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Home My WebLink AboutMiscellaneous - 54 SPRING HILL ROAD 4/30/2018 / 54 SPRING HILL ROAD - J 210/107.A-0234-0000.0 Date...... ..................................... 0*OORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,sSACHU This certifies that .......... ✓.. ...... ....................4;;J.......................................................................... has perrmission to perform ....... C7,— ............................... . ........................................................ wiring in the building of...... .!.. n ..................... ............ nn at N?r ...... .......Sr........... .............................. ......... th/Andover,Mass. Fee ............Lic.No. ELECTRICAL INSPECTOR Check# 12644- 1 -<\- Commonwealth of Massachusetts Official Use Only - Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] w� (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 52 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date:,Y —s-f t City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives tice of his or intention to nerform the electrical work described below. Location(Street&Number) - f l Owner or Tenant Telephone No. Owner's Address Is this permit in cnjunction with a building permit? Yes ❑ No ❑ (Check Appropriate]Box) M Purpose of Building 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 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- El o mergency Lighting 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 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of er' t1 t the information on this application is true and complete.. FIRM NAME: • 40wie-0 6L. W cI r~iQ`r1a 1 LIC.NO.: 6 �� ✓ Licensee: �j�., _ Signature LIC.NO.: 7 �� (If appli e,en er "exemp in the license umber line.)p Bus.Tel.No.• Address: /� Alt.Tel.No.: *Per M.G.L c. 1 7,s.57-61,security work requires Deflartment of Public Safety"S"License: Lic.I No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance a verage 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 F E. $ 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,arr ' 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 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass[N Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: 4 44 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r ne Commonwealth of Massachusetts Department of IndustrialAceldents 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 YERMITf1NG AUTHORITY. Please Print Le 'bl A ' licant Information Name()3usiness/6rgariization/Tndividual). Address. �qy City/State/Zip: G Phone#: 5 . . Are you an employer?Check the appropriate box: Type of project(required): em to ees full and/or part-time)." 7. ❑New'donstriiotlon 1.Q I am a employer with P y 4_;ny am a sole proprietor or partnership and have no employeesworking forme in 8. Remodeli ug aci oworkers,comp.insurance required.] 9, Demolitionca ty [N •P 3.E]I am a homeowner doing all work myself'[No workers'comp.insurance required.] 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 . rr 12�D plumbing repairs or additions proprietors with no employees. $.❑I am a general contractor'and Ihave hired the sub-contractors listed on the attached sheet. 13•.0 Roof repairs ,_ These sub-contractors have employees and have workers'comp.insurance., 14Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and vve have rio employees:[No workers'comp.insurance required.] applicant that check's bbk#1 niiist also fill out tn: P he section below showing their workers'compensation policy information, *Any a Homeowners who submit this•affrdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- os $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those,entit}es 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 insurancefor my employees. .Below is the policy andjob site information. Insurance Company Name- Expiration Date:. Policy#or Self-ins.Lic.#: . City/State/Zip: Job Site Address: ompensation policy declaration page(showing the policy number and expiration date). Attach a copy of the vsToxkers' c e as require under MGL e.152,§25A is a criminal violation punishable by a fine up to$1,500-00 a cure coverage q u to 250. Failure to se g and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER of the DIA for insurance y esti ati ' .ator.A co Of this statement may be forwarded to the Office o£Inv g da against the viol COPY Y g coverage verification. Ido He�certider tliepainsandpenalties of pery that the information provided ab ;��dcorrectDate: Si at Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# IssuingAuthority(circle one): 'cal Inspector 5.Plumbing Inspector Clerk 4.Electra p 1.Board of Health 2.Building Department 3.City/Town Cl 6.Other Phone#: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their ennpl6yees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of We, express or implied,oral or written." An employer is'de£uied as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiv6for 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 b6 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(1)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 ofthis 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 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(ifnecessary)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-AIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia s 0MMONWEA.LTH OF MASSACHUSETTS "4 BOAf�IJ OF EL1=CTI C1 ANS 'a ISSUES THE FOLLOWING LICENSE A� A RSG JOURNEYMAN .ELECTRtChAI� r.. � EDWARD G ' HAJJAR i: ._N. . r fYZ �Z 1200 SA:LEI� `f � �r,�� I1 NOVMit `01$45 49 2 350 A „ 17982 .:. ::.;0 7 .COMMONWEALTH OF MASSACHUSETTS • Wo "A"I c'1 AN$ + ISSUES THE FfTLLOWING I�I;CirNSE 'AS 1 E12F MASTER.....ELECT�,�"C � EDIrARO G: HAJJAR to NO-PITH "ANDOVER MA 01845 4924` L27356 1 • 639A Date.................................. NORT1� °!t"`°;•�"° TOWN OF NORTH ANDOVER • o p PERMIT FOR WIRING �Ss�cwUSE� This certifies that ................ U /` .... ...................... has permission to perform .......... ..r � �jvEh/................................... ......... wiring in the building of....... /G L rtj................................................... at....S.��.. � -�c j. 1�-q...f�. .......... ... ......North Andover,Mass. " Fee...,�_Q .... Lic.No. d ��j ..... . ........ �2 ' ELECTRICAL INSPECTOR/ �; Check N .�6/ / r . 2012 Massachusetts Electrical Code Amendments 527 CMR 12..--,< .00§Rule 8: In accordance-with the provisions of M.G.L.o.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 acceptad.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 ori 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_ifhe—_. ._ 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 entitystated 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. L>dwv 8—Permit/Date Closed: —l S ***Note:Reapply for new perm' 0 Permit Extension Act—Permit/Date.Closed: COnunoneuaaLtlL o y�j�a7dac�nu�ei Official Use Only cc�� cc77 Permit No. qsze eLJeParfinei�o�}irs�aruice� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort:to be performed in accordance with the Massachusetts Electrical Code( C),5 7 CMR 13.00 (PLEASE PRINT IN INK O TYPE L INFORMATION) Date: W Wio City or Town of: d o J r To the Inspe for of Wires: By this application the unders g'nid gives notice of his or her intention toerV the e],ep cal work described below. Location(Street&Number) fl. it , Owner or Tenant ( i t eq Telephone No. Owner's Address Is this permit in conjunction with a b "lding p rmit. Yes 5V No ❑ (Check Appropriate Box) Purpose of Building , t ILI, Utility Authorization No. Existing Service Amps J 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: kfmo Com letion of the olloivin table ma be waived b),the li!5eEctor of Wires. No.of Recessed Luminaires 0 No.of Ceil:Susp.(Paddle)Fans r o Tota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above E] In- ❑ o.o Emergency Lighting rnd. grnd. :Battery Units No.of Receptacle Outlets (0 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o initiatinDevices an evices No.of Ranges No.of Air Cond.. Total Tons No.of Alerting Devices No.of Waste Disposers eat Pump umber ons K o.oSe-If-Contained Totals: Detection/Alertin Devices No.of Dishwashers S ace/Area Heating KW Local❑ umect [I Other P g Connection No.of Dryers Heating Appliances I(W ecurity Systems:* ry No.of Devices or Equivalent No.ofater , o.of No.of Data Wiring: Heaters, Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP clNo o fDevice o r Wiring No.of Devices or E uivalent Y OTHER: Attach additional detail if desired,or as required by the Inspector of hires. 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 Iicensee provides proof of liability insiWance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of wae to the ermit issuing o ce. CHECK ONE: INSURANCE BOND F1OTHER [I (Specify:) KI L 71,9 j X 31 /� t lX-12 1 certify,under the pains and enalties o erjury,that the information ort t/lts appltcattori is true arul con p h' P P IPiCLIC.NO FIRM NAME: _J a Eof:. n . Licensee: S r iJ Signature LIC.NO.: (If applicable,enter 'exem^"in the I c nse nwnber line I- �, /j Bus.Tel.No.• �— Address: vt 1 Alt.Tel.No.: *Per M.G.L.c. I47,s.57-61,security wor equires Department of liub is 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)El owner 0 owner's 77� Owner/Agent I PERMIT FEE: $ Signature Telephone No. r_ Date... .�.. ..!{�... .� + .................. NOR7�y TOWN OF NORTH ANDOVER �.¢�... PERMIT FOR GAS INSTALLATION Causs Thiscertifies that ..'....!....................................... ............................................................ has permission for gas inst lation .... ..1Y4.. 1...!? ��Z �--.............. in the buildings of.............. '....... at............. `...�- ......... �....�..................a...t..........., North Andover, Mass. Fee 31)..- . .1 ..... Lic. No . ` ....... ........................................... ............. . IN.SPECTOR Check# ,7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ?IrMA DATE Z f 3 PERMIT# D `� JOBSITE ADDRESS Y S ;n ' f O OWNER'S NAME GOWNERADDRESS15- 11TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL�— PRINT CLEARLY NEW: . RENOVATION: REPLACEMENT:El PLANS SUBMITTED: YES E—J1 NO APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTERS 1 __ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR - GRILLE - -I -_ __— ( _1 __- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN �— POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER i WATER HEATER __ _. —-1 -. - --_._ �� k OTHER F INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [3<0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY __ OTHER TYPE INDEMNITYE] 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. s CHECK ONE ONLY: OWNER 0i AGENT F-3 1 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 S 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 !W2 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GA ITTER NAME LICENSE b SIGNATURE MP Lff MGF 0 JP® JGF© LPGI© CORPORATION[ v?. �' ( PARTNERSHIP©#L—_.._ .J LLC 0#= COMPANY NAME: G PFf co .;,f -e--,r ADDRESS CITY /� ^ I, I e -- _ STATE ZIP O� ._`l_F TEL FAX CELL _ EMAIL _ -- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 17 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Mlassachusettslcx " Department oflndustriglAccidents Office ofInvestigations 600 Washington.Street Boston,MA.02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2lbly Name(Business/Organization/Individual): 6-/y� Address: City/State/Zip: B �!S XnJ4Phone#: g a�- ' _Z-e"9_3' Are you an employer?Check the appropriate box: 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. �• FJ Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 El Buff addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.[I Electrical repairs or additions required.] officers have exercised their 3.El 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 .re uiredemployees.[No workers' required.) 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir 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 their workers'comp.policy information. lam an employer that is provltling workers'compeztsation insurance for my employees Below is the policy andjob site information. 11 Insurance Company Name:. w'T Policy#or Self-ins.Lie.#:, 0FTS/!'/4 U q 5_2> _D (=) Expiration Date: a c� Job Site Address: S� S��Y� . /l f 7 City/State/Zip: IA'J, 0'"-L� 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. X do Hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Simafore: Date: e 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 - - - C'nntart Persnn: Phone#: i e Information and Inst uctio�� 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-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 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 k any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for 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: `aha Gommonwoalth ofM-assac usetts ftaftent ofhndustdal.Accidents ofrace of avestigatioln 600 WasWVoa Stroet Boston MA 02111 TQL#617-727,4900 eYt406 or 1-877MASSAFF, Revised 5-26-05 Fax#617-727-7749 Division of Professional Licensure:License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES&RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Home>Division of Professional Licensure> ....................................................................................................................................................................................................................................................................................................... Check A Professional License By the Division of Professional Licensure I NEW SEARCH LICENSING BOARD TYPE LIC. # LICENSEE'S NAME CITY/STATE STATUS Sheet Metal Workers Master/unrestricted 13848 .MARK B MAGNIFICO MIDDLETON, MA Current Plumbers a Gasfitters Journeyman Plumber 25002 MARK B MAGNIFICO MIDDLETON, MA Current { Plumbers a Gasfitters Master Plumber_ 13559 MARK B MAGNIFICO MIDDLETON, MA Current Plumbers a Gasfitters Plumbing Corporation 3266 MARK MAGNIFICO MIDDLETON, MA Current Plumbers a Gasfitters Apprentice Plumber 20301 MARK B MAGNIFICO l MIDDLETON, MA Expired �jire The page above has been generated by the Division of Professional Licensure web server on Thursday, September 12, 2013 at 8:59:28 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pub]Licsn.asp?board code--PL&type class_M&license number=000013559&color=red 9/12/2013 w ^� Date.........�.`..2./.^.o.6 NORTH Of t��a°±a 1ti0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SS�cHU This certifies that ...................... U ............................................. has permission to perform ..........Z,.�'-T F--*0f , a �...... wiring in the building of....................(�-. .�... n/................................ ..... at.......- tf.........5 f2t .q..../`7l1.,............ .North Andover,Mass. a' Fee..-`.�..'. '.. Lic.No.x..13.34........... . .. .. . -I'J/ ........ ELECTRICAL INSPEOTOR Check # �? 674 Peri-nit:No. Department of Fire Services - - Occupancy and Fee Chemed �Q\ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05) — S" (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code1M C),527 CMR 12.00 (PI,kASE PRINT IN INK OR T P.E AL. INFO/RMATION) Date: s c/ City or Town of: o f To the Inspe . or of YVtres: By chis application the undersigned gi P notice of his or her intenIn to erfor he electrical work described below. Location (Street &Number) S — -- --__.--- Owner o1-'Tenant _ Q ' 1 � I Telephone No. Owner's Address Ayn-e Is this permit in conjunction with a building permit? YesNo ❑ (Check Appropriate Box) Purpose of Building (Gj 1 Utility Authorization No. _ Existing Service Amps / Volts v`�1 erhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity I:ocation and Nature of Proposed Electric^l Work: Completion of the folio-wing table may be waived by the Inspector of N,i* 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 Swimming Pool Above ❑ In- ❑ o. o mergency ,ig mg -_--__ rnd. rnd. :Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS 1No. of Zones I� No. of—Detection Dettiand No. of Switches No.of Gas Burners Initiatir,Devices i Total No. of Ranges No.of Air Cond. Tons No. of Alerting Devices J No. of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained _ _ Totals: I 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 _ l No, ofWater KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent _ ENo. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent_ OTHER --- ---- - -- i Attach additional detail if desired, or as required by the Inspector of Estimated Value of Electrical Work: '' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 16, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue urnle s the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent_ The undersigned certifies that such cover is in force, and has exhibited proof of same to the permit issuin office. ONE: INSURANCE BOND [:1OTHER ❑ (Specify:) J/l�✓�!/ 2S /Zt .1 certify, under thepains and penalties o perjur thae information on this application is true and ntplete. _ �� D FIRM NAME: �j lC j _ LIC.NO.: •.� 13�--_ Licensee: 5 .t __4010A_ Signature LIC.NO.:' (Jfapplicable, enter "exergpt"m th license num me.) -'-- i ((�� ? Bus.Tel.t c3r2�_� `.. �_� Address: !C I n a AA 0 P Alt.Tel.No.: *Security System Contractor License r&Juired for this work-, if applicable, enter the license number here: 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. 0 Date.....9! . )" O*r10RT/y, TOWN OF NORTH ANDOVER F 9 PERMIT FOR GAS INSTALLATION sSgCHUS� .ti This certifies that ...e�..4......)?004v-.v .............................................................. has permission for gas installation . .............................................. in the buildings of......,....... .. ................. . ................................................. ,Ft......,r^........................... , N h dover, Mass. Fee.��.................. Lic. No.1,57f.T•••......... '�•,...... .... AS NSPECTO Check#, 10144 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY D' Cl�� _ MA DATE - PERMIT `,�- - JOBSITE ADDRESS I `7�„�/.� s OWNER'S NAME GOWNER ADDRESS TE -FAX TYPE OCCUPANCY TYPE COMMERCIAL EDUCATI NAL RESIDENTIAL PRINTT CLEARLY NEW:E1 RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER M _....._..1.__ 1 . I E:__ , ::j I: ,__ 1:::J - BOOSTER ---I - - - -- - - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACES FRYOLATOR FURNACE GENERATOR T - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER -- - _i�- �- ROOM/SPACE HEATER _ ROOF TOP UNIT TEST - _ _I_. _ - UNIT HEATER _ I_ U,,I ENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 92 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true ur o the a my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp lance all erti vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME (' / LICENSE# /3 — SIGN TURE MP GF EjI JP El JGF D LPGI© CORPORATION F- #©PARTNERSHIP©#=LLC E6#fie COMPANY NAME:I,� irv�' ADDRESS CITY STATE®ZIP ® TEL r cr += Z07 FAX��CELL EMAIL _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INS ECTIO OTES Yes No Z/f-11r" THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES b The Commonwealth of Massachusetts Department of IndustrialAceldents 1 congress Street,Suite 100 Boston,MA.02114-2017 �r www mass.gov/dia Workers'Compensation Insurance Affidavit:Builder/Contractors/Electricians/Plwmbers. TO BE FILED WITH THE PERMITTING AUTHORITY. -,Please Print Le 'bI A ' licant Information Name(Business/Oigatization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): (Rill to em full and/or P arkime).' 7. El New'd6nstr6dtion 1.❑I am a employer With • . P y 2.❑I am a sole proprietor or partnership and have no employees Working for me in 8. Remo deli ig any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.F]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 properly. 1 will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole -' proprietors with no employees. 12.Q.pj:`mbing repairs or additions 5.Q I am a general contract o`'and I have hired the sub-contractors listed on the attached sheet. 11 F]Roof repairs These sub-contractors have employees and have workers'comp.insurance 14.n.Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),andwe have no employees:[No workers'comp.insurance required.] *Any applicant that checks bbk#i must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•tlus 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'n 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. X am an employer that is providing workers'compensation insurancefor my employees. below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date:. City/State/Zip: Job Site Address: 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 fifle 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. eby cert under the pains andpenalties of perjury that the information provided above is true and correct. 7do her Date: Si ature: 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 Phone#: Contact Person: � 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'd'efvied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,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 b6 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=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 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 1.00 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 Date....,?hhr............ 11337 OF NONTF�,�O TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that)K!.......... . ................................................................. has permission to perform.......... .............................................................. plumbingin the buildings 0 ............................................................................................. W.-So..t.........................0"4Ndover, Mass. c. .... ... ............. .. Fee.W..W.... No. ...... ..... IVIBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE / .S' ( PERMIT# r/ OWNER'S NAME JOBSITE ADDRESS _�_ So,�,� POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:D REPLACEMENT: Q' PLANS SUBMITTED: YESE11 NOo" FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _f — _f==== ,_.-__..! .�._,1====== CROSS CONNECTION DEVICE F11 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I--ji DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f . DEDICATED WATER RECYCLE SYSTEM I _.__..__1 ._._..__f __—.1 _..__ DISHWASHER f ___._._f —J= .-__._I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY f f � ! _ _f J __.__..f ._.__� f _---...._J ---._..... I ROOF DRAIN SHOWER STALL SE VICE/MOP SINK TOILET _ f _ _ I ___.__f _._ ._ URINAL WASHING MACHINE CONNECTION # _---J WATER HEATER ALL TYPES WATER PIPING OTHER _..—__s T. __..— ___f f ._____1 __.__ f _,____ --_____f .----JL-,J INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESH-190-1a0 D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-- OTHER TYPE OF INDEMNITY 0 BOND Q 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 Q 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 ac c rate t est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i om ce wi a IngAt provision of th (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME f ° vlr (LICENSE# . f SIGNATURE MPR— JPnI CORPORATION # PARTNERSHIPOW LLC0 i COMPANY NAME --- �J ADDRESS /y me - CITY _I--- STATE ZIP TEL G� FAX ( CELL __ EMAIL L— _ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECInONAOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts . F Department oflndustrialAccidents . . � te 100A.: Street,Sho 1 Congress Sty' , tl Roston,MA 02114-2017 �< www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/l le4*lcians/Plumbers. TO BE FILED WITH THE pERMCTTING AUTAORITY. Please Print Le 'bl A licant Information 5 Name(Business/Oiganization/Individual): Address: f//ii � City/State/Zip: Phone .. ._. ,. : ....<�... ,. Are you an employer?Check the appropriate box: Type of project(xequired): toyeesrand/or parttime).` 7. ❑New'd6nstrd6 on 1.❑Iamaemployerwith em an 2.❑I am a sole proprietor or partnership and have no employees working forme in $. 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 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repaixs or additions ensure that all contractors either C] her have workers'compensation insurance or are sole , proprietors with no en plbyees. � ,PjiimDing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13T]Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 14.'n Other 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and' have no employees:[No workers'comp.insurance required.] Any applicant that check's box#1 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 additional sheet showing the name of the sub-contractors and state whether or not(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name' Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). e by a fiftb Up to$1,500-00 Failure to secure coverage as required under sd iviM enalties in§the form of 25A is a STOP al violation RK ORDER Iand fine f p to $250.00 a and/or one-year imprisonment,as w P ay forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement m coverage verification. X do hereby cerci a ins enalt' s of perjury that the information provided above is tr.e and correct Date: Si ature: Phone#: Official use only. Do not write in this area,to he completed by city or town official. Permit/License City or Town: # Issuing Authority(circle one): i 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 6.Other Phone#• Contact Person: u Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for theiremployees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of bore, express or implied,oral or written." An employer is•defni.ed as"an individual;partnership,association,corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiv&4 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 opdrate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage iequiired" Additionally,MGL chapter 152,§25C(1)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 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 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"fob Site Address"the applicant should write"all locations in (city or to-am)."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 DateORTH . ... . TOWN OF NORTH AND ER Of '1,�, ° p PERMIT FOR PIBING 'r ,SSACMUS� This certifies that . . . . �:. . ��a.t ... .`. . .. . . . . . . . has permission to perform . . .L,,— .<!�, C. . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at . . . .5 ��. ..F./.'/i!''.).�.,. .�. .(. . . . . . . . . . . . .. North Andover, Mass. Fee. AU1 . . .Lic. No.)s- `. . . .. r f PL WING INSPECT6R Check ,H 7009 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Xners Building Location S /L (, Name r`! �� Permit# Type of Occup,nc Amount New Renovation Replacement13Plans Submitted Yes ❑ No FIXTURES a a w w U ° z U ° w 3 A a w x 3 a �a A � H � � a �iVENr ` isr m" MFU)M 3M FL" 4M Hi" M FU)M 6M>tioat TT-- gm H-"- (Print ortype)Co n ' /~ �� !� � �� C Check one: Certificate Installin Comp any Name _ yr / � ❑ Corp. Address �U 1 � 1 +'L �0 Irki�— Partner. Business Telephone aFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 1 Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner Agent 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 under Pe it Issued for this application will be in compliance with all pertinent provisions of the Massa u. tts Sta imbifC0dA Chapter A of the General Laws. By: ignaure ot LIWISCC17M77-r— Title i Type of Plumbing License City/Town [cense lNumuer Master Journeyman ❑ APPROVED(OFFICE USE ONLY D ate.. . . . .. .... NORTH Of ..ao 14, 3? �` TOWN OF p D • PERMIT FOR GAS INSTALLATION �,SSNCMUSES This certifies that . . . . . ... .. . . . . . . . . . . . . . . . . has permission for gas installation . . 1./ -. .77-. . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . .`.'. . . . . . !.:f. . . .. . . C . . . . . . , North Andover, Mass. Fee. . �C . . Lic. No.k.! .� . . . a S, Check# 5639 MASSACHUSETIN UNN ORMAPPUCATON FOR PERM TO DO GAS FMING (Type or print) Date b Z U NORTH ANDOVER, MAS�S^A/CHUSETTS ( J Building Locations " ( /'4 c /L- d" I j Permit# Amount$ Owner's Name New❑ Renovation ❑ Replacement ❑ Plans Submitted E] a z c H a x r~ o w z z W w w x a� `� a N x c� N z wwF z w w 0 w a O x A O a > A a F O SUB -BA SEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR • 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR (Print or type) Q j Check one: Certificate Installing Company Name l r I do tac t l Corp. 4 .P �.{— �� _ El Address - i6 R 2h Partner. Business Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent.. Yes 0-� No If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond IJ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installation rformed under Permit Issued or this application will be in compliance with all pertinent provisions of the Massachusetts S Gas Code nd Chap 142 he— !eneS. j By: ignature of Licensed Plumb&Or Gas Fitter Title Plumber City/Town El Gas Fitter License N77377 easteman r APPROVED Journe(OFFICE use ONLY) � Y Location p. No. Date I—Zd4elze, a oR*M TOWN OF NORTH ANDOVER"-.> : p Certificate of Occupancy $ Building/Frame Permit Fee $ � #J C�USEt� Foundation Permit Fee $ m Other Permit Fee $ o, Sewer Connection Fee $ x Water Connection Fee TOTAL $` uilding Inspector A-n 10590 C Div. Public Works PEa.AciT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP+JO. j 1 O I LOT NO. L-3y 2 RECORD OF OWNERSHIP IDATE (BOOK .'PAGE — ZONE 1 SUB DIV. LOT TNNO. F-- i LOCATION (/ 8r, r` _ PURPOSE OF BUILDING OWNER'S NAME ,j NO. OF STORIES SIZE OWNER'S ADDRESS _/� T r-lr� - BASEMENT OR SLAB ARCHITECT'S NAME �! eaw / SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME c /'..., sicu- �4OY` SPAN -- DISTANCE TO NEAREST BUILD�I./Nf►G l Cq• DIMENSIONS OF SILLS DISTANCE FROM STREET ) GV POSTS DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS AREA OF LOT �Jd S,G- o FRONTAGE HEIGHT OF FOUNDATION /1 THICKNESS /D IS BUILDING NEW Ifo O SIZE OF FOOTING UII�/` X IS BUILDING ADDITION Y MATERIAL OF CHIMNEY V IS BUILDING ALTERATIONf. IS BUILDING ON SOLID OR FILLED LAND S� 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 /0 PAGE 1 FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 000, •DATE FILED BUILDING INSPRCTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT [/^ FEE ? � OWNER TEL.# t� w 71 PERMIT GRANTED CONTR.TEL.# 19 CONTR.LIC.# w H.I.C.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILYSOLI 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'T' AREA _ y, 1/7 34 FIN. ATTIC AREA _ N_O B M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD DD _ ASBESTOS SIDING COMMCN 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 I� POOR ADEQUATE NONE t 5 ROOF 10 PLUMBING GABLE I HIP BATH 13BATH 13 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) _ FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 3 COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 1-3rd NO HEATING 0VM (A .-d ove No. ;77 - s - . dover, Mass., 410 19 5�' w O'94_COCMLAKE ICNEWICK L~''�• f� Q r '9_A AATED v �G BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT ae-Of �jEUILDING INSPECTOR ............................. ..''"..�G� l..!,!1........ `�G.1��..1.2.. ..........,............................ ,.� """" Foundation bas permission to erect........ '��..(..1.�.�?.!11.. buildings on .......5 .4:....3Ftk.1! .5......X/44 ........IRP A.... Rough to b4 occupied as....................................,T WR.a C n /A1?'!X' . ...................................................... Chimra:y prov''dad that the person accepting this permit shall in everyrespect,conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relatinf to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST TS Rough ................................... ................................................ Service.. .. .. . UILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done E FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. I ��.�rmrvneo;u aa/�/c o�/�avaac�uiaella � HOME IMPRO'EMENT CONTRACTOR : :{egistral.ion 112674 TYHl-t ]NDIVIDU;AL EXPirati'cn 04/15/97 E CONSTRUCTIUN ERIC D. TETREAULT t,�80 fNDOVER ST 42 ADMINISTRATOR NIV'JU "R MA 01810 'T(lV31 C C?a to �q ud1j-4-si y 4 i r t s�8•-�7��9ay 'rI , FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************_**Applicant fills out this section***************** APPLICANT: ;1� le + AVc P14L'a Phone &6 -W LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street S� ,�P�^rx, St. Number Use Only****************************TT**�** RECOMMENDATIONS OFT WN A S: / i Date Approved Conservation Admi intra or Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved ItV 11712 LS-e-ptic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit ,Fire. Department Received by Building Inspector Date 1 NS � • MSC Order # �� 817117 ��,z' c�ry �ov�se . lo/ry MORTGAGE INSPECTION PLAN This is a mortgage loan inpection for mortgage purposes only 152.56 LOCATION North Andover MA City or Town State LOT 11 DATE November 14, 1991 SCALE i inch= 50 feet Certification is hereby made to The Cooperative Bank of Concord that the existing structures shown on this plan are situated on the lot designated in compliance with the setback requirements of the applicable zoning bylaws of the municipality when constructed This insppection was prepared in accordance with the 4bjLY), technical standards for Mortgage Loan Inspections as adopted by the Commonwealth of Massachusetts. ti 3B � 2s�dYr by LOT 10 LOT 12 egis ere and Surveyor DEED AND PLAN REFERENCE Essex North Registry of Deeds Deed Book 2296 page 104 Plan Book na Plan 9779 Certification is hereby made that the structure shown on this plan IS NOT located within a Special Flood Hazard Area as delineated on the map of community No. 250098-0010B Nr Effective Date: June 15 1983 150. 00 ' , By the U.S. Department of Housing 6 Urban Development, Federal Insurance Administration. SPRING HIL L ROA �a��Sits N JF ROAD q�gSsgcS JEAN (� NYSTEN d l NO.26049 y '== MORTGAGE SURVEY CONSULTANTS, INC . 1 INCH 50 FEET 126A PLEASANT VALLEY ST. —SUITE 7 — METHUEN. MA 0 iB44 . 50 0 _ _ 5o 100 150 200 TEL. (508) 975-2700 Location /f No. 9 v Date NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ 9 s" °'"tn Building/Frame/Frame Permit Fee $ s�cMust Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # f 701 15 5 U Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 77 777-7-7 7777 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dis1rid Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required— Provided Required Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ _A SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ ! E t Licensed Construction Supervisor: �i< ,S a Z T O 7'1 LLL1• / / �� License Number 0" Address b y .6 7 1 - r WI Expiration Date s O ic Wnhrure Telephone r 3.2 Registered Home Improvement Contractor Not Applicable 0 14S 4'tj Company Name 3 Registration Number Address Expiration Date! Si at Telephone !�� 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 ail applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: (Z�gln L k 26tk gcld lis-w) SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFIFICiA-USE-ONLY Completed by permit applicant 1. Building (a) Building Permit Fee zolV Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORI,Z/ED AGENT DECLARATION I, /6N 10L99 eG I as Augter/Authorized Agent of subject property Hereby declare that the tatements and information on the foregoing application are true and accurate,to the best of my knowledge and bel* Pri t Z Signature of Owner/Agent Date an NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1ST2 ND 3 RD SPAN DINIENSIONS OF SILLS DINIENSIONS 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 --- -.-, Th a Commonwealth of Massachusetts --Y=-� --=i . Department of Industrial Accidents al office o//nsesugatians 600 Washington Street Boston,Mass 02111 Workers' Compensation Insurance Affidavit A licant in ormatton.:--rT•�+�e� :::.K�:: .. .,: ,. ;,-. leases Ri +- �t l .ate. . �� ., :., . .ae�».,.. .::.,�• . sn.... name: LEcw 0.0/V S fa aC- ;ciej tF NN C L, kaey 1 Location: 77—/ ./7 e-ki i 7r /7[/E city A/z - j2NQ6iJ1n phone# 97S 671'•S46) I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity M, C3 .l am an employerproviding workers' compensation for my employees working on this job. company name: address C%ty• _ _ .. Rhone# insurance co 7 policy:# - ..'�" ..a�..:.r..s .......... �....t..�...:r?a '?'^:;%1- -.RF"hL. iifW.g�G.. "' zti °• "f2tiX+lG.f.2'i+f' ..aRn47f [ am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'.compensation polices: company name: address: ress: • phone# insur ince co 061i6# company name. -.: - .. .. address cam. phone Al _ . insurance co Att'ac addih —!ra1sheef'it rcessa .-, Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby certify under the ins and penalties of perjury that the information provided above is true and correct Signature Date Print name kENu E to e-6-IJ'" ._ ._. ._._. Phone# %%'official use only do not write in this area to be completed by city or town official,..; ... .. city or town permit/license# n Building Department OLiceiisingBoard check if immediate response is required _ oSelectmen's Office Health Department contact person: phone#; nOther (raised 3195 PIA) BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR } Number: CS 058245 t Birthdate: 03/24/1943 ^+ �+ Expires: 03/24/2004 Tr.no: 20021 Restricted: 00 KENNETH B KEEN 21 HEWITT AVE N ANDOVER,.MA 01845 Administrator A j HONE IMPROVEMENT CONTRRCTOR ` Registration 108383 z EXpiration� 8/18/02 type: OBA KEEN CONSTRUCTION CO. + Kenneth Keen 21 Hewitt AVe 01845 ADMINISTRATOR Np, pndouer NA NpRTIy of over o _ �. S-4Dy •adGa o L A o dover, Mass., COCHICHEWICK V A°RATED P'PC7 S H BOARD OF HEALTH Food/Kitchen PERMIT T Septic System //�� BUILDING INSPECTOR THIS CERTIFIES THAT.........4.0 .4mlm..1. ....4.....�..t ato.!! .......Ia..I...�.�1.�............I................ Foundation has permission to erect..... :s rt/............. buildings on .... ... R�N�� .�!.�..�L.... ............ Rough to be occupied as... O w 4 Opvd/'4.�....,�14��,....��............................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Ins ion, Alteration and Construction of Buildings in the Town of North Andover. /&ea/ .7C/ G t, i 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 ....W� ..................... ................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE i. Location �" PQ 06 kA't LC. No. Date d s NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ �� • . Building/Frame Permit Fee $ 4*. �h �cFoundation Permit Fee $ sMust :t Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ !! TOTAL $ i. Building Inspector 10/24/95 12:53 124.00 PAID i : 9290 Div. Public Works i PER3i1T NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK PAGE ZONE I SUB DIV. LOT NO. F— =iL OCATION fj s P PURPOSE OF BUILDING }��meAf OWNER'S NAME NO. OF STORIES �•C.['� SIZE OWNER'S ADDRESS ;t�-qSD<`lhQylt-C( �C°/ BASEMENT OR SLAB - ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST 2ND 3RD BUILDER'S NAMEr-" P PAN -- 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 -fes ' MATERIAL OF CHIMNEY IS BUILDING ALTERATION -84, IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE , 1 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 n l� EST. BLDG. COST Q y� �At LEST. BLDG. COST PER SQQ7� PAGE 1 FILL OUT SECTIONS I - 3 - ,� - PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ^ ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR V DATE FILED Z , NUILDINO INSP[CTOR SIGfTATlJRE OF OWNER OR AUTHORIZED AGENT ] F E E l -2-+ OWNER TEL.# 6 " ^ PERMIT GRANTED CONTR.TEL.# 97L/ fffZ 9 Z4- 19 S 65-q & 3 CONTR.LIC.# r H.I.C.# Z(a7 9w C ww 1,"1.cLcL , BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S-OR1ES 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 —I 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'T' AREA _ 1/ 1/1 V. FIN. ATTIC AREA _ NO 8 MT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDVVD _ ASBESTOS SIDING COMMC:N VERT. SIDING ASPH. TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICK 5 N—M—A-S-6 N R Y ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. ' STONE ON MASONRY WIRING STONE ON FRAME .. SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 3 COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS IL O B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING NORTH F Tovm of d 0 ,;4 .0 ON'46, WAF � co dower, Mass., Oc"ea Z4 19gs," AORATE1) PP��7 5 BOARD OF HEALTH Food/Kitchen PERMIT T. D Septic System 1, BUILDING INSPECTOR THISCERTIFIES THAT...M.. .M,... �.r� V ................................................................................................................ Foundation has permission to ereet...A. 01,,................. buildings on ...'.5.4'......5�.�•!��"�:�.... .................... Rough to be occupied as. �MN�'........\ �IQ Chimney provided that the person accepting this permit shall n every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough '� l lZ<0-1� PERMIT EXP SIN MONTHS Final UNLESS CON TR S ELECTRICAL INSPECTOR Rough Service BUILDING INSPE TOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. :s:,::.. _. ._.. v+w:,. .....a�wR.'-_'� v'+..:., ...�.fi.. ,.. ,.k x�ss.w.:s.. "•: �.-.,...».. ......�.. .. ... z_.... .. -::a.��..'f.a�..8..�'^.:.�F -.._. ,. ' - - tiDy� Ix� _ R'9istr _ - T at1on 112674 TRACTOR Exp Type INDIVIDUDt - _ iration 44/15/97 CONSTRUCTION D AD&ftmsii� t�l8o ANDDVfr REAUL T . Al'joJvr• SI #2 XA 01870 COMMONWEALTH ---�---__,_ OF I DEPARTMENT OF PUBLIC SAFETY fab+rsto 1w, MASSAC I ONE ASHBORTON P09+++041Q•rt HUSETTS PLACE M+ssocbr++tt+st+y ��t BOSTON,MA 02108 $ 'Cod+I+come*for r 8+lldJ�� EXPIRATION DATE � L I E%+$ of this nc••+0. woe+t/oo CONSTR. JUP_RVISOR CAUTION 11/19/1995 RESTRICTIONS ^ EFFECTIVE DATE U TION i I�y E C NO. FOR PROTECTION AGAINST + NST IJ o- 1313 1 /19-73 THEFT,•PU TRIGHT THUMB 1 so;1 PRINT IN APPROPRIATE_=TR`AULT BOX ON LICENSE.z 92 ELf" STR`zTss —sU— Say ayOO Ar ' n T 31 ° BLASTING OPERATORS PHO teusJJN-OPR ONII� FE z UST . '0 C. r,0 I�(J() 7t NOT VALID LINTY S*NED e,.Lx 1 HEIGHT: I sraoEO.� NSEEANDOFF�c1Auv j h DOB: SKalNT7XiE OF CJMMISSIONER I r-� 11/19/19701.' 8`p 2 1993 THISCARDOCUMME MUST l`'<• PER,SONOF :Ra-. THE HOLDER WHEN EN- 7TIRE OF SIGN NpM � . _ .. F!G!!T?Hws@ PRINT GAGED W THISOCCUPATION. LICENSEE — �. GN�11RE Q ER i CONTRACT AGREEMENT FROM: E.T. Construction DATE:10-23-95 180 Andover Street#2 Andover,MA 01810 PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: Pickle 54 Springhill Road N. Andover, MA 01845 WE HEREBY PROPOSE TO FL7R-N, -LSH ALL THE MATERIALS AND PERFORM ALL THE LABOR NECESSARY FOR THE COMPLETION OF Basement renovation. Frame perimeter walls. Add closet space and enclosure for A/C unit next to stairs. AC unit will be moved to new closet space. Move water main and enclose in closet. Create seating area and hook space in front of entrance from garage. Box in all ducts that hang below suspended ceiling with blue board. Remove existing sheetrock in stairwell and install new blueboard and plaster. Create 1/2 wall to enclose sewer line. Create 1/2 wall with shelve under windows. Encase lolly column with Tambor wrap. Create closet with louvered doors under stairs. All perimeter walls will be framed out of 2x4's, insulated with r-11 unfaced insulation, wrapped with a 4 mil vapor barrier, 1/2" blueboard and veneer plaster. Finished trim will match existing. All walls and trim will be painted or stained to customers choice. A suspended ceiling with 2x2 tiles will be installed in the renovated space. New baseboard heat will be installed to heat room. Heating and relocation of any plumbing is included. All electrical work is included. Electrical work includes 10 outlets,2-3 way switches, 14 way, 6 single pole switches, 2-18" flourecent closet lights, and 18 recessed lights with dimmers. All ceiling work is included. A 2'0"x6'-6" raised panel door will be installed for water main closet. Door leading to unfinished basement will be a 2'-8" x 6'-6" raised panel pine, and louvered pine unit to closet under stairs. Finished flooring is not included in this contract. ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED, AND THE ABOVE WORK TO BE PERFORMED IN ACCORDANCE WITH THE DRAWINGS AND SPECIFICATIONS SUBMITTED FOR ABOVE WORK AND COMPLETED IN A SUBSTANTIAL WORKMANLIKE MANNER FOR THE SUM OF DOLLARS (S18,600.00) 29'4 41 2'3 2'6 716 �� T8 9'5 3'5 4'3 N N 9) M M SN Utility closet helve and hooks Seat with opening cover 2'6 i I i i 0 112 wall with shelve Y I I j 13' T r � r N CO : I • r closet t0 fV n fV r N New AC unit 46 o UP VfRT �u�-n ice L ocm. 2'4 14' 2'6 1016 29'4 i �\ Office Use ty 0i 4t Crommonwalth of -49us rffs Permit No._ �-- Je;rartMnft of ItubUr $afetq Occupancy&Fee Checked 49 BOARD OF FIRE PREVENTION REGULATIONS 527 CAR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date =', %)Q or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the eiectricai, k desc ibed below. Location (Street & Number) Owner or Tenant Owner's Address �- Is this permit in conjunction with a building permit: Yes _ No C (Check Appropriate Box) Purpose of Building �� r Utility Authorization No. Existing Service Amps Voits Overhead '` Undgrnd L-1 No. of Meters New Service Amps _J Volts Overhead _ Unogrnc No. of Meters Numeer of Feeders anc Ampacity Location and Nature of Preoosed Electrical Work H I No. of Transformers plat No. of Lignung Outlets ��j I No. of ..ct -.:cs K`JA No. of Lighting Fixtures Jy� i Swimming P_ot r.Qe_ ar.c. I Generators KVA No. of Emergency Lighting No. of Oil Surners No. of Recectac:e Cutlets Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges I No. of Air Cohc• :ons Initiating Devices No.of Heat Tc:at Total No. of Oisdosals Purr.ps -ons K:v No. of Bouncing Devices iNo. of Self Container No. of Dishwasners SoacerArea Heatma K. W Detec::onfSounring Devices Municioat No. of Dryers I Heating Cev:ces K:/ Local _ Connecnon _Other No. of No. ct Low Voltage No. of Water Heaters KW I Signs Sadasts Wirinc No. -ivero Massage Tubs I No. of Motors otai HP OTHER: INSURANCE CCVERAGE. Pursuant :o the reouirements pf Massacr-usens general Laws _ I have a current Liaciiity Insurance Policy inctucing Ccmp:etec Operations Coverage or its sues;antial eduivaient. YES _ NO — I have suomineo valid proof of same to the Office. YES = NO = if you have checxed YES. please indicate the type of coverage Cy cnecxing the appropriate Cox. INSURANCE — —BOND OTHER = (Please Spec:!-i) — (Expiration Dater Estimated value of Eiec:ncai Work S e©0, C� r Final + �— 1 f WrnC t0 Start �-7'-/?� `r•� InSDec::On Cate nartlaS:eC: Rough Signeo under ;he Penalties f pe•ury / 9�- FIRM NAM i / S /!� ✓/l S LIC. NO. / Licensee Sic^a:ure % LIC. NO. Bus. :ei. No. '3 g :31"3 �y—L_ Address f ! Alt. :el. No. OWNERS INSURANCE WAIVER: I am aware that tr4 Licensee aces not nave trio insurance coverage or its suostantiai eruivale t as c ouired oy Massachusetts General Laws. and that my signature on :h:s permit application waives this reruirement. Owner ` 9chi (Please checx one) Tetecrone No. PERMIT FEE S (Signature of Owner or Agent) ti•d5c5 Date.... .../ ... . . ....7.2. ii 806 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SSACH This certifies that ......../A.T427, ..................Cn�.yj� ..... . ....... ..... ............... EE has permission to perform ........... AQ. 4 ...................... wiring in the building,of.....15--.1.......- ........ .2 Z at................ (..................................... North Andover,Mass. Fee......�.8....... Lic.N(W.OP.-7.............................................................. CU ELECTRICALINSPECTOR 4 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer