑ Licensed ConstructionSu rvisor: d;�, �—/ J License Number 0 n�,'- '-Z � Expiration date � Signature' Telephone 3.2 red Home Improvement Contractor Not Applicable ❑ Company Name ! (/ C/ M �GcG� 5 Registration Number Ad a Ep,,atf,,Daj4K ^ Si nature Telephone G) c SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check ali applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: f 00 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OF ICL4VV'E O1T1(y Completed b permit a licant � 1. Building (a) Building Permit Fee 00 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinZ 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 i 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 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 i Print Name SiNature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE it Rubera Construction, Inc. 201 Wheeler Street Established 1977 Methuen, MA 01844 Residential N Commercial 978 687-2942 FAX 978 686-3106 11/27/04 Hennelly 53 Chestnut Street North Andover, MA 01845 Strip existing roof to sheathing. Install T of Ice&Water shield to all edges. Install 8"aluminum drip edge. Install 30 year IKO roof shingles with ridge vents. Clean work area and remove debris. Note: Permit not included. Payment schedule to be determined. Rubera Construction Inc. proposes to furnish labor and material -complete in accordance with the above specifications for the sum of: $7,840.00 (plus permit). All material is guaranteed to be as specified. All work will be completed in a workman like manner to standard practices. Any alteration or deviation from the above specifications involving extra costs, (I.e. excavation required for ledge removal etc.)will be executed only upon written change orders, and will become an extra charge over and above this quote. These additional charges must be paid in full before said extra wok is initiated. All agreements contingent upon strikes, accidents or delays beyond our control. Acceptance of Proposal -The above price(s), specifications and conditions are satisfactory and are hereby accepted. You are authorized to complete the work as specified. Payment will be made as outlined above. Date Accepted Sign 1f L Date Accepted Signatye n Hennelly 28nov04.wps 11/28/2004 1 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 ignature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I I The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: F city Phone # I am a homeowner performing all work myself. 71 , I am a sole proprietor and have no one working in any capacity I am an emplover providing workers'compensation for my employees working on this job. Corrivagy name: rr� ti r Address :2-0 ct� I City: Phone# -2 2 y 2� Insurance.Co. Po1ICV# O z/ Comoarni name: Address C •ItV' Phone# 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 ntell_as_civil..penatties inkelixm de.STOP WORKORDER.and_a.fine d..(..$100.0W-aA i.agaimt-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 hereby certify u thensan n ties of erjury that the information provided above is true and correct. Signatu Date OCL_ Print nam f✓ ��—. P.hone# iffy Official use only . do not write in this area to be completed by city or town official' City or Town Permft/Licensi ❑ [:]Check if immediate response is required Building Dept Licensing Board ❑ Selectman's Office Contact person: Phone#.• ❑ Health Department ❑ Other i i �X011' � BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR -. Number: CS 025158 Birthdate: 08/19/1956 I Expires: 08/19/2005 Tr.no: 942 i. Restricted: 00 RICHARD J RUBERA I 201 WHEELER ST METHUEN, MA 01844 4 _ Administrator I OAA KW"XA"je& 0-7 -6 Re la ions and Standards Board of Building gu One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement:Contractor Registration Registration: 100756 ' y Type: DBA Expiration: 6/23/2006 RUBERA CONSTRUCTION INC.-. Richard Rubera . = �J 201 Wheeler Street Methuen, MA 01844 F ;,�:/_.-.._�,•,�,;� Update Address and return card.Mark reason for change. E] Address E] Renewal El Employment Lost Card DPS-CAI is 50M•04/04-G101216 �lze �iamirno�uue�� �✓�aaciclzuaetta Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 100756 One Ashburton Place Rm 1301 Expiration: 6/23/2006 Boston,Ma.02108 TYPe=: DBA RUBERA CONSTRUCTION INC. Richard Rubera 201 Wheeler Street ,,�, �✓ Methuen,MA 01844 Administrator Not valid without signature BOARD OF BUILDING REGULATIONS f E VISOR License. • CONSTRUCTION SUP R i Number: CS 025158 Birthdate: 08/19/1956 Expires:08119/2005 Tr.no: 942 ' Restricted: 00 _ RICHARD J RUBERA 201 WHEELER STS�i E METHUEN, MA 01844 Administrator �.- i i I NORTH TONM Of And No. X _ �D q E o dover, Mass., d m COCMICKEWICK �ADRATE D PPS\ 5 '4S � BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System '� BUILDING INSPECTOR THIS CERTIFIES THAT........�'..0 4e t t............ ... .....4041104...... �... .................................................................. Foundation has permission to erect...J.f.&f.A......... buildings on .......6-43....C`1.�.kK—&! ......5�.. Rough ALW", & RP4161� Chimney to be occupied as ................................. ................................................................................................................. ............... . 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. ` O C/q y PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS 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. SEE REVERSE SIDE Smoke Det.