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Miscellaneous - 63 BARKER STREET 4/30/2018
63 BARKER STREET 2101035.0-0107-0000.0 it 4 Date.0 ... ......................... NORTH ?; ;�•��om TOWN OF NORTH ANDOVER c PERMIT FOR WIRING ssAc►,u5�s Thiscertifies that �..,1„1� {'G GU� t ...................................... has permission to perform ..................r PQ., C?cM 9P'4'm.. wiring in the building of A? at ...... ........ lPr'” ................ North An over,Mass. . ...............Lic. Nol.V`.kd)Fee..'Y5 ...... "... ........ ' ... ....... ELECTRICALINSPECTOR Check# �� aa// Print Form ICIX C1mmonweallh o�///adsac of Official Use Only Permit No. a - aLJePartm¢nt o�.}ire�ervices Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: u"c� i, - S City or Town of: _L,l�)�. �(� �� To the Inspector of Wires: By this application the undersigned Ives otice of his or her- tention to perform the electrical work described below. Location(Street&Number) Owner or Tenant r Telephone No.0 .—6 -3n Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Boa) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters i New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity �\ Location and Nature of Proposed Electrical Work: Wire- ax ria1p r 0 (.j 1�(1�f c�.� 1 Com letion of the followin 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- ❑ o.o mergency ig ng 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 Initiatin Devices TotNo.of Ranges No.of Air Cond. ons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Secu a f Sys em Devices or Equivalent No.of Water aeaters KW No.of No.Bal aor-s Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin 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: $200.00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: DIPIETRO HEATING & COOLING SOME LIC.NO.:A18265 Licensee: ERIK PIERMATTEI Signature LIC.NO.:40803E (If applicable,enter "exempt"in the license number line.) Bus.Tel.No..-978-372-4111 Address: 5 SOUTH SUMMER ST BRADFORD MA 01835 Alt.Tel.No.:978-994-0725 *Per M.G.L.c. 147,s.57-61,security work requires Department of public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: ,$ The Commonwealth of Massachusetts x Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 a,M SVBy`o� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeOlily Name (Business/Organization/Individual):DiPietro Heating and Cooling Address:5 South Summer Street City/State/Zip:Bradford MA 01835 Phone#:978-372-4111 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 30 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. f will 10❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. ✓❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.'T 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- -Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Merchants Insurance Group(( /-� Policy#or Self-ins.Lic.#:WA ° 0655 _y] 15 Expiration Date:07/25/2014 Job Site Address:63 Barker Street City/State/Zip:N. Andover MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm 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. Ido hereby certify unde the pains and penalties of perjury that the information provided above is true andel correct. Signature: Date: Phone#:9783724111 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#: rp J ' Ftp CONTROL# -:1 a ,:� 1," IMPORTANT If your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. 1�0 Wn1d 4-43338 Z { 4� 13;x.1,:t1 :13!" >'' N 1213 J;9NUV3H ONIDd10 d Hd'3: }71' I4��1`�1J313` :LdW 03±131«x ; �13S t ✓ skf g % , 7SN3 t"I; D:N J"! I` S3f1SS I 51'1111.01 U1037T plow ' • • • • • S�tIHQlrSia i1141Vb W1JN0 Date...../... :.. .. .. . .. +1 F NORTh 3a°.•'"':;':1.•��o� TOWN OF NORTH ANDOVER O 9 PERMIT FOR WIRING ,88,CMU5 t4� This certifies that ................. /vG ,....... l C �2ifJ S ......--................. .. .................................,...................... has permission to perform .., ................... c-,.... TL� .......... ......................................... wiring in the building of................ „ '� at .... �' ...... f ..........�.T".................... ....North Andover,Mass. Fee �`�....Lic.No. .. . . .... ......... 'ELECTRICALINSPECTOR J Check# 1303 /J 1 BUJ -� Official Use Only Commonwealth of Massachusetts Permit No. " a Department of Fire Services Z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ),527 MR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the In ector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No.9' 76 Owner's Address 6 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Servictko 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 nlay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.fif Total ry Tr,/-q formers KVA No.of Luminaire Outlets No.of Hot Tubs enerators KVA Above In- o.o Emergency Lighting Y No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total s No.of Alerting Devices TXnNo.of Waste Disposers Heat Pump Number s KW No.of Self-Contained Totals: - ' ' """"" 'I" Detection/Alerting Devices No.of Dishwashers Space/Area Heat' g KW Local❑ Municipal E] Other Connection No.of Dryers Heating A lances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No. No.of Data Wiring: Heaters Si ns Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eg uivalent " OTHER: Attach additional detail if desired,or as required by the Inspector of*Vires. Estimated Value of ctrl al Wo r . A 60 (When required by municipal policy.) Work to Start:14/ d Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA-NCE ;V BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:Gf1��i-G/4//f/ G��t LIC.NO.:,jIdl711 Licensee: 1WC,1i(/,(//,J Signature/f�A� LIC.NO.: (If applicable,enter "exempt"in the license number line.) �� Bus.Tel.No.-CE726 Address: /2 0/949 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ -� Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed ` on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32 electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible forThe 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 M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: c Pass 0 Failed Re-Inspection Required($.) ❑ r Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comment Inspectors Signature: t/N Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 1 /J • The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 1-11444-1Z 4&6_14WIS Address: 12 *,/ r)COS17 City/State/Zip-AIIOY,-)I,-?�7OAIA�• 0/5/7'7 Phone#:J�6 7Ro' Are you an employer?Check the appropriate bog: Type of project(required): 1. I am a employer with ;7, 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. 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs Jinsurance required.]T employees.[No workers' 13.❑Other 1 comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aid doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ��!ZT�ip? Policy#or Self-ins.Lic.#: C5 �� Expiration Date: Job Site Address-,(O,1 A i�� LS� 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 requiredunder 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 again t the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of urance coverage verification. I do hereb Ller�tjfyu er t e ai s and penalties ofperjury that the information provided abor/e and correct. Si a e: Date: �v Phone . zz cJ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 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 maybe submitted to the Department of Industrial o 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,anapplicant 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 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: `rho Commonwealth of Massachusetts Department of Industdal Accidents Office ofInVestigaflons 600 Washington Street Boston,MA 0.2111 Tel,#617-727-4900 eyt 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-727-7749 www-Mass,govaa Date.... .................... F NOprM TOWN OF NORTH ANDOVER o PERMIT FOR WIRING 's`SACHUS�� This certifies that ` Nf v ............................................................................................................................ has permission to perform ...b�,�..vv�P �� cJlP�Q ......................................................................... wiring in the building of..'6,� .......................,...A�.............................................................................. at........v.. ` 1'-� C ................................................................................... ...North Andove ,Mass. Fee. .. .+...."."_.......Lic.No. ..C.'. .��.......... ...............1....... . . . . ............... ELECTRICAL INSPECTOR Check# 2F33 3 D �. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1716 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the"Peck r of Wires: By this application the undersigned give�otice of his or her intention to perform the electrical work described below. Location(Street&Number) "O' Owner or Tenant mt'Q r fl C_ r-8 c l ' /g- Telephone No. 979`e7k) Owner's Address SA nl-.e- as Ak cv-c Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Buildin;7R2 5 t3 Q 1��I q Utility Authorization No. / - Existing Servicea.s-O Amps l/d /240 Volts Overhead®' Undgrd❑ No.of Meters I New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: onl ( 6 Completion of thefollowing table may be waived by the Inspector of Wires. j No.of Recessed Luminaires g No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA AboveIn- No.—Of Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ arnA_ ElRattery Units No.of Receptacle Outlets q No.of Oil Burners i No.of Switches No.of Gas Burners No.of Ranges No.of Air Cond. t No.of Waste Disposers Heat Pump Number" Totals: No.of Dishwashers Space/Area Heating KV No.of Dryers Heating Appliances No.of Water No.of N Signs Heaters KW B; � No.Hydromassage Bathtubs No.of Motors T1 OTHER: Attach ad sires. Estimated Value of Electrical Work: (When re(. Work to Start: Inspections to be requested in acc INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance or eiecmcai worx may xssuc unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove age ism force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) F0 re rn 0 5 f .Z&,s , X certify, under the pains and penalties o,per'ury,that the information on this application is true and complete. FIRM NAME: "�6 ri l 6 LIC.NO.: a 4 l'�,9 Licensee: S AM--f- CAS A Signature LIC.NO.: E 3 4 R$ (If applicable, nter " em t"in the lice a 11 mber ine.) Bus.Tel.No.-9`1(�-917G"O 8 5 9 Address: 0&I f" '� 0� 3 S Yca o a�y m s O I �j(a t� Alt.Tel.No.: *Per M.G.L - securi work re wiresD6partment of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware es not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signat Telephone No. i ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the Q permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an o 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 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUG_H INSPECTION: Pa Failed Re-Inspection Required($.) ❑ Inspectors Comments: �L Inspectors Signature: Date: ? FINAL INSPECTION: Pass Failed '❑ Re-Inspection Required($.) ❑ N Inspectors Comments: Zr rl .. Inspectors Signa ure: ` Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r D a Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. I �� 69 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the X pect r of Wires: By this application the undersigned give�otice of his or her intention to perform the electrical work described below. Location(Street&Number) �,� / eY a i' Owner or Tenant fnq lr' c— �.� Telephone No. J76 Owner's Address SAT)?-e- as Ah ova Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Buildin;7RQ S �6 Q►'t I qI Utility Authorization No. - Existing Service P.d-0 Amps /2ez0 Volts Overhead [9'�- 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: q /g6U1/te ao Jen,, tuire- -on/ ( , Completion of the following table maybe waived by the Inspector of Wires. j 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 Ei In- o.o-Emergency Lighting rnd. rnd. El 0. Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat PumpNuer Tons KW No.of Self-Contained Totals: mb"""**"*'`"**---'j*'"'""""""' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection A No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent .y No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent " OTHER: Attach additional detail if desired,or as required by the Inspector of*Vires. 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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [KBOND ❑ OTHER ❑ (Specify:) "Fa•re rn )S f Zk.S , I certify,tinder the pains and penalties gfper'ury,that the information on Ili is application is true and complete. F1RM NAME: .M 0 h 1 r ( LIC.NO.: A 014 9 30 Licensee: S A M-p. CAS A tc-e-c, Signature (fir LTC.NO.: E3 3 y R-9 (If applicable, n r " em t"in the license 4,4mber line) Bus.Tel.No.•9'�9—9 79-08 5 8 Address: ��'011 st.. P-,Q 6®�y mass O/rj G v Alt.Tel.No.: *Per M.G.L - securi work re wires partment of Public Safety"S"License: Lic.No. O ER'S INSURANCE WAIVER: I am aware es not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am a owner ❑owner's agent. Owner/Agent PERMIT FEE: $' ��J Signat Telephone No. i . ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the (� permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an e O 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 M Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ y Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: w Inspectors Signature: Date: ,t ROUG INSPECTION: PaCT Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: �L Inspectors Signature: Date: 9 FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Zr1 Inspectors Signa ure: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com f The Commonwealth of Massachusetts Department of lhdustriqlAccWnts Office of Invesfigations qu 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):?d 0 C, Address:_ 02/ 7� Ha i1 S4 . ZOJ4 qCity/State/Zip: D Phone#: q 7� "�7 q- 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 nployees(full and/or part-time).* have hired the sub-contractors 2.[N�`Iam] a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g ❑Building addition [No workers' comp.insurance 5. El We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3111 am a homeowner doing all work right of exemption per MGL 11.ElPlumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance re fired. P reqaired.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyt fy under the pains a p-�nalties of perjury that the information provided above is true and correct. Si afore: Date; q 5-11 Phone#: 78 ` q 7 0 855? 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 10 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 employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint 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 numbers)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 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 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gomy4onwealthofMossaclhusPtts Department ofI.ndustrial.Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel#617-727-4900 est 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-727-7749 v ww-Mass.govaa. 4 COMMONWEALTH OF-MASSACHUSETTS, ' Com.° � . ° � � • BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS-.A :. i REG I STERED MASTER:.E.LECTR I CI-AN�: r? . a RONALD A VITALE � u ( 21 FELTON ST P,..EA$OD'Y MA 01960 806'7 20829 A 07/31/16 50869 i 6OMMONWEALTH OF MASSAt✓HI SETTS • • "Dimiumleig • 0. , I ::WAP'OF I I EIItlt#1 C I ANS ' ISSUES TH f OLLOW I NG l i i=NS1 AS ROtTI`RE{l MASTER ELECT 1 d LANC1 I] MAG I NN I S 12 LOCUST ST zt % E M}:lJt3LETON MA 01949-12 s 2121 A b7/3I . 96024 s C I 4 s ' i i Date......�� l..1. .............. NORTh � e� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION BgCMUS� /}� This certifies that ......!��. ....!!C���jf�l.�.....c.0.............................z................ has permission for gas installati n ... e r,,�.,, i�c,Cu' in the buildings of..�,r'...��.. r...� I M...........-..... � .................... at........................Q�5...... r ?............, North Idover,Mass. Fee,, , . 1 Lic. No. .......................... .........: ....................................................... GASINSPECTOR Check# i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY d �� ( MA DATE I AU /5-201 j I PERMIT# b I� JOBSITE ADDRESS S OWNER S NAME GOWNER ADDRESS A- rsi TE I_._ FAX[ TYPE OR OCCUPANC TYPE COMMERCIAL( EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: .-..-. RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES E] NO APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER m—f1_E . . _ I _1. _ BOOSTER CONVERSION BURNER _ _ E. COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR I .•_–TI _ I E _ = GRILLE ... INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT � TEST !�.� !� ! I — _ _. -.�_I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ..............._..................._. . ..I.........._... .............. - i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND F 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 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provis. of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ,C c_,. LICENSE#� � SIGNATURE MP MGF 0 JP 0 JGF 0 LPGI CORPORATION g# 3o2t; _ E PARTNERSHIP®#�!I LLC D# COMPANY NAME/1f��..,-_ ADDRESS CITY /��_ ��• - _m – - — –-- -- —� STATE�ZIP d!- =TEL FAX CELL EMAIL r• ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 y The Commonwealth ofMassachusetts Massachusetts - Department o,fkdustrialAccidents Office o,fInvestigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: - ` i City/State/Zip:f /I �1�}( `T �� Phone#: g�7 of- Are yoyau employer?Check the appropriate box: Typo of project(required): 1. am a employer with 3 4. ❑ I am a general contractor and I 6 ew construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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, g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing allwork 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] '%ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they 8ie doing all work and then hire outside contractors must submit a new affidavit indicating such. „ tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: l r/ d- Policy#or Self-ins.Lic.#: Q;�r S�-1 UQ-5-3 �) d Expiration Date: 3/,-? Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 'Investigations of the DIA-for insurance coverage verification. I do hereby�certlo under the pains andpenalties ofperjury that the information provided at. above is true and correct - Date: /1"acl 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Percnn: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written.." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance With the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have a employees,a policy is required. De 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 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a homeowner 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 CoauMouMalth ofMomarlimetts Department offaduatdal.A rxidauts oface of javestigatiom 600 Wasbiugtoa Street Boston}MA 02111 TQ1,#517-727-4900 W405 ox 1-877;MASSAFB Revised 5-26-05 F40 617-727-7749 61156 rt HONTM - TOWN OF NORTH ANDOVER �4 p PERMIT FOR WIRING �-- °•,r.°�. ACMUS� U /, N This certifies that .... !.A.. ....... ... ...; ..... . ................................. has permission to perform ....... `? (. ..... .a.e—ttr.. '.................... wiring in the building of......,� f-�y�.. lc__,,.11/................................ at.. ..,!�l�f.!4 1 .'...........'.Y...................... .North Andover,Mass. Fee.. .!90......... Lic.No.......�r 1 ... .. ................................... n c.� ELECTRICAL INSPECTOR Check # �y �/ DEFAJU1'NW0FPl1B1V AF= Permit Na �G. BOAMOFFIREPRuvzv UIVRBGVLA7Xai116521a12- Occupmry R Fees Checked APPUCAHONFOR PERIVIl'f TO PERFORM ELECTRICAL WORK V ALL WORK To BE PERFORMED IN ACCORDANCE WMi THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 i (PLEASE PRINT IN INK OR TYPE ALL MRMATION) D �S Town of Noah Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described bel Location(Street&Number) Owner or Tenant Owner's Address ls this permit in conjunction with a building permit: Yes No [:3 (Check Appropriate Bos) Purpose of Building Utility Authorization No. Existing Service Ampa�.V olts Overhead Underground a No.of Meters New Service Amps Volts Overhead C3 Underground Q No.of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work X C'V-4AJ Ir Na of UBhdrta Outiw No.of Hot Tubs No.of Trmsibntters Totd Na of Uaht1M Furtma Swhamina Pooh AboveZrWnd Below KVA KVA No.of Receptacle Outlets No.of OU Bunters No.of Emerpmey Ushdna Battery Uniti Na of Switch outlea No.of Ou Burners No.of Rw4p$ No.of Air Cond. Toud FIRE ALARMS No.of Zaees Taos No.of Dispossle No.of Ham Tool TOW No.of Dqwc&@rd Pumps TOM KW m -- No.of Dishwuhers Spsce Ara Haft XW NO fS Devises Devloss No. -_ No.of Dryers Hestina Devices KW DeactiaNSomr ft Devices a o o °� No.of Waal Heaters KW Na d Na of Sion Henri No.Hydra Musge Tubs Na of Molars Told HP OTHER, lrteuanoeCDVWV P�ratbleragit3rdbdMeardaraelltGalmtlLaM ]tmeacr�clietiYhaaroe�i�yindudrBtlott�ide orkatarAwaW a t YES NOIt�estrbrt>ibdvaidpAafdsanetofleOfflm YM NO dreddt�fte beammm" WSURANC E M BMOTIMR �leeae �� /)P.q. 6 6 DW EliniadValiedFho"Wadc 4-8 WodcIDSWIt !Q litepec�ll7ateRec�teOsd Rot�¢I find I�tMNAIv18 a ✓ A41Nva / Li=Na c "TaMa OWI�MS2ISURANCEWA1VIIt;lanawaetlli telmwdmwi eirX ante ALTKNa arddtetmysi@resaernQiispemitappic��IKstlivaquimns ��°��e��m10���+�esad><�GareralLawB (Please check one) Owner Age a Telephone No, pgR�.FEE s Location _� �fi` ' No. j� Date TOWN OF NORTH ANDOVER s • • : . Certificate of Occupancy $ Building/Frame Permit Fee $ /2� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 18675 `Building Inspector 1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATIONS TO CONSTRUCT YREP v RENOVATOR DEMOLISH A ONE OR TWO FAMILY DWELLING a ' BUILDING PERMrr NUMBER: DATE ISSUED: OT SIGNATURE: Bittilding Commissioner/I r of Buildings Date SECTION 1-SITE INFORMATION Z 1.1 Property Address: 1.2 Assessors Map and Parcel Number: o 3 S - 0 0/ 07 SMap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dii;id Proposed Use Lot Area Fronto ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RegWred Provide ReWrW Provided ReWred Provided v 1.5. Flood Zone Information: 1.8 Sew S tem: 1.7 Water Supply M.G.L.C.40. 54) Sewerage Disposal System- public , Public ❑ private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHENAUTHORIZED AGENT Historic District: Yes_ No_ rn 2.1 Owner of Record Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Nami;Print Address for Service: O z z Signature Telephone m SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. O Licens Number Address Signature Telephone Expiration Date ic r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name /� Ll m Registration Number r. Addressk0o, 71 E ' Signature Telephone G) t 3 SECTION 4-WORKERS COMPENSATION(1VLG.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.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant . 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC j 5 Fire Protection 6 Total 1+2+3+4+5 Q Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING 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 r SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, {)(7 �(/ �'� /t�r/ ~y ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 16J��/""�/A'l Print Nam v � Signa of Owner/Agent Dat NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iST2ND 3 SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations y 600 Washington Street Jv Boston, MA 02111 V. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnNicant Information �j Please Print Legibly Name (Business/Organization/Individual): ial ii/L� l C(,,, 14,1 , L64jl- - Address: bio--tom City/State/Zip: J?J✓V -�'- � Phone 206( 3 Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with 6 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. * 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ 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' 131-1 Other comp. insurance required.] 'Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: I 1' Policy#or Self-ins. Lic.#: Expiration Date: 0- Job Job Site Address: 6 9 /) N�/e S7' City/State/Zip: /V 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 tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certify ruder the pain andpenalties of perjury that the information providedaho a is tr a and correct. Si nature: Date: Phone#: /�G'G' a .� 7 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#: J Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-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 cavy 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 till 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 ,vww.mass.gov/dia Oct 11 05 U8,36a CColl 1` 1.800.306-3949 Federal I.D.# 000853966 Fax:'(781)853.4464 Mass,Registration# 141031 349 Broadway St., Revere,MA 02151 Home IMprover�ent.Co..Inc. AGREEMENT Since 1975 Name: Jtit.v>AV--►' 0 a=Q C- 3a A%"'z1-y Date 16!S,Jr Address: 61 S0,MhaL Sv -D� City: WMA, tA.,J= O-•'1. State: ttitw-V Zip: 0 t-?lL.tI Home Phone: 1--7-4,Sly Wore Phone: INCLUDED NOT INCLUDED A.Coverall Walls&Gables with TQjS1'*A40%%A 40M(!�VINYL SIDING in e,L,0%-q cola,( ❑ B. Remove and Had Away Existing Siding(Excluding Asbestos). ❑ C.Remove and Replace Rotten Wood as Necessary to Perform Work. [V ❑ D.Furnish and Ins:all Extruded Weather Barrier Around all Openings in tAjA.jnrcolor. [�, ❑ E.Furnish and Install .ety �-� �*-M—K o i°eMPo'sts on Exterior Corners of Home in r..��t+��or.C� E]F.Ata,Home wRh Insulated Underlayment System. ❑i/ ❑ G.Custom Fubricate PREMIUM SOFFIT AND FASCIA SYSTEM For Overhangs tri color.❑ H.Fumish and install Continuous Seemless Gutter System and Downspouts in color.❑ [� 1.Custom Fabricale Premium Window Casement Wraps in oclor, ❑ J. Custom Fabricate Aµ- Premium Door Casement Wraps In avJ-►_rW color. ❑ K.Custom Fabricate 2 Premlum Garage Door Ca` nt Wraps in Lei►CIIILC color. ❑ L.Furnish End Install as Pair of Shutters, vuvered❑Raised Panel in L-4,TIe calor. Cg- M.Furnish and Install Vinyl Gable Vents. n N.Cover Front,Back,Parch Ceilings/Carport Ceilings(Describe Below)in color. ❑ [h 0,Remove+haul away existing Rook.g. ❑ P.Cover Roof in 30 YrRoofirrg•Shingle-•- ❑ 0.Clean All Jots-Related Debris on a daily Basis. ` ❑ R.All work Performed by the Contractor is Ful'•y Covered by Workmen's Compensation. [ ❑ and Public LiabilityInsurance. Other Watt to be Performed: !=� TOTAL PRICE $ IZr000 (Prices includes as promotions+dhcountaj PAYMENT SCHEDULE DOWN PAYMENT UPON JOB START DUE UPON COMPLETION INITIALS Amount $ 4,oco $ Lt i(:-ao S L7.0 0 0` NOTE:11 financing is chosen huyer understands that cancelling the finance agreement does not cancel this agreement.Buyer is responsible for any amount American Home Improvement Co.,Inc.incurs in obtaining financing,including but not limited to fibs search fees.It shat be in the obligation of the Home Improvement Contractor to obtain such permits as the Owners Agent The Owrees wAo secure their own construction,related permits, as deal with unregistered Contractors w(iJ be excluced from the guaranty find provisions of MGLC,142A. WI h:)rre Imprarement Contractors and Subcontractors shall be registered by the Director and that any inquiries about a contractor or Subcontractor relating to a registration should be directed to: Director some Improvement Contractor Registration THE OWNER SHALL PAY FOR THE WOK BY THE FOLLOWING METHOD: One Ashburton Plaoe,Rocm:301 CASH UPON COMPLETION( BY MODERNIZATION LOAN( ) Bceton,MA02108 COMPANY'S GUARANTEE The company guarantees its workmanship for L.1 izt-s C� replace defe98 Meas. II wia replace detective material within the period of guarantee free of charge. All requests for service must be it writing! This agreement must be accepted by an officer of the co-itractor within thirty(30)days from the data of execution. You may cancel this agreement without any liability to you,provided that you send a written notice to the Contractor by midnight of the third business day following your signing of this agreement,by ordinary mall,posted,by telegram, or sent by delivery. Owner(s)agree(s)that in the event of�;ancellation cf:his contract by ovener(s)after the third business day,owner(s)shall pay contractor on demand (25%)(wenty-five percent of the cortract price as its stipulated damages for the breach of the contract. WITNESS our lands and seal this day of �'L'OLS(it!�- P00_� American Homs Improvem Co.,Inc. DO NOT SIGN THIS AGREEMENT BEFORE YOU ;SCBJcCTTO HOME OF E AOv READ TORIF THERJ=A E ANY BLANK SPACES. Ey: (Representative) (Oanerj Accepted by Mar 10 2005 2:31PM HP LASERJET FAX 617-796-89Fi8 P. 1 ,•.I � 3���� Iy " daHeHMge''�wPooxrH t:rattxataxu,ae�at�m,a rt3 '¢i f . ' c; :z:sd iso"x - t� 3 10 5 Pn000t�n : TNS] CERINWATE IS I MED`At A NATTER OF WFOpYATf1DN ONLr AND THS WI (MA Professional Risk lLaaagea�snt CONF05 NO MGM UPON 71E CINTMA7E MOLDER. TE ooe's NOT ASEND.WITI lD OR ALTRI THE IDDIYlRAt#E AFMORD BV Tete 1171 Na ski>nugton St POLICIM SELOMO. :....._.. .__..._._....._. ...._..................................._.......................................................---....................... West Newton, 1LA 0165 COMPANIES AFFORDING COVERAGE .............................................................._...............................................-,..._........................... cEr A Scottsdale Ins. Co. ....._..__.......,_.._................._._......._.......,..........................I......._.._.........................I..................... ........ ..................._........................................._..............................._....:.- LET00r 8 Granite State Ins. 00. (AIG) ...C........ ... _................................. .................._.__. . _ A nerican Home lbprovemeat LETfW Company, Inc. .............................._.........................._........................................................................................._......... 349 BroadwayLETW D REevete. adA 02151 ..,._,._..._.,....__.._._._.._._..._..._ .........._..........._............................_...................................................... conlrrtvr E MW`Sw:». THS IS 10 CERTHTY MAT THE POLICIES OF HNSURANCE UVED WOW HAVE 6EEN ISSUED TO THE INSULA NWED AWYE FOR WE POLICY PEFSOD INCICATFO,NOTIMTHiSTANDING ANY REDUIRfMINT,WJVA OR CMDMON OF ANY=JTRAor OR OTWER DOCUMENT Y11TH RES9PEC'T TO WHICH THIS CERTRICATE MAY BE HSSUED OR MAY PERTAIN,W WSURANCE AFFORDED 8Y AIE POUCFE,S DEICFMW HEREIN 13 BULJWT TO ALL 14E 1I91MS. 9CLUm9p! AND COM-0mIm O°SUCH Poualm LVWT3 SHCWN MAY HIWE SEEN IIECWAD 9V PAID CIMMS. »..............,.........,...........................,... OD i TVm OP NVAUM E POLAEY AiYN11 �41Ct afC11Yl 3POLICV nwr* m t 6111 i ; . aH►n 1MMID 's HiA7S D&OD" :................__....._.................,..................... .........................•....................... A6PA�IAL LUNRJtV ._........... ....................._..._........................... „z8�f •f,.„.,_.,......,i ,......,, , :._W._.M..E_1W. .A._G.O,MILM __..s 300,000 ..........I............................ colweccEIFa LWun ftomy#-Csv"m300,000 ...................................... s a""6u1ADE X ovap. 02I18105 ' 02/18106' reaowltaa3V.HMII7NY340,000 }._.._.. ....,,...,..,.,..... w.i...._._....30. . F Gomm A CCMMACIP(In WW. i EAM OOCIAPN,CE ii _ ........................._.............._.. ..... FRE DMIgOE I °N 'i........................000 ;.,.....�............. IED.WENIE 4m :i . ' wn o.�+all: S,000 eAulp�Drii WNfFY ..._..... ..._... ....._-•ED 3"KE_...._..... »_....................... .. oOiON a Arvr AtFtb Lam' /ill.DtMNp AUTOS >............_..................__......................._........................ gookly t•.•...•;soeou w wtoi ps—) i �........: ........_....._I..................._............................................. g ;HRED AM POPILY KAM I.... .5 NOILdM�4D AUTni ?t�rC1laA ;i .........i @miA&UILDY FROPOW Doom ..•...... ....................... ...'.. i�P fJnam ..........�....................... ........._......._......__................. ................_.................. Spot 00DUV o X ` _........._.... ........._._._............_..... LIMWIEL A POW :i w oFHEt 1,uw tHIO1IiFLut Fm =rAW ......>...................................».......,.._....................................................-._..............._...�._.C....._....................�...,6w.�......,................�....fiRSL� tFfl:O):7-�. ... fit.%'i...�. tPPH.w�I.OOYiIi♦INi71DM TOIM� O13.4Yg V 4't _••y Y: E : 02/05/06!!T!.! ;.x .. HENRI �r.:`: Peft mce boa/05/05 OZ/05/06 " 10�'r,._._. i 100,©00 ...._........,_........_.._............... DEE�sE•Poucr LWff e/F011NIV H1iAOUTY ; ................................_........_...;_............100..... _. ................... ..................................................._. ._...................................... ........_,_.,. .... iDBEAS...... EMLOH� ,OQO _ _...._......................_.... ........,...._..._.. .........._..........'j.._...._._....................... Ot1I61 I i i `- } 00KIM 11 Or OPNth MONYSMA"" immLO iffim L nm 781/S53.4464 SHOULD AW OF THE ABOVE OEMNSED POUCIEB W CANCELLED BEFORE THE . BORAT CH OATS THEREOF,THE ISSUING COMPANY WILL W4MVOR TO MAIL 3S DAYS WRITTEN NOTICE TO THE CERnSCATE HOI.DVA NAM®TO THE insured t s :Copy ' LEFT,SLIT FAHLUFE TO MAIL SUCH N 3K4LL HMPOBE M0 oeumnm on x. LIABILITY OF ANY y THE PUNY ITS AGIRM OR 1TARVI31. -" I'd +AmArmo101 dQ77n Qn 9.7. semi t l�_ -; ✓fL�Board of of Building ula/ions and Stan ar s B g Re L�, ,- One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Horne Improvement Contractor Registration Registration: 141031 Type: Private Corporation. Expiration_ 12129/2005 AMERICAN HOME IMPROVEMENT CO, INC CHRISTOPHER COLL 349 BROADWAY !� REVERE, MA 02151 -- Update Address and return card.Mark reason for chang Address ❑ Renewal [—] Employment Lost Card _\ v711ie 2�d�,ru:ron...eall/ o�lutaclfutc�Q`a Board of Building Regulations and Standards License or registration valid for individul use only ' HOME IMPROVEMENT CONTRACTOR before the expiration date. Hfound return to: Board of Building Regulations and Standards Registration_ 141031 y Expiration: 12I29I2005 One Ashburton Place Rm 1301 Boston,Ma.02108 Type: Private Corp oration AMERICAN HOME IMPROVEMENT CO,INC. CHRISTOPHER COLI 345 BROADWAY � .✓ __ REVERE,MA 02151 Administrator Not valid without signature I NORTH own of sAndover 0 J* 7? idover, Mass., T ° - LA C OC MIC KE WICK '7,q A°RATED C7 `S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 6 BUILDING INSPECTOR THISCERTIFIES THAT........... ... .............. ................................................................... .. . ........................... Foundation has permission to erect........................................ Idings on ... ... Rough • to be occupied a ...�-�! � � Chimney ... . . ............................................................................................. .... provided that the person accepting ermit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service B 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 I FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location 4 t? 4v/ .S� No. Date NORTq TOWN OF NORTH ANDOVER •o ,•'1y0 C? ,. • OL � 9 i • ; Certificate of Occupancy $ �'�J'"^°•Eta' Building/Frame Permit Fee $ — �CNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I Y ` Check # ✓Building Inspector 1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING sx - BUILDING PERMIT NUMBER: DATE ISSUED. m a SIGNATURE: /f Building Commissioner/I wor of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 35- - Nath /1, ,VM D)Cbt',_/ Map Number Parcel Number r rm 7 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No m 2.1 Owner of Record 1/ VUieri e -t- 11arlt 31;/eg �/ jec Su Name(Print) _ Address for Service: Q ignature Telephone 2.2 Owner of Record: Nara&Print Address for Service: 0 M Si nature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: O License Number Address Expiration Date ic Signature Telephone r ,q 3.2'Registered Home Improvement Contractor Not Applicable ❑ 0 a Company Name M Registration Number r Address r ae Expiration Date ^z Signature Telephone V r SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitt is application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0- No...... SECTION 5 Desch tion of Pro osed- ork check au applicable) New Construction ❑ -ixisting Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory-Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: +)�sd1An e. W d lseo_54J Gk . AP'C4>)5-&rock 1&a AC•(L l✓rth L"WGj Tmrt _ Gill SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY. Completed by permit applicant I. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(s)X (b) 4 Mechanical HVAC C 1" 5 Fire Protection 6 Total 1+2+3+4+5 000 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1> A) ,as Owne Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. 1 A-G 05' iature Owne Date SECTION 7b OWNER/AtITUbRIZED AGENT DECLARATION w 1, as Owner/Authorized Agent of subject property \\ I Hereby declarethat the statements and information on the foregoing application are true and accurate,to the best of my knowledge + and belief Print Name Si ature of Owner/A ent Date t NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 2�( 1 2ND 3RD SPAN DRAENSIONS OF SILLS ` DIMENSIONS OF POSTS r DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION 1HIICKNES SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH own of 4Andover 0 No. ,3 y yD C% = dover, Mass., COCKICKEWICK A- 7�S RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System .r t� BUILDING INSPECTOR THIS CERTIFIES THAT ��. ...................... �4.I...1 f .......................................................... Foundation ..... .... ................................. has permission to erect... �.,. a.�............. buildings on ......`..3.....a..............................................�................ Rough to be occupied as IDS N A-ot''K P- 0 r 0 Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application o 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. 3C /10 7 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI N ST TS Rough Service ........ .... ........................................................... BUILDING INSPECTOR Final I Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. e^0 d` • FORM U - LOT RELEASE FORM PlA-�'D�c(C S� 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT I FQ - � PHONE q1$ 637 JU58 LOCATION: Assessor's Map Number p� PARCEL ,` 10-T SUBDIVISION NA LOT (S) STREETST. NUMBER (��J * *******OFFICIAL USE ONLY************************ VMNSERVATIONADMINISTRATINR SID S OFT GENTS: DATE APPROVED DATE REJECTED COMMENTS 1 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Page 1 of 1 21' 3'- 6' 2' 11' 8` 4' 2' 21' 3` 3` 8' T 4' 10' optional freestandng bench 3' 14' 14' 24' http://www.decksusa.com/plans/dimages/DD1063pin.gif 8/11/2005 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 63 1.0 r keX- is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: �)O yd ty l dVnPS&A— (Location of Facility) Signature Permit Applicant Fire Department Sign off• Dumpster Permit Date f pORTM TOWN OF NORTH ANDOVER OFFICE OF A BUILDING DEPARTMENT 400 Osgood Street 4,0o 7 North Andover, Massachusetts 01 845 ,Ss^GHVs�t D. Robert Nicetta, Telephone(978)688-95454 Building Commissioner Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: b3 Number Street Address Map/Lot HOMEOWNER OXV— 11� t$7 dL-5'`d 617 b7q V5/-7 Name Home Phone Work Phone PRESENT MAILING ADDRESS (03 50rKt- Sl= City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) 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 intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. "" l HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL BOARD OF ATPEALS 688-9541 CONS IiR.V ATION 6980530 11EAJ,T1I 699-9540 PLANNING 688-9535 BUYER: SOS UTIL.rT ►31'1.c�©' Arun T J Oil . i w STORY \.v ocza LoT DoT 1 2 �3 Y--E2 ST MD 17S TITLE INSURERS. ) MORTGAGE INSPECTION PLAN I CERTIFY VAT THE BUILDINGS SHOWN DO ( ) CONFORM TO SETBACK REQUIREMENTS OolpTq ATP IN /P ► 11�.�. fG�I.E. (FRONT, SIDE. & REAR SETBACK ONLY) OF No�-T� ,dNp-1¢TL AQ1,> WHEN CONSTRUOTED, OR ARE EXEMPT FROM.VIOLATION ENFORCEMENT ACTION UNDER MAS& G.L TITLE WI. CHAPTER 40A. SEOTION 7. UNLESS OTHERWISE NOTED. MASSACHUSEM ZQAE )PC o%rT I FURTHER CERTIFY THAT THIS PROPERTY IS Na-r LOCATED IN THE ESTABLISHED FLOOD HAZARD AREA.OOMMUNITY PANEL NO.:2J 0�8- Q0(35CDATE: 6 '2-'`3"3 DEED THIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUENT TO THE RECORDED 9ooK O DATE OF THE LATEST DEED OF RECORD. PAGE ^WHENEVER BULLRINGS ARE SHOWN LESS THAN ONE FOOT FROM THE P IT IS ADVISED CERT. N0. THAT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE M ' E THIS CERTIFICATION IS BASED ON THE LOCATION OF SURVEY V �-,t .i.1; I NOT PLAN BK. PAGE REP T A PROPERTY SURVEY. VERIFICATION OF SURVEY AND SHOWN, MA BE ACOOMPUSHED ONLY BY AN ACCURATE. INSTRUM p EPICTED PLAN f ►O�Z I DATED TII9 & _I�a� L!�. • RINI[IMi4YS DR-nnCA11ON TO BE USED FOR MOR PURPOSES ONL UL-( Z,O 04r OFFSETS AS SHOWN ARE K •>l` . T. USED FOR THE ESTABLISHMENT OF TY UNEP, BRADFORD �/ � ) '' ► ENGINEERING CO. r> �. �.• c.: t,;t P.O. BOX 1244 JAMES W. BOUGIOUKAS R.L.S. 09529 T A%S) MA. 3-2396 Date.. . . . . .. OE`NORTH 1,y TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACHUSES This certifies that .�'':-�::T1. . �.1 .��. . -:�. . . . . . . . . . . . . . . . �, [� has permission for ga installation . . .� . 1.�/.. . . . . . . . . . . . . . in the buildings of (� 1'x/ �. . �r'-�X. �t/:... . . . . . . . . . � U at ./ 1 ! . . . . . . . . ., North Andover, Mass. 4�0 Fees"� . Lic. No.. � 1' . GAS INSPECTOR Check# W-5/ 4841 I 1 1 MASSACHUSETTS LTIN 'ORM APPLICATON FO ERMIT TO DO GAS FITTING Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations C 3 3�21Cd2 5�- Permit# Amount S Owner's Namey A L a a I� �A� L&�Z i New❑ Renovation ❑ Replacement Plans Submitted ❑ A z Z tn eA L .: = n z — z v, = z C SUG-SASEM ENT HASEM ENT IST. FLUOR 2ND . FLOOR I 3RD . FLUOR 4T 11 . FLOG R 't Sill . FLOUR 6T11 . FLAUR 7T II . FLOUR ST11 . F1. QOR (Print or type)����� � �� � ���� Ci�k one: Installing Company Name �- Address . �• S�t ❑ Partner. Business Telephone --Z� Firm/Co. Name of Licensed Plumber or Gas Fitter ' INSURANCE COVERAGE Check one: A I have a current liability insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves,please indicate the type coverage by checking the appropriate box. • Liability insurance policy0 Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Asent ❑ 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 State Gas Code and Chapter 142 of the General Laws. Bv: Signature of Licensed umber Or Gas Fitter Title Plumber CityiTuwn Gas Fitter License i'umoer Master APPROVED wfrm-USE ONLY) Journeyman s � Date./?)/* * *�`G/5 N2 4Lu6 NORTH TOWN OF NORTH ANDOVER o PERMIT FOR PLUMBING ysSACNus� y This certifies that has permission to perform . .` .s 4-�.`!. l.'�.t. . . . . . . . . . . . . plumbing in the buildings of ././Z,. a.'.f. . .: l. . . . . . . . . . . . . . . . at . .CI . . . . . . . . . . . . . . . . . North Andover, Mass. Fee.: . ?. . '. .Lic. Nab. ..'.?. .3 . . . . . . .2. .'. . . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ,�� ,& U`F�Y' . Mass. Date G 19� Permit # - / Building Location Ig Owner's NA ��!� F Type of Occupanc r t E Q ri A L_ y New ❑ Renovation ❑ Replacement t►d' Plan Submitted: Yes ❑ -No ❑ FIXTURES z I z m < N Pz Y !- N O of 0 z y N W Y J N y U < N z W W m Z N < ¢ < . ~ Z C N ¢ J N W y �- W N F- U cc x ¢ Y < H W Z d ` a F- O ¢ m W ¢ } < F W Z C a 0 < < X = O O ¢ < W ¢ < W O Q N Z .¢ a C 0 W W O O h V < S = d. z S Y m 0 I- _ = d W k Y W N O O O < Jj < ¢ C C Q O < F- N W �7 O < S ¢ (C O sue—gSIMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR a. STH FLOOR r 6TH FLOOR y 7TH FLOOR 8TH FLOOR Installing Company Name �Ot3Ee7 S4(rMATAe0 Check one: Certificate Address 3 0 C"' C H ❑ Corporation IY) E TW i 'c--AJ Al A 0 t LI ❑ Partnership Business Telephone_ -�7�Z-i17 9-6m,/Co �- Name of Licensed Plumber f ,%3 F/_'T h' SA>MrVI r4 rrCl INSURANCE COVERAGE: I have a current I• bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Vis, please/indicate the type coverage by checking the appropriate box U A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent❑ Signature of Owner or Owner's Agent 1 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 petformed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g Oode and apter of the eral laws. Title re of Linen Pum r City/Town Type of License Master % Journeyma,b❑ APPROVED OFFICE US ONL License Number �_3 3 5 BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR Location No. 1 Date &177 lz�l'�z ^T►► TOWN OF NORTH ANDOVER 1 a Certificate of Occupancy $ s,Z. t� Building/Frame Permit Fee $CHU -v v Foundation Permit Fee $ Other Permit Fee $ j TOTAL Check # X7695 / � � __ Building In a TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUE DING PERMIT'NUMBER. DATE ISSUED: Q m �3 0 - X SIGNATURE: BuildinCommissioner/In for of Buildin Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: o3s /d7 Map Number Parcel Number to 1.3 Zoning Information: 1.4 Property Dimensions: CD Zoning District Proposed Use Lot Area s Fronts ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Regaired Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.3. Flood Zone lafomoation: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ct: yes NO m 2.1 Owner of Record ,- [/X K K - A )�/ Z e G/ - Name(Print) Address for Service Signature Telephone O 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ vLicensed Construction Supervisor: 4 , 14 / License NumbqV11, 11/ Address Expiration Date RE Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ ,�- /7�/�/ �i9-� /fin �l� ���/�o��.�i>a�v�• //�� Company Name �(J� Registration Number r Address Expirati n Date z Si mature Telephone i t SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......❑ SECTION 5 Descri tion of Proposed Work check a0 a ucable New Construction ❑ y Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify --�-- Brief Description of Proposed Work: 40 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by pennit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(,)X(b) 4 Mechanical HVAC ///. U v 5 Fire Protection ! �J 6 Total 1+2+3+4+5) Check Number n SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN t OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i w I, as Owner/Authorized Agent of subject property Herebv authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION l7b OWNER/AUTHORIZED AGENT DECLARATION 1, i ()`I N �Q S / /����� as Owner/AJon�z�Ageiof subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief J 6/94/ 60S 7'�"/ Print Name Si t Owner/ entq Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 15 2' 3RD SPAN DIMENSIONS OF SILLS DRVIENSIONS OF POSTS DRAENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUR.DING CONNECTED TO NATURAL GAS LINE NORTH Town of Andover A- C over, Mass., 0 COC IC EWICK ��S ATE 43 BOARD OF HEALTH Food/Kitchen PERMI D Septic System BUILDING INSPECTOR THISCERTIFIES THAT........................................ .................... ....................... ............................................. Foundation .......*"**A- -A has permission to erect........................................ buildings .... ..... sad .. ............. Rough .3....... n tobe occupied as........................................................................................................................................................................ 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 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 S Service .................................. ...... ....................................... BUILDING 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. r 1.800-306+3949 Federal LD-N 000853966 Mrolivenew.co- Fax:(781)853-4464 Mass.Registration� 141031 f 349 Broadway St., Revere,MA 02151 2-CD trio. ,Yin"1973 / AGREEMENT Nd ter'/ .�//�i�i�y� ri�� Date:�i 1, Address: -- City: rp: Home Phone: WorkPhone: INCLUDED NOT INCLUD Cover all Walls Gables ED ra. S with _ _ 1 [: .. VINYL SIDING in.....-•------color.�E. Remove anti Haran Away Existing Siding(Excluding Asbestos), C.Remove and Replace Rotten Wood as Necessary to Perforin Work. i-1• D.Fumish and Install Extruded Weather BarfwArourid all Openings in color r71 E.Furnish and install New Comer Pos%on Exterior Ctimarsof Home in __color. F.Wrap Home with Insulated Underlayrnent System. J G.Custom Fubricate PREMIUM SOFFIT AND FASCIA SYSTEM For Overhangs in— color.t^ H,Furnish tart Install Continuous Seemless Gutter System and Dowrispou4s utsic l _3 1.Custom fabricate "Premarm yVmdow Casement Wraps in.-_,__------.-.-----..__...�. ..__._. Flo •..i J. Custom Fabricate Premium Door Casemerd'Wraps in color. [ L K.Custom Fabricate.. Premium Garage Door Casement Wraps in L.Furnish and Install_ Pairof Shutters.(`]Louvered(_1 Raised Panel in L 'r U t__J M,Furnish and Install-_ Vinyl Gable Vents. N.Cover Front Back,Porch CeifingsiCarpor'Ceilings(Describe Below)In......._..........................................odor. _ 0.Remove+haul away existing RR/octlsng,,.t� P.Cover Roof in 30 yr _.. /nr.iJl�j s!./ f�L ........._Roofing Shingle- L•/ ..-) ter.Gear All Job-Related Debris on a daily Basis. [ �, R.All work Performed by the Contractor is Fully Covered by Workmen's Compensation. i..., (..._� and Public Liability Insurance Other Work to be Performed:'_ TOTAL PRICE 7 ,I prt+mulgnv*damunts) PAYMENT SCHEDULE DOWN PAYMENT UPON JOB_START DUE UPON COMPLETION INITIALS Amount TGG g / gOl�ri � NCTF:If financing is chosen buyer understands ftsAl concelling the finance agreement does not cancel this agreement,Guyer is msprnrihie fol any amount American Mane Improvement Co.,Inn,.incursin obtaining financing,including but not limited to Ilia ssarch fees.it stall be in the oblication of the Home Improvement Contracbx to obtain such permits as the Gwner's Agent.The Owner's who secure their own c isiruction related Penn ts, as deal with urregisrered Contractors will be excluded from tho guaranty find proymons of MGLC,142A. All hame!mprcvement ContraetOB and Subcontractors shall be registered by the 0imctor and that any inquiries about a contractorcr Subcontracter relating W a registration snoAd be directed to: Director Home ImprovementContractDr Regis!ration THE OWNER SHALL PAY FOR THE WORK BY THE FOLLOWING METHOD: OneAshbunon Place,Room+301 CASH UPON COMPLETION( ) BY MODERNIZATION LOAN( ) Boston,MA02108 (Gni)727-85%COMPANY'S GUAR.4tiEE:The company gurararflees ds workmanshi for tsars. it will replace defective material wf!hin the Denied of guarantee free of charge. All requests for service must he in writing! This agreement must be accepter by an officer of the contractor w:tNn thirty(30)days from the date of execution. fou may canoe!this agreement without ary Ilablilly to you,provided"•.flat you sand o written notice to the Contractor by nnidnight of the third busir^;5 day foflowini,.your signing ct ibis a,ruemtcnt,by ordinary mrul,posteG,by teiegrarr.., or sent by delivery. Dwner(s).igrce(s)that it the event of cancellation of this contract.ny owner(s)after the third hmmir ess day.cwrrr(s;shelf pay rontrtctnr on drw.,md (251;);comfy-five percent of the contract price as its stipulated damagss for fine oreach.of Ile u;nt:ora tNITNESS our hands and sial this.__._.....-_......_......... ... _.. dal'c{..... __._ roD_.. Amerior.Hime Improvement,Co.,Inc. i30 NOT SIGN THIS AGREEMENT t3FrrrRE YOU III tsueJEcr r cFFtcE nvr ov >, BEAD IT OR 1'T+i E- RE ANY BLANK SPACES. BY (anwn.•.cntative; ioWrleriT.. Accenlo by. - .... ......_.... A T 'd b9isbESBTt3G ei•E T T t10 00 100 ti I r ' D t Board of Building Re ulaions and Sta One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 141031 Type: Private Corporation Expiration: 12/29/2005 AMERICAN HOME IMPROVEMENT CO, INC CHRISTOPHER COIL 349 BROADWAY REVERE, MA 02151 -- Update Address and return card.Mark reason for thing Address ❑ Renewal ❑ Employment ❑ Lost Card �T/-{�io�x�i�onueall/c o�� iaracv�tweku Board of Building Regulations and Standards License or registration valid for individul use only 1� w _ HOME IMPROVEMENT CONTRACTOR before the expiration date. if Fouad return to: Board of Building Regulations and Standards n , Registration: 141031 Expiration: 12/29/2005 One Ashburton Place Rm 001 .. �� Type: Private Corporation Boston,Ma,02108 d AMERICAN HOME IMPROVEMENT CO,INC. D CHRISTOPHER COLI n 349 BROADWAY REVERE,MA 02151 Administrator Not valid without signature C A 414*DIM* DATE 9/24/ ...... ......... THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY. . ..AND.......... CONFERS NO RIGHTS UPON THE CEFICATE HOLDER. THIS CERTIFICATE Professional Risk Management 00113 NOT AMEND, EXTEND OR ALTERRTITHE COVERAGE AFFORDED BY THE 1171 Washington Sit - POLICIES BELOW. West Newton, MA 02165 ................................ ....................I........... ...... .. ....... ... COMPANIES AFFORDING COVERAGE . .................................................-...............:.................. ........ . GON`PA'4 A Scottsdale ins. CO. Li ....... ..... .......................... ....... -jjjjjjjjjjj�......................................................... COMPANY LETTER Granite State Ins. Co. (AIG) .. CCW ..C................................................................ American Home Improvement CCWANY Company, Inc. LETIM 349 Broadway COMPANY I'll"I'll"", *-1............................................ ................. .... COMPANY Revere, MA 02151 `EM, D ............................... ..................................... LOE wT MPA NY E M , -.20 2 ,-- ON I THIS Is 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BFLOIM INDICATED. NOTWITHISTANDIN(I ANY REOUIREMENT. AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P�CY PEMOD TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. ExC.wSION3 AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y PAID CLAIMS. ........................te............................... ............... co ....... ........... ............ LIN: TM OF INSIXANCE POL=Nukaw -Pau"appamm . .... .............. ....... 10472 (MMD" rgUATROMOD" LEM . ....................... A: .............................. ...... ....................................... ........ ........ ..... ....... Z X *OMM0WAAL GEMEPAL LIABILITY AGGAEGATE 00,000 Policy #:CLSM?M ................... ........................ .................66.............. -CLAI j,MO0UCTSi A00. 9 MS MADE X WOM 3 ..................... ... .............. b2/18/04 2 1 a 0 5i6� 00,000 &CONTRACTORS PROT, :....................ADV..................................-3PERSONAL& .INAW I fM, N. E .!-00",- ............... OCCI f................I.. ......... ... .. 000 ......... ............. ......................... ....... DAmAi(A-y—fi-) ...... ............................................ 50,000 .............................. . ........... ........................- -qMED-E)WE*SE(Any one pq,w*j ....................... ................................. .............. ..........$�...................... 5 000 .... ... ..... AUTO 00-lwo SINOLE AMIT *1 OWNED AUTOS .......... ........j$CMEOLkED AVM ;%WPeron)ILY NAM $141ED AUTOS For . ....... ...... .... -NON-OWNED AUTOS #BODILY NAIRY per seeds" Li :7 "OPIRPW,1jF .... ............................... TY D KIMM LIAIMIM ........................... K S ............................... .................... ............................ ........... ......... ......... ....... ..... ............ :M FdIMA 3 0ACH.OCCURRENCE C U R R EMU ...................... ................ .............. �ER TIM t1l"18FIELLA FORMREOATE 'i ................................................................. ..................... ......................... STATUTORY ............... ..................... Aro Pblky #:WC4310140 b2/0s/04 V" 2/05/05r aftavlow unpuff .................. 100106d ....................... -DkWASE POLICY LIMIT 5001-qq0 .................................................................. .............. --I..... .......... .... ................................................................................ EACH SHPT 00 ...................... ............................................. 0010 ............. t E .......... ....................................................................AL ffm .........................781 #717776"7=1 1m1;ur*vcgr0ecLn'3te0m"irio15216655 781/853.4464 nSHOULO ANY OF THE ABpVE OESCRiBED POLICIES BE CANCELLED BEFORE THE MON. Pown ofStoneham MAIL 3O DAYS WRITTEN NOTICE TO THE CERnFICA7E HOLDER NAME NA D TO THE LEFT, BUT FAILURE TO MAIL 5 H NOTICE H NO OBLIGATION OR LIABILITY OF 0 u qFCOMPANY- In AGENTS OR REPRESENTATIVES. t North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location o Facility) Signature of Permit Applicant l� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I%O R TFI w- BUILDING PERMIT TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION Permit No#: ' Date Received �gSSACHUS Date Issued: LC IMO TANT: Applicant must complete all items on this page --- i LOCATION Print PROPERTY OWNER _. Print 100 Year Structure yes no MAP' PARCEL:_4_ZO ING DISTRICT: Historic District yes o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain El Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: �Ar�L �/�..1 Phone: 9,78 (c2� :�37U Address: (?) 60rkCT 5t /VAnrb-jvZ/ Ol Sq5 Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: _ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ A) O a 6c- FEE: $ /.2-o Check No.: t `'r I y Receipt No.: a —�-�-3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor f Location Na Date L • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# IK a:. e} U L Building Inspector Plans Submitted ❑ Plans Waived D Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS ' CONSERVATION Reviewed on Signature i COMMENTS I HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS pool LAYOUT c � r } Dp,ev to �vrjcbboA wa 115 Corr/)Cr� stN,�- 0 E w A wn A If A E r ti r L +I {}oPP�� Fvrncc-e- �orler tv wboti/ A _ 3 �. i I _ „s s �p1r+ Ox W S�v�� - I a y 1,no ^�YJ N � d SJox! ��^d7 �5�3YJd b �--+tov/tel s �vju��rap VO "J�Lvp)av! UVI :nom�q����•,� vaa0 gs.'ol u -J pi,v Q 1�iaJ"�ti 910/h u0qopu"l 9141,0 . spm S V %0 � VOW �nahb'� syn-1-n� 'd�a et.('� d oLo _- }/ _ � N (fovR ax ys) PT pwuz Pr WLE TAX-STuoS S7ZOS_ y(n'/Z Nz IV'IAM &V Opf/vw r 01'Izx 41%z � - P'r SILL PLATE 2 ,'s x312,X 3(0 - _ T 'dx 10(PT) ( sca�,e 9oubt-E . TAGL SN�DS ��t T qu Grode2 1. Oz aX,D (o-r) poobL E SAGS SNS R,yht �53iy„ ONE a x 140 SILL OPT) sry„ 5 MND o„ VI/VWQ = :31 x 4 r F1 cOR 1 block- = i r ` NORTH own o ndover G - 0 No. - h C, ver, Mass, LAKG CO[MICKt WI[K �1• 'll.9s R�rEo Pa�,�S U BOARD OF HEALTH Food/Kitchen PERM LD Septic System THIS CERTIFIES THAT ........................................................................ BUILDING INSPECTOR Foundation has permission to erect ..... ............. buildings on .. .............4P J ...... (, .��- -. ... Rough tobe occupied as ............. ............................... .... ... ......................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Final 00 . PERMIT EXPIRES IN 6 MOVIS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONMTILRough Service �. ............................. ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 10,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 63 Barker 075-15 on 7/23/2014 Basement Buildout _ I NORT1i E Town of �. : _ Andover No. * t - �` z h ver, Mass cocMCA.". S U BOARD OF HEALTH Food/Kitchen PERM T T Septic System LD THIS CERTIFIES THAT . ....... ......................................................................... BUILDING INSPECTOR .......... .. . ... �I _ Foundation has permission to erect ....... .............. buildings on ... ............... ....... ... .................n.... Rough tobe occupied as .............%5i%kv^T............................... .... ...A......................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Final 'av , PERMIT EXPIRES IN 6 MOVYS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONMT Rough Service ............................. ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. I Ho TOWN OF NORTH AND OVEP, �`- • ° OMCE OF BUILDING DEPARTMENT ` • ' ���p���,.y� :'1600 Osgood Street Btiii.ding 20,•Suite 2-36 Y�s�AFuus���y 'North Andovex,lVlassachuseftg 0I845 Gerald A.Brawn Telephone(978)68$-9545 Inspector ofBi ildings . - HOMEMBR'LICENSE EXEMPTIOIIT ` Fax (978)688-9542 BTffD1NGPFRWT APPLICATION �leaseyrint - DATE: 91 (Tq j Ll ' rp13 LOCATION: Number StreetAddress Map/Lot • z�oMEo R (yarl� it q�.$ ,� ai• 33-7(f, • 7 Name. H e Phone WorkPhone PRESENT MAILING ADDRESS Tod=m State. - zip Code The currenf exemption for"homeowners" ID alto" Was extended to inchideotyner-occupied dtvellinas to i�vo N such hor). State to engage anincividsal,forhire w:ho does not possess a 1 cense,provided thatts-0Y iess fhe oym�tt1 acts as supervisor). State 3ulding (Code Section 108.3.5,i) DEFINITION OFHOMEOWNEd. Persons)Who owns apazceI of land on one or two family tructuzes. which helshe resides or intends to reside,on which fhere is,or is intended to considered a homeowner, , be,a person who constn ets more that-0120 home in a iwa yearperiod shall not be The undersigned"homeowner"assumes responsibility for compliances with the State Building Applicable codes,by Jaws,rules and regalatiom g Code and other The undersigned"homeowner"certifies that helshe understands the Town of North AndoverBuilding Department �irnum inspection procedures and requirements and fhat he/she Wilt comply With,said procedures and requirements, - -RO1vM0WNBRS SIGNATURE APPROVAL OF BUILDING OFFIC . IAI, Revised 7.2009 Form Homeowners Exdmpiion 'BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 6889535 The Commonveafth of'M'assachasegis -• .�epaY€�neni oflnci�rs;�irclAccicien�s • . Office of Invesfigadons 660 Washington Street Boston,.A 02111 -wmmass go-v/dza Wo rkeys,Compensat on.Jfi wance.r.'�f davit:BuRderg/GoytractorofFlectrix lanslPX*bero A.pplzcant WorranatXOn Please Print Low—, Name(BusinosiorganizationMidividual): �al�1�� 6a1 Address: City/State/Z.p: /1/ r)cbvVL IA o) 9q S Phone#: 9-7 8 Are you[an.employer?Check the appropriate Yoox: Type of project(required.): 1.❑ f am.a employe 6.�• n Z am a general contractor and f 6. ❑New construction F employees(f'ulland/or parttime).* have hiredthesub-contractors 2.E] f am a sale proprietor or partner listed on the attached sheet. 7• R emodeling ship and'haveno•employees These sub-contractors have 8. [(Demolition working forme in any capacity. workers'comp.insurance. 9. ❑BOding addition [No workers'comp.insurance 5• ❑We are a corporation and 10 p Electricalrepairs or additions xeclu3xed.] officers have exexcised.theix 3. Z am a homeowner doing allwork right of exemption perlt OL 11..0 Plumbiagrepairs or additions ' c.1.52 14 andwehaveno e . § ), 12. Roofx airs myself [No workers comp. ( ��, 1} Y e em to es. o workers'insurancerecituxed.�i p �' � k13.0 Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section bel6w showingtheir workers'compensationpolicy information. i Homeowners who submitibis affidavit indioatingthey go doing aawork and then hire outside contractors must,submit a new affidavit indicating such. xConiractorsthatcheekthisbo mustattachedartaddifionalsheetsliow4 thenameofthesub-contractorsandtheirworkers'camp.policyinformation. I am an employer that is providing workers'cos�tpeiasatlon insurance for r,zy employees Belox�is thepolicy anrij0 site in,fo�matior2. . fusuxance CompanyName% Policy#or Selz ins.Lit,. V. Expiratzon Date: lob Site.A.ddress: City/StatelZ7p: -policydeclaratiortpage(showing-the policynnnhex and expirations crate). attach a copy aft teworlters'compensatioxt Failme to secure coverage as requiredunder Section 25.A,ofMGL o.152 can lead to the imposition of eximinal enalties of'a fine np to$1,500.00 and/or ones-year immisgment,as well us obit penalties in the form of a STOP-WORK ORDER and a fate ofup to$250.0 0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of fnvestigations of the DfA.for insurance coverage verification. 1,110 hereby certify under tree_&ns and penalties of per•/ury that tree in,foetation providal above is true and eorreet, Si attire. Date: 9 i L Y I Phone#: Oficialuse oply. vo not write in this area,torte completed by city or town official. City or Town: PerraitlGicextse 0 Issuing Authority(circle ane): 1.Board of Health 2.Building 1)epartment 3.City/Towa Clerk 4.Electrical Inspector 5.11mbingl spector 6.Other - � - RO... Iva (Le jo, L / Y• 11 wf OA FF -11 • X1111 71 C�- �, - LIM Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i i Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract Li Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 1 ,� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ZJ Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION� Y 1✓ a Print PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: PARCE(P–'+— ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Aenode/ Fop/oce- : ConUf�t qp5 �polic�C�_ Add stone arc-,and -9'reploce open1n9 Or each 5,& J I'1ObD1"- A bout Stone-one, vC,?.ee, Cp vc,- b ri c,K,.s w� d y �,,a/l . vp -Lo irke- Ce,' Identification Please Type or Print Clearly) OWNER: Name: carr— 601.1eN Phone: 97a fob/ 33� Address: V3 b4r St Al. Andover; 17� D! CONTRACTOR Name: Phone: Address: LEO AIE Supervisor's Constructionlicense: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ����� FEE: $ —t--2--- 1 3c> Check No.: per- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Own "rr Signature of contractor Plans Submitted 0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location (7t'�,AC4 r � e<-- No. ! _No. - Date — • TOWN OF NORTH ANDOVER fiLED{��' . Certificate of Occupancy $ Building/Frame Permit FeG Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#I . " I", (b ' e"- L Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP "OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/BodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM I DATE REJECTED DATE APPROVED i PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I I CONSERVATION Reviewed on Signature COMMENTS 0 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTOVI�®N -Temp Dumpster on site yes no Located at 124 Mair, Street Fire Department signature/date COMMENTS � NO R T!•� F � Town of ndover O - to NPA4 No. - ' h ver, Mass, Z o K6 coc N1c N!W1c. ��A�R�TEO I•Pa�,(5 `S U BOARD OF HEALTH I PERMIT L D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ....... .. .... ••••••••••• ^Ao.. �.�. Foundation • has permission to erect .......................... buildings on .. ...... ........•••••.�'�*�• Rough to be occupied as ...Cdrtwvr �� ••• •• Vftili ••••••�+••••• Chimney .... ............. provided that the person accepting this permit shall in every res ect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final t3b ma PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST TS Rough Service .............. ........................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 r�/-�CJ"OF NORTH 04 Oen '4 1 AmY O .uT ' fi OFFICE OF L`lJ j� x h BUILDING DEPARTMENT a4 0�„;' , . :',1600 Osgood Street Building 20,-Suite 2-36 7�SSAcuus���� North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 ' - Fax (978)688-9542 � + HOVIEMNER-LICENSE EXENfpTION 'U"MG PERMIT APPLICATION Pleaseyrint i DATE: JOB LOCATION: �� �Jl9R10EIZ ST, Number SireetAddress IJoMEOWNER P1)%K, 8 q)LEY E q-7 Map/Lot Y -1021- 337 -1a�- y�y-d3o5� Name. Home Phone Work phone PRESENT MAILING ADDRESS (.*3 6AA KE lz ST' //- A � /1,4 8 y S� city Toz*iln State. lip Code The current exemption for"homeowners"was extended to 1-iclude owner-occupied dwellings to i�vo units or less am to allow su;b homeovmers to en gage an i. __i g^o -!dividual•for hire who does notpossess a-license,provided that acts as supervisor). State 3u?lding (Code Section 10S.3.5.1) the owner DEFINITION OFHOMEOVMR Persons)who wns a parcel R p I of land on hick he/she resides re is,or is be a or intend on which one or h o family structures. A person who constructs more that-one home�in a two yeareperio d shall notintende to considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and p requirements, - HOMEOWNERS SIGNATURE ' APPROVAL OF BUILDING OFFICIAL Revised 7.2009 F0-TM Homeowners Exemption +'BOARD OFAPPEALS 688-9541 CO3\TSERVA-n0N688-9530r;. HEALTH 688-9540 PLANNING 688-9531 The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations UV 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information � L Please Print Leg=ibly Name(Business/Organization/Individual): +(`'Q r l _ 6A1 Address: (05 aar w St City/State/Zip: N,AMP�, � O18Y� Phone#: �� IS �-t a-2)-7 to 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.t 7. J%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 officers have exercised their 10.❑Electrical repairs or additions required.] 3.0 I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. 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. Ido hereby certify ununder �the pains andpenalties ofperjury that the information provided above is true and correct. - Signature: Date: 3 3 Phone#: 9-1 % t-p Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 confnmation 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of MossachvsPtts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TeX.#617-727-4900 est 406 or 1-877-MASS.AFE Revised 5-26-05 Fax#617-727-7749 www.xnass,govfdia Dimension Number of Stories: 2 Total square feet of floor area, based on Exterior dimensions. 2 y(° Total land area, sq. ft.: H 3 991v ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The foE13w�ing is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance ors special permit was required the Town Clerks office must stain the decision from the Boar P P 9 p d of Appeals , that thea w-al period is over. The applicant licant must then et this recorded at the Registry of Dee P PP g g y ds. One copy and proof of recording must be subm.+ted with the building application Doc: Doc.Bui?ding permit Revised 2012