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HomeMy WebLinkAboutMiscellaneous - 60 INGLEWOOD STREET 4/30/2018 / 601NGLEWOOD STREET 210/007.0-0026-0000.0 i i I I Date.�. . z_s �C.�.. . OF Mp oTk �h o� �°� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r � • y �,SSACHUSES This certifies that � . . . . ! has permission for gas installatio> T !^�'�'t . .��. in the buildings of/. /1 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at 1',"1nn� . . /v, /`t° �� v . . . . . . . .. North Andover, Mass. Fee a-0. . . . Lic. No `� ���.." . . . . . . . . . . . . . . . . . . .v. . . . GAS INSPECTOR Check# 75uu MASSACHUSETTS UNHORMAPPUCATONFORPERMITTODO GAS F1TI NG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations �': (� � �� ���©� Permit# Amount$ Owner's Name 13 g/1-) New❑ Renovation Q Replacement Plans Submitted ❑ d On � wz rn U G W W O UO M O. W d 9 x 0 � O Z W 0.1 rid H w O „� � O W F-� O CL L. O A CW7 � 0 WO GU QZ OO CWaU Z O rn 0 O 44 U 4 > W F R' H O SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH. FLOOR 5TH. FLOOR 6TH . FLO O R 7TH . FLOOR B.TH, FI OOR (Print or type) Check one: Certificate Installing Company Name- - ❑ Corp. Address 16 y• 1) 4�2/L .� . -- - �:� Partner. Business-Telephone 7 Firm7Co. Name of Licensed Plumber or Gas Fitter e INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes,please indicate the type coverage by checking the appropriate box.-'` Liability insurance policy Other type of indemnity Bond E Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 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 a plumbing work and installatio performed un e? 't Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S t Gas Eode er 142 of the General Laws. By: Signator/ of Licensed Plumber Or Gas Fitter Title Pl r City/Town Gas Fitter License Number Master APPROVED(OFFICEUSEONLY) burneyman The Commonwealth of Massachusetts Department o fIndustrial Accidents Office of Investigations UV 600 Washington Street Boston, 334 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am aemployer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. EJ New construction 2 I am a sole proprietor or partner- listed on the attached sheet 1 7• E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL .1 LM 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' c9mp.insurance required.] 13.0 Other .Any apphcaat hat checxs box rI must also M out£ae sectio^belong sho ffL-b t'^_e:.`-'-'orke s'com^=s;tion policy infor nation. 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 workerscompensation insurance for my employees Below,is thepolicy and job site information. Insurance Company Name:_ /��� C �j'�irK nt✓ `��� Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pain .a d penalties ofperjury that the information provided above is true and correct. Signature: Date.: Phone#: 91 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#- Information as d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee'is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or.other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including t1he 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, onthe 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 licensimg'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 coxnpliance 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 stun to sign and date the affidavit. The affidavit should be returned to the city or town that the applrca ion for the per amt'or I,cense 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 permit4icense 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 Ince to#bank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. 'Ihe Department's address,telephone and fax number: °The Commonwealth of Massachusetts Department of Industrial Accidents Of-See,of Investigations: 600 Washington Street Boston,MA 0.2111 Tel. ##617-7274900.ext 406 or 1-877-MAS SAFE Revised 5-26-05 ' Fax#6.17-727-7749 w rvr.mass._govfdia Date.-.Z-3. . ./J NCRTTOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING s ♦ i ,SSACMUSE� F This certifies that . .,.h't. . �? '�". .� . . . . . . . has permission to perform . . .ODT. Kz. .h4'i . T`�. . . . . . plumbing in the buildings of . f �.i -. . . . . . . . . . . . . . . . . . . . at. . .(0J. . . . . . .` . . . . . . , North Andover, Mass. Fee\3 . . .Lic. No.. . . .(.S .S U.4'. . . . . . . . . . . . . . . . . . .\ter PLUMBING INSPECTOR Check 83u0 MASSACHUSETTS U1 HORM APPLICATION FOR PERMIT TO DO PLU.MEBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Dateyo Building Location U 1ti�9���t.r/GC�Q Owners Name /3 N Li 1A nj CL 0 Permit Jl Amount Type of Occupancy X rW(9/Ag- "e-'q /mss y New Renovation Replacement P9 Plans Submitted Yes El No FIXTURES rA rn h a o *� a P a H a a • wLn a a w. 2 w a w � a H a � a � rn r ISE IIOCR •2M Iffla;L _ 4IRFLOCR S1HFIZZ MK"R 7IRFLOCR Check one: Certificate (Print or type) -�- • Installing Company Name �1 G -V1 ro ,y/l Corp. Partner. Address Business Telephone Pirm/Co. �� Name of.Licensed Plumber: l�C - � ��� Insurance Coverage: Indicate the type of insurance coverage by checking the box:Bond El insurance policy Other type of indemnity Insurance Waiver: I,the undersigned,have been made aware that the licensee o£this application does not have any one of the above three insurance igaature �� Owner n Agent I hereby f9 certi that all of the details an d information I have submitted(or entered)in above application are.true and accurate to the best of myJmowledge and that all plumbing work and installations performed under Permit Issue for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Plumbing Codwfmd Cha 142 of the General Laws. By: -signature ot LicensecinumBer Type of Plumbing License Title c7L's n City/Town icense um er Master L...J Journeyman APPROVED(OFFICE USE ONLY u The Commonwex1th of A,assachusetts Department o f£radustf-ia1 Accidents Office of i.-fivestzgations ..600 Washington Street Boston, 3L4 02I11 x-ww_mrzs,£gov/dia Workers' Compensation Insurance Affida-vit: Builders/Contractors/EIectrician s/Flumbers tin licant Informafion Please Print Legibly Name(Business/Organization/individual): Address: City/State/Zip: Phone#: -Are you an employer?Check the appropriate box. 1.❑ ram a empioyer with. 4. 1 am a a Type of project(required): employees(full and/or part time).* have hir d •the sub-concontractortor ands 5. ❑New construction 2 I am a sole proprietor or partner- listed on the attached sheet T 7• ❑Remodeling ship and have no employees These subcontractors have working for mein any capacity. workers' comp,insurance. 8. El Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Bddigg addition r 3.❑ equire ] officers have exercised their 10.11Electrical repairs or additions .I am a homeowner doing all•work right of cXemption per MGL 11.[]Plumbing repairs or additions Myself[No workers'comp. c. 152,§_1(4),and we have no ine,n-ancere required.] t 1?.❑Roofrepairs • q ] employees. [No workers' POMP.msUranc@ required.] I3.❑Other .e"–.tIT'�T'ptiran+t�Y?t ch.—1-L!bJOv.�� etl•�ef ci3Ci 12L1 C.Mr t the ae.:L��`:Ot!'g.^.Qun., FToxmeowners who submitiEs affidavit iadicatin th ,_d mss'cozrPees`uu .t•�•• �_ g e1 c�a ail:acic an , , «.o--� +Contractors that ch='„this bLx er,� - d �hire nutsidE con'LMCtm 4&,t r wit a new amdavit indira6ng such. mt:o. ...ached as additional sheet sfiowinQ the . b name of the sub-contractors and their workers'COMP.Pow'informa8nn. f am an employer that is providing workers'compensadon insurance for my entptoyees Beloit/is thepolicy and job site information Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a coprof the workers'compensation policy declaration page(shoe ng 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 penalises in the form of a STOP WORT{ORDER and a tine of zip to$250:00 a day against the violator. Be advised that a copy of this stern may be forwarded to the Office a Investigations of the DIA for insurance coverage verification I do hereby cerci under the ns andpenalties ofperjury that the in formationprovidednbove is true¢n'.correct Si�ature: l Phone#: Official use only. Do not write'in this area, to be completed by city or town official City or Town P`ermitUcense# Issuing Authority(circle one): L Board of Health 2.Building,Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector G. Other Contact Persorc: Phone#. Information. am. d. Instructions J Massachusetts General Laws chapter 152 requires all employers to provide work--rs'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 t3ae legal representatives of a deceased employer, or the receiver or trustee of an indzvidual,partnership,association ag other legal entity,employing employees. However the owner of a dwelling house having not more than three apart a:x cuts and who resides therdin,or the occupant of the dwelling house of another who employs persons to do maint--mance,construction or repair work on such dwelling house or on the grounds or budging appurtenint thereto shall not because of such.employment be deemed to be an ermployer." MGL chapter 152, §25C(6)also states that"every state or Io-cal 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 cairnpliance 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 um-til 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 certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)ivith.no employees other than the y members or partners,.are not required to carry workers'comp=sation 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 rvir•e to sign and date the affidavit_ The affidavit should he retuned to the city or t.a%m that the application r the nP ' men-e f be, re Abe Y .r�iit or E :ng. q.esfea,not . -part—nt of Industrial Accidents. Should you have any questions reg�rdLg the la--.,,or if you.are r��rired to obtain a workers' compensationpolicy,please call the Department at the numbe=r listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. , o 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 lnvestigations 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 afiidivit The Office of Investigations would lie 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.fagnumber._.. The.Cammonwealh of Massachusetts. Department of Tadusttial Accidents Office of I—estiaations - 600 Wa"gbn Street Boston,ILA 02111 Tel. #•617-727-4900 ext 4=0.6 or 1-8 77-1vASS_AFE Revised 5-26-05 Fal #6.17-727-7749 9MJx7vmass._aov/dia Date. .7// . . ... .. NORTH O?Oya ..ao ,a 1ti0� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION S �SSAC'HUSEt This certifies t at .�4. . . . . . . . . . . . . . . 1. . . . . . . . . . . . . . . . has permission for,gas installation . . . � in the buildings of . . . at . .�� . . ��.y��. .4'.° . . . . . . . . . . , North Andover, Mass. a Fee. .3i� . .` Lic. GAS INSPECTOR` Check# A")- 7299 `72 » MASSACHUSETTS UNH ORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS s Building Locations Permit# L G 1 � Amount$ D Owner's Name 'A- �S ca C S _ t c New❑ Renovation Replacement ® Plans Submitted ❑ U w x D UCk a � x < `� z z W H zw w o > w U a a w > w z a a o o w c U x > SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 18-T H . -FLOOR (Print or type) ��\�� �� Check one: Certificate Installing Company _. Name \ ❑ Corp. Address \` - Partner. F �• usmess Te ep one Firm/Co. Name of Licensed Plumber or Gas Fitter p L , c :116 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy E] Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St to Gas Code Cha er 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber � City/Town Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) r] Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesiigations 600 Washington Street Boston, ALL 02111 w w.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 1 Name(Business/Organization/Individual): 9l Address: City/State/Zip: L"Pt- ' -1 o Phone 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 employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. �o workers' comp. insurance 5. 9• Building addition p. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.14Plumbing 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 showinn r- s,,.r;;= information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubmit 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 isproviding workers'compensation insurance for my employees. Below is thepolicy 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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u der the pa' a enaldes of perjury that the information provided bove is true and correct Signature: `-� wD - Date.: Phone#: 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 Clerk 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 orother legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three 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 conira.cting 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 certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the ' members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sive to sign and date the affidavit. The affidavit should be retaued to the city or town that the application-for the pernaif 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to than 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 010ce of Investigations 600 Washington Street Boston,MA 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MAS.SAFE Fax#617-727-7749 Revised 5-26-05 www.mass-gov/dia Location N. No. Date g' 4 NORTq TOWN OF NORTH ANDOVER O��«a0 I•,h0 „ Certificate of Occupancy $ t s 4 ♦ 1, +' � Building/Frame Permit Fee $ A Foundation Permit Fee $ scHuse O$t9f Permit Fee $ too Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 9 /295014:52 35.00 pain Div. Public Works PERMIT'NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. � PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. /LOCATION �^ 1�/�!, PURPOSE OF BUILDINGA/ OWNER'S NAME n�� [Lr-+-�IIX�+�Y/ICiLt+C.C/ l� NO. OF STORIES SIZE I OWNER'S ADDRESS zL07K ++���iLU/l��s y BASEMENT OR SLAB ARCHITECT'S NAME /YJ , / SIZE OF FLOOR TIMBERS IST 2ND 3RD �'111LDER'S NAME ' � ��� 'Ti )/J , SPAN V DISTANCE TO NEAREST BUILDING �C/7A. -1-�./C� DIMENSIONS OF SILLS DISTANCE FROM STREET '" POSTS / _DISTANCE FROM LOT LINES-SIDES3/1 feeT REAR )/ FEET GIRDERS AREA OF LOT FRONTAGE/ HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES `� ,1 ,f i ,oO ST. BLDG. C08T y/, PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PE 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 VIDATE FILED 'A NUILDING INtPECTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT F E'E � OWNER TEL.It PERMIT GRANTED19 9 7- CONTR.TEL.J/ CONTR.LIC.# H.I.C.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY 11S"ORIES 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 I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETEJII 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 _ FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 22 f 3 DROP SIDING CONCRETE I_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD%tJ'D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. L FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIORI� POOR ADEQUATE ONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) _ FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR L 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. L COLS. STEAM STEEL BMS. L 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 13rd NO HEATING 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. ****************Appl ' cat fil'Alss out this section**********-BLc******** APPLICANT: b__ I WU QUI Phone 7 LOCATION: Assessor' s Map Number Parcel Subdivision C f Lot(s) ,,�,^^ Street VV St. Number 4o — ************************Official Use Only************************ RECOMME DATIO S OF O GENTS: Date Approved 2� Conservation Ad((mini�trator 11 JJ11 Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date V� �' " a I � 'i i I � r .. F j �' ` �J 1 i n _� � , r ` � _�_ ._ __...___w____._ C_ e. .____ ___ e a NORT _ e over Town of . � o m No. ISO * - _T - -` * �- 1997 dovert Mass., T 0 s LAKE, 4O OCNICH Ew�SP`y TED �'P BOARD OF HEATH Food/Kitchen Septic System / AlBUILDING INSPECTOR PERMI e (. .�./`!./T• +'................................... Foundation zo ........ ... THIS CERTIFIES THAT............................................ """ has permission to erect............. .° " ' �� to v I Chimney zta........ ..,...... ........... ......................... ' e � .....tea� ...... ... application on file in Final to be occupied as............................................Z... m tothe Alteration and Construction of provided that the person accepting this permit sha I in LeavWe s respect to the Inspection, Altermof the app PLUMBING INSPECTOR his office, and to the provisions of the Codes and By P Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .................... ....................... Service ...... .. .. ............. UILDING INSPECTOR Final GAS INSPECTOR OCcupancy Permit Required to Occupy Buildin g Rough a Cons icuous Place on the Premises — Do Not Remove Final Display in P No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until inspected and APP by the Building Inspector. Burner U P pprStreet No. Smoke Det. _"�T1...�.-�---�- ___ Town of North Andover • BUILDING DEPARTMENT ' Homeowner Li�_ense Exemption (Please print) i)A 1 E JOB LOCATION jIIj�rzr_ Number . Street Address Section of town ,OMEOWNER" ���� ,� /�/1d�/� M -/2 17 l �J'J2 Name Home Phone Work Phone ,,RESENT MAILING ADDRESS City Town State Zip code Che current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to :ngage an individual for hire who does not possess a license , provided ghat the owner acts as supervisor. (State Building Code, Section 109 . 1 . 1) DEFINITION OF HOMEOWNER: Person(s) who owns' a parcel of land on which he/she resides or intends to reside, on which there is , or is ,J n*ended to be, a one to six family dwell- ing , attached or detached structures accessory t:o 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 . Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the building permit . (Section 109 . 1 . 1) The undersigned "homeowner" assumes responsibility for compliance with the Slate Building Code and other applicable codes , by-laws , rules and regulations . The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements . HOMEOWNER' S SIGNATURE ,, APPROVAL OF BUILDING OFFICIAL Note : Three family dwellings 35 ,000 cubic feet , or larger , will be required to comply with State Building Code Section 127 .0, Construction Control . - ..e _.1q e,.t.'4 .�.=} .r.s.L"�+�,.;."'>!�f#>+�s.��c�I.1+a�(..'.RK'y=.�'. �.�+,,..:io-'��.�'. �:'n♦-..�'.` - _ �- .:,.,.�„y.y.,. .-. . �, �.,,.,,. ,...._{,.� -,.F �.,, .t ,..: ;'.-a xy. 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