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HomeMy WebLinkAboutMiscellaneous - 54 OLD VILLAGE LANE 4/30/2018 54 OLD VILLAGE LANE 210/059.0-0064-0000.0 1 Date.✓.44?11Z . ... . NORTH TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �,SSACHUSE� This certifies that -An. S ua7ua . . . . . . . . . . . . . . . . . .1 �,�' has permission for gas installat onl� �Jt�ls in the buildings of R. . . . . . . . . . . . . . . . . . . . . . . . . . • ti at . ... .. Z11. . . ., North Andover, Mass. Fee.`;;; :.,?Lic. No,�,�7. �7. . /,1-- A c4�. , �f.•�r,,-4, GASINSPECTOR Check# 8078 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING b CityITown: !VDr+-k A1V6ue( , MA. Date 29 12 Permit# Building Location:5401A VdiA�6d L4� Owners Name:GftM& U t1�i-Q.l A Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional❑ Residential K New: ❑ Alteration: [ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES co Cd Z F_ cnU = Q U) O m = 0 Lu W U (n Fes- 0 = W W mww Z z g Z W W Z LU W 0 F w W w m 0 a a H o w X W o w o7 U W (n O F.W. W W Z Lu (7 -� F- I- O Z --I 0 LL � = W W W W O W W Q W W m W O Z O ca F-' > Z l- _ V o u_ C7 C7 z z � O a H j > O SUB BSMT. BASEMENT 1 FLOOR 2 NuFLOOR 3 FLOOR 4 TH FLOOR ST HIFLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: SAVIA1ctE Pic 3 H'Ra ❑Corporation Address:('.0-bOX 31City/Town: S&L(LTA State: ❑Partnership Business Tel: 1$`$OQ- 11 s0 Fax: [Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy K 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 Signature of Owner or Owner's Agent Owner El Agent El By checking this box❑;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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑Plumber E]Gas Fitter Till Z Master Signature of Licensed Plumbe /Gas Fitter Cit /Town Journeyman License Number: 3 �-7 APPROVED OFFICE USE ONLY El LP Installer . I The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street .Foston, MA 02111 '" www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizafion/Individual): SAVAL-rf F19 3 - Address: 39 –– — City/State/Zip: SA Le m T{ f J 63a,11 Phone#: 178-809 • I ISO Are you an employer?Check the appropriate boz: [2. ❑ I am a employer with 4. [] 1 'I am a general contractor and I TyE f project(required):' employees(full and/or part-time).* have hired the sub-contractors [7. ' New construction [ I am a sole proprietor or partner- listed on the attached sheet t ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp,insurance. [No workers'comp.insurance 5. 9• Building addition p ❑ We area corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑.I 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•E]Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.R]Other AS .An y applicant that ehee:s box 41 must also fill out the Section below aho:�^r. their T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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.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 Section 25A ofMGL 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. l do hereby ce under the pains and penalties of perju?y that the information provided above is true and correct Si re: Date: 2.12.4 Z Phone#: — �Q .. '5� F only. Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.PIumbing Inspector son: 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 licensmg'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 coinpliance 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-contractors)name(s),address(es) and phone number(s)along with their certificates)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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date-the affidavit. The affidavit should by returned t0 the Oiiy or town"that the appl ioa`ion for the permi4 or licen!se $ e' requested, t ' t i b :ng iaQ fn--Drift en 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 1-8.77 MASSAEE Revised 5-26-05 Fax#6.17-727-7749 www.mass...govfdia Location oldyel1,4G No. p� Date NaRTh TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ s <� Building/Frame/Frame Permit Fee $ J�cMusa g > ; Foundation Permit Fee $ Other Permit Few $ TOTAL r t Check # 1 8 1 9 4 Building Inspector ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING , '. _ R,3s: +e+ctio 'for tli �cilai' set)nI :; BUILDING PERMIT NUMBER: DATE ISSUED: r 0 M >r SIGNATURE: Alk" (C44o� Building Commissioner/1for of Buildings Date SECTION 1-SITE INFORMATION A Z 1.1 Property Address:: / 1.2 Assessors Map and Parcel Number: O �IV v Map Numrxr Parcel Number 1.3 Zomig Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard -Required Provide R red Provided R uired Provided 1.7 Water Supply M.G.L.C.40.§54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHENAUTHORIZED AGENT 2.1 Owner of Record m 4 . Name(Pint) Address for Service NINDO VE A, Signature Telephone e 2.2 Owner of Record: tame Print Address for Service: O Z Si nature Telephone- M SECTION 3-CONSTRUCTION SERVICES Qo 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. License Number O Address Signature Telephone Expiration Date ic r 3.2 Registered Home Improvement Contractor. Not Applicable ❑ 2AVLR_ CASTR1 �0�1��2�G. Company Name /b [,.,,( t) a_=0�'T7 SY1TE Registration Number ` r 3 ��1� � z �3f� Expiration Date A Signature Telephone y, SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ xa. L qtr"R v Accessory Bldg. � "F Demolition' ❑ Other ❑ Specify R d E Brief Description of Proposed Work: - -4 S'T r h `�'V i S�1.� 1,�% o c� ���.t n1�i f/� , 'a-V UJ L Q SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be QFFICIAL-USE-OnY Completed b ern a licant 1. Building (a) Building Permit Fee l 1 (� C • O Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(8) X (b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 0 , 00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 40 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, M/T C1J S 7—k L La A2E as Owner/Authorized Agent of subject. property i Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief V A V' C D C,1I S TX i cin)E Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2ND 3RD SPAN DM ENSIONS OF SILLS DIN ENSIONS OF POSTS llIMENSIONS OF GIRDERS ` HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X �. MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS.BUILDING CONNECTED TO NATURAL GAS LINE ��. The Co=wnweafth of Wwsachusetts W; t Department ofIndustriar.Accidents T4s i Office ofInvestigations 600 Washington Street Boston, WA 02111 Workers'Compensation Insurance Affidavit APPLICANT INFOIRMATION Please PRINT Legibly, Name: Location: City: No -K1,6 p1 Telephone#: `� 7 30 ❑I am a homeowner performing all work myself. I am sole proprietor and have no one working in my capacity ❑I am an employer providing workers' compensation for my employees working on this job Company Name: ,DAVID CASTR,IC Al9 ROOr'i/y6 Address: 200 . 5(477Z ST Swore Z.7-Ito City: /V ID /'�N D 0U6K Telephone#: q�o � �`' — 3 4 Insurance Company: IT I /►1 Policy#: Y /a o o Al 13 I am(circle one) sole proprietor,general_contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City: Telephone M Insurance Company: Policy#: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional.sheet if necessary Failure to secure coverage as required under'Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby ce under a pains and enalties of perjury that the information above is true and correc f 1 Signature: r Date: Print Name: •V i D C AS•r"�2l CIV AJ Ir Phone# l n 3q za _ Official Use ONLY-Do not write in this area ❑Building Department City or Town: Permit/License#: o Licensing Board ❑Selectmen's Office D Health Department 13 Check if Immediate response is required 0 Other INFORMATION&INSTRUCTIONS Massachusetts General Laws chapter 152 section'25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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,, co oration or al entityor any or more of the foregoing engaged m a joint enterprise, and including the legal epresentati es of a,deceased o 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 reside 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 ap urtenant there such em P to s ployment be deemed to be an employer. hall not because of MGL chapter 152 section 25 also states that 'every state or to or renewal of a liten �' cal_licensing agency shall.withhold the ' se off-permit to� ' „ . issuance p operate a business or to constructbuildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, 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,ofthfs chapter,have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the.box that applies and supplying company names, address and phone numbers as all affidavits may be submitted tootyhe. situation Department of Industrial Accidents forconfirmation 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 listed below. number City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for your cooperation and should you have an questions, please do not hesitate to give us a call. Y 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 Fax# (617) 727-7749 Telephone# (617) 727-4900 ' ext. 406, 409, or 375 Town of North Andover Of ,AORTH Building Department o 27 Charles Street North Andover, Massachusetts 01845 z (978) 688-9545 Fax (978) 688-9542 ,) 7 reo US DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in/at: V y ' DSD ' a , Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. F NORTH Town of _ RAndover 0 No. 7 Z• '— / Q — = A K E dover, Mass., COCHICHEWICK y�• 7�S RATED P'Pa\ �5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT....... '� �� V BUILDING INSPECTOR �Id r...................................................................../................................. Foundation has permission to erect.ws.... R.A p.......... buildings on.... ..... ...............�..�...................v.......A... ........... . Rough to be occupied as �` ....r. • O .......... .W �. ........................................................... Chimney ................. .. .............. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Lavp relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. (S- Vepe PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION �' ELECTRICAL INSPECTOR ► Rough ...kAAAO.6"o. ........ ...... ............... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. Date....... 1 f NORTH, o:;.�`` :•_e"�o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING, s o• _ ,�•�a ��sJACHU This certifies that ......A............... .. . .... ( has permission to perform ........C ................................ wiring in the buildin of v f� �L:'..1. ........ ..... at - ( 1 ... North Andover,M S. Fee.� �. Lic,No... �S 9� ff� ��............ ..cmicAL MpEcroi/ Check # 10521 Commonwealth of Massachusetts Official Use Only 105-21-1 Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: k2-"1—It 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 electric/al work describ�eylow. Location(Street&Number) 5 L4 OIL y kkk,p e,1 L4L (� ✓a Owner or Tenant G c.®-r G.X b\-s7+;;C,L Telephone No. ei'Ig_(0C41- l SL3 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No A (Check Appropriate Box) Purpose of Building t'tovhc� 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: 5 � ,. a� Completion of the following table may be waived by the Inspector o 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 Above In- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Totals T. """"....._....".... W.......... No.of Self-Contained Heat um um er Tons K 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 1 No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: _ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 4 5 Cyc� "' (When required by municipal policy.) Work to Start: \?-- \0-I ( Inspections to be requestedin accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I cert,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: w� i.�c iCLlu�-��c�.-C Sc�✓�tc� '�n LIC.NO.: i0l.5q Z9 Licensee: � � �Jpct�.o Signature Jp _ LIC.NO.: 41510-oi (If applicable, enter "exem,p�t in the license umber line.) Bus.Tel.No.: (6,2-GS4-14!'(Yty Address: `-] 1�cci-V;cA . S� vo _1 ,,, N1+ o3,w7 9 Alt.Tel.No.:(-C;-4 233--q " *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. A 15 4 z g 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 Owner/Agent Signature Telephone No. PERMIT FEE. $ i ,� ,, . �/Z -� -Z._ � � �- �� �- 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kEEREEZI 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leszibly n Name (Business/Organization/Individual): + pt.%,.,- �u�c�c.�( Address: L S-k--r�L� City/State/Zip: Pit b3o-74 Phone#: C 03 SZ- `fS"-lO Are you an employer?Check the appropriate box: Type of project(required): 1.�C] l am a employer with 3 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. # E] Remodeling k 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.❑ I 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 insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *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. ��ll Insurance Company Name: 1-�SS �1_L (-y" , i Policy#or Self-ins.Lic.#: LJ CC-S 0 0 Q, cto3 camsro Expiration Date: 3 - Job ^Job Site Address: JL4 ©Q_ Ut 1�/ASr-,,_ LA�,C_ City/State/Zip: d 9 f,;h 4 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cy under t e pains andpenaldes ofQperjury that the information provided above is true and correct. r 2' ? '�Si nature: Phone#: (-w,- -; -133 - _79V Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date. N° 4513 "I..T TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING s o� - •'a This certifies that ./F�.A PQ.Z-1 .r. . . . . . . . . . . . . . . has permission to perform . e'!'.v. '. . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . at. .S`!. c>.c : . : :: : . ., North Andover, Mass. 4. Fee.Z2..". .Lic. No/ /C. -t om. . . . . . . . PLUMBING INSPE T0R Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLh M1131 .� It Tint a 7yp4 _ • Mass. Date 7 27 — 49(DI P it Building Location V/U Owners Name Type of Occupancy / New O Renovation Id Replacement O Pians Submitted: Yes O No W FIXTURES W Px }— N ' W H � C N 6 C ¢ X ¢ a W - - r^ o to r m N r v m x < Q d C O v = a a rc yr m ¢ < m = o < z d Q Us x o ry } r- v x m r o o v� w ►- < F _ �_ < O S l7O—D S MT. IASEMEHT ST FLOOR 2liD FLOOR 3RD FLOOR ATH FLOOR STH FLOOR ' 6TH FLOOR 7TH FLOOR ETH FLOOR I I Installing Company me �U '� YDS Check one: Certificate Address . . KOk I OZ O Corporation l7tt't>'Ve lis vLAAA D 1$.34Partners;rip Business Telephone 117� S7 L) 7 37 O ZCo_ Name of Ucensed Plumber INSURANCE COVERAGE: 1 have a current ltability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have Aecked yes, please Indicate the type coverage by checking the appropriate box A liability Insurance policy Other type of Indemnity ❑ Bond O OWNER'S INSURANCE WAIVER:l 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: Owner ❑ Agent❑ Signature of Owner or Owner s Agent I hereby certify that an of the details and information 1 have submitted for entered)in above application are true and accuratp to the.M_Jt of mv knowledge and that all plumbing work and installatim performed under the permit ism:ed ter this aepkcation will be in compliance with all Pertinent provisions of the Massachusetts Slate Plumbing a and Chapter 14;11 the General laws aal�urye�at licensed _r / 9 Title - "p- �� b/ JN2 z) 5 Date.................................. Ff TOWN OF NORTH ANDOVER 0 1 0 PERMIT FOR WIRING 14 Nu Thiscertifies that .............................................................................................. has permission to perform .. ...... ........................................................... wiring in the building .................................................... ........ North Andover,Mass. ............. ...................................... ..........;. .......... Fee.'.�%................. Lic.No!A'�' � /-�— - . - ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer THECOMMONWE4LTHOFMASS4Cf USEf7S Office Use only DEPARTMENTOFPUBLICS MY Permit No. BOARD OFMEPREYEWONREGMT10A N52702IZOO Occupancy&Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 f (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 01-0 U 1e 6,4 6 e 12 Pi J2 Owner or Tenant Owner's Address ��/ OL/� (//r�Gv? A.JV Is this permit in conjunction with a building permit: Yes[Z] No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead Underground No.of Meters New Service Amps volts Overhead J= Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work� 17-CIP N ee PP No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA groundg1:1round No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges y No.of Air Cond. Total FIRE ALARMS No.of Zones ,F Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tans KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices r. .of Dryers Heating Devices KW Local Municipal a Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER- tQ /?�` P Sy ,yBG- Ir�strxreCotaage RffSU3tb1hetaquaaret& nftGmaWLaws Iha%eatamatLi okk r&=Pd yerlu&gCa CaaaWcritsmbsti>5aletpriva YES M NO M IhaaesthnJadv*lpoofof§wrlotheOffm YES M No =-,/ of uha� duck dYES,pleaseitdicalethewcfwmagebydakirgthe ll• IC EE BOND a OTl&R (Plea9espatafy) Estat&d VahaedBeMiral Wade$ '41,Vdk>DSralt 1 D,-iL-RqxsW Ragh _/ Oa Etrtal Fdd Sigttedutdx"& cfpetw FIRMNAM/E Lioa>seNa Lica>see T/�/'�`y/Ge vTej�'`- Slgn0lute �' �.._.�� LIt eNo x/37 / / Bts¢IessTd.N x Ad,.S 201 .S�l�P(-1f00 SSP ✓�z �y t/�i� /y1 f¢ (�!��� AItTeLNtz OWt,M'SINSURANCEWATVER,I.amm=ftat1heUmwft not mquaedbyNimodxselisCa awlam anddtmysgdiaecnftpwnitappkMatmw,,esdrisregtlaarlat 00 (Pl � e=hecone) O ner Agent L...�.i q �- .f �"--�+ Telephone No. / �Z� PERMIT FEE L 06 .�_ Location �� C 4r- //,4lf J No. ` Date i NaRTM TOWN OF NORTH ANDOVER Certificate of Occupancy $ cNusE`� . Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ s' Check # S f -� 47 ; S Building Inspector r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING MOMwe ..?T ..'ffx!i . �.&�.,f.y1;.,.. �^ .. J. .:S' ' '.:x. ,,.. ! ... .., 's*a» ,�.'^. ■ ■ BUILDING PERMIT NUMBER: 7 DATE ISSUED: ��` D / ic SIGNATURE: I Building Commissioner/Inspector of Buildings Date SECTION 1-SITE INFORMATION I z1.1 Property Address: 1.2 Assessors Map and Parcel Number: L� C- ) circ,-e ( y, l Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Re red Provide R red Provided R red Provided 1.7 Water S ly M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) c Address for Service: Signature Telephone 0 2.2 Owner of Record: Name Print Address for Service: .oy M Signature Tele one SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction.Supervisor: License Number M Address ,� Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M Address Expiration Date Signature Telephone Q r � SECTION 4-WORKERS COMPENSATION(AG.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 Bui)di g ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ` ❑ Other Specify Brief Description of Proposed Work: ` SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be ,�*3 a " QFF1C AL U k Q1�3I.Y i y Completed b permit applicant ;1 1. Building (a) Building Permit Fee ® Q Multiplier i 2 Electrical (b) Estimated Total Cost of i Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ./ SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN `« OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT— ._.. I, as Owner/Authdrized Agent of subject property t Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Own Date .— SECTION 7b R/AUTHORI D AGENT15ECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name i Signature of Owner/A ent Date Z gill 11191 F NO. OF STORIES SIZE S , BASEMENT OR SLAB \o G ei,c wT SIZE OF FLOOR TIMBERS 1sT 2ND 3 SPAN DIMENSIONS OF SILLS DDAENSIONS 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 I VYVJI VI IVVIUI miiuuver � ,,"" !• ,� Building Department 27 Charles Street14 *:a North Andover,d ver MA. 01845 � D. Robert Nicetta Building Commissioner (978) 688-9545 .,..:(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE JOB LOCATIONNumber l// Street Address Map/lot "HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1 j DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which hetshe resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE �../' ��� � Ike- APPROVAL LSAPPROVAL OF BUILDING OFFICIAL NORTH 0" � o T ` E D over No. � C, - h � COCHiC , dower, Mass., 0R ATE D PPS BOARD OF HEALTH PERM.. IT T Food/Kitchen Septic System A k e r / `e. :J) V 1 /J BUILDING INSPEC'T'OR THISCERTIFIES THAT......................................................................�................................................................................. Foundation has permission to erect........'e�� ...... buildings on ( lal v// q'� ill./.'� Rough ....... ....... ...... .. . to be occupied as c `� ^� w /4-'' rl /�' �i°S l O�`2�tJ e� Chimney ................................................................................................................................... provided that the person accepting this permit shall in every respeaconform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to t e Inspection746r, oration and Construction of Buildings in the Town of North Andover. � CY6 7 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ." .. .....................`............................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. 4 SEE REVERSE SIDE Smoke Det. Jul 04 01 08: 33a George Duffield 978-557-9176 p. 1 Town of North Andover ao ...0 O Building Department o °� 27 Charles Street North Andover,Massachusetts 01845 10 i (978) 688-9545 Fax.(978) 688-9542 �9SSgCFiU���� F DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, anda condition of Building permit-# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl'l, 3150a. The debris will be disposed of in/at, Facili location Signature of plicant Date NOTE: A demolition permit from the Town of,North Andaver must be obtained for this project through the Office of the Building Inspector,