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Miscellaneous - 65 SAILE WAY 4/30/2018 (2)
9 8 Y NORTry °f,"'°:•1"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACMUSEt This certifies that ., % .......g�lQ......... ��/..�""..'"".....1..... has permission to perform ... ... 5✓0... 4. x............... wiring in the building ofAG!'ctfS //........... ....... .......................................................... at.. ...... /�rw..... �•••••........................,North Andover,Mass. Fee.,P-.Q. : Lic.No...&PY6.. .......................................... .. ELEcnucA.ImPwroR • Check # r� 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-w.ith the provisions of M.G.L.c.143,§.3L,the \ permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed" " on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application.Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. r Permits shat be limited as to the time of ongoing construction activity,and maybe.deemed_by-byabandoned-and_invalid iflme_. 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 j&growth and Iong-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certaiirpermits and licenses concerning the use or development ofreal property.With limited exceptions,the Act automatically dxtends,for four years beyond its otherwise applicable expiration date,anypermit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2608.and extending trough August 15,2012. ule8—Permit/Date Closed:^ 5E: ZS_ *Note:Reapply for new permit ❑Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use Only 4 Permit No. l�j Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS V [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( E ),5 7 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFO �ITION) Date: f t) J City or Town of: I To the Inspector f Wires: By this application the undersi ed gives not' e of hi iqr her intention to perform the electrical work described below. Location(Street&Number) �,(j -e Owner or Tenant Telephone No. &U3-a31-V107 Owner's Address S"av; S' Is this permit in conjunction with a building permit? Yes No ❑ BLDG PERMIT# Purpose of Building &5;,J,A-S Utility thorization No. Existing Service �o c) Amps /a1U / nLtJ 6 Volts Overhead Utility rd 1 g ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Locat'on and Nature of Proposed Electrical Work:1uo �,�P Paul c PoL,I l 1A•t re t!nx Ra,. Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total. Transformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above o.o In- mergency LightinT rnd. rnd. BatteKy 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 InitiatingTotaDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number .Tons KW No.of Self-Contained Totals: Detection/AlertingDevices No. of Dishwashers Space/Area Heating KWLocal❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No. of Water No.of No.of Data Wirin KW ; a Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Q� Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Ele trical Work:�i 6� (When required by municipal policy.) Work to Start: a a' Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO GE: Unless waived by the owner,no permit for the performance of electrical work may issue unl1ss the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. Th undersigned certifies that such coveraAw is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [9"-BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties oferju ,that the information on this application is true and complet FIRM NAME: ; ¢ FJo.I\Oi.l 1C; i o•h LIC.NO.: Licensee:ftckp&e-1 1, (3w 1al Signature . LIC.NO.: (If applicable, ter ,.g mpt"in the li e numbe ine.) _ Address: 1,.1 A h 2P /a" � ;����;'� d�rim 1 Bus.Tel.No.: Alt.Tel.No.: *Per M.G.L. c.147,s.57-61,security work requires Department of Public Safety"S"Licen 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 (n Signature Telephone No. PERMIT FEE. $ i Y ELECTRICAL PERMIT NO. INSPECTION REPORT: ` ELECTRICAL INSPECTOR-DOUG SMALL , F CTION: Failed—( ] Re-inspection required($50.00)-nts: pectors'Signature-no initials) Date 2.FINAL INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date j 4 3.UNDER GROUND INSPECTION: Passed—[ j Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: I (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)- [ ] Inspectors' comments: (Inspectors'Signature-no initials) Date r 5.INSPECTION- OTHER: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: POOL gem (Inspectors' Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. T The Commonwealth of Massachusetts Department oflndustrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.go-p1dia Workers' Compensation Insurance Affidavit: Builders/Con>tractors/FIectricians/Plumbers Applicant Information Please Print Legibly Nana(Business/Organization/Individual): '4e l I /� t �IC�" `[ 4 Address: -, J "ce City/State/Zip: 1�4� � !/�0� O i Phone#: ( �� -7— 9_,4 06 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 (Ml es(full and/or part-time).* have hired the sub-contractors 2�am a sole proprietor or partner- listed on the attached sheet.? 7• FJ Remodeling . w ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition e [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.F1 Plumbing repairs or additions myself. (No workers'comp. c.152,§1(4),and we have no 12.0 Roofrepairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employes•that isproviding workers'compensation insurancefor 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. I do hereby certif r the ai s 2Z e Ides ofperjury that the information provided above , tr and correct. 1 / / Si ature: Date: -7 �!/ Phone#: 2O F only. Do not write in this area,to be completed by city or town official n: Permiit/License# hority(circle one): Health 2.Building Department 3.CiWTown CIerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION P This certifies that . . . . C k 14 has ennission for as installation . . . �.�. . . r-ic 1- . . . A g �tie. . . . . . . . . . in the buildings of. . . . V o^. c,s S(/r ± rk..v'. . . . . . . . . . . . at . . . U S. . S-1.�! :�- . . . . . . . . . . . . .North Andover, Mass. Fee .3a"o. . Lic. No. . 11660. . . . . . . . . . GASINSPECTOR Check# 3033 8438 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' . .. A CITY �/� _ MA DATE //-/S _/ - II PERMIT# JOBSITE ADDRESS , OWNER'S NAME L)W- M&S-4 MEE3 Ll OWNER ADDRESS SA&CE1 TEL __ _ FAX TYPE � TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:[_Q RENOVATION:Q REPLACEMENT:Fj PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE (— —_�a m�I -..._,I ��JI ( DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR ._ J GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT .- TEST UNIT HEATER —�-- s=---.1 --�=J .. I _ .�-r-! -- h._. _ _ - _- ' UNVENTED ROOM HEATER WATER HEATER OTHER �` i -- J --.—j _ I _- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 YES 21NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0-1 AGENT El 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 c pliance with a!LPertinent pr vi ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME _ -� w LICENSE# /_ SIGNKKAE MP 0 MGF ]I JP 0J JGF F-] LPGI CORPORATION ] ' PARTNERSHIP©(# LLC j# COMPANY NAME: ADDRESS CITY _ STATE=ZIP 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 a � 5 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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. ❑Remodeling I ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. 9 y p ty• ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]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' 1311 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Df 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. F do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. i Signature: Date: Suburban Phone#: @a - Official use only. Do not write in this area,to be completed by city or town of Sh°wrQ O� T�wk� g PI(,//nbinM °m sale b�//"�/ •I9 City or Town: Permit/License# 1 s service`�Instal/atio_/1 Inc. >50 Mair n Issuing Authority(circle one): r@I' (s78)85�t Tewksbu S/nce 1gq� ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Elects Email 7786 F ry )8 0187 6.Other Daaniet T Clury SubhtgP1@a01 C0rn51-7600 CIc 11660 Contact Person: Phone McMpo5s9 , 21 f IN r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents 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 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 Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia i .COMMONWEALTH OF MASSACHUSETTS` 'PLUMBERS AND GASFITTERS 'LICENSED AS A MASTER PLUMBER `f i ISSUES THE ABOVE LICENSE TO: ' DANIEL T CLUFF 77 EMERY RD m< TOWNSE:ND MA 0'146`:9.-1274 11660 05/01/14 145462 CONTROL# H 3 41614 IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 1000 Washington St., Suite 710,Boston,MA 02118-6100. If your name or address shown is changed, notify your board. of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended.It is a personal privilege,and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. 11 `k. mi r;y / tf j/ 5 f' I I 1 f GENERATOR APP DATE: LOCATION: (-Pg OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: E�9-cU' C PHONE NUMBER: 1 ELECTRICAL RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: �y r`G1�1 fi R&a���v✓� �- 'ZONING DISTRICT: 'CONSERVATION APPROVAL 1 / t Date . l/ — • sx.�cti~�u Jam. TOWN OF NORTH ANDOVER PERMIT FOR WIRING o This certifies that . . . . . ... . . . .?71`G. . .a . . has permission to perform . .3 . . . . . .?vClz. . T'.. . . . . . . . wiring in the building of . . . . . . . . . . . . . . . . . . . . . at . . b L--A—W Al. z . . . . . . . . . . . . . . .NoAh Andover, Mass. R6Z Fee . . . ic. No. . . . . . . . . . . . . . . • ELECTRICAL INSPECTOR Check# V 1,3 I 1204 Commonwealth of Massachusetts Official Use Only 4 Department of Fire Services Permit No. ©� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11-L ` I City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersiZ"Fe, d otice ofhisor her intention to perform the electrical work described below. Location(Street&Number) .l.1z wovv Owner or Tenant e Telephone No. g Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building_ -e Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: rot I I k k/ Sfi Ay �jQ1nT,F-/k�Q� Completion of the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA / No.of Luminaire Outlets No.of Hot Tubs Generators Ll KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Ligbting rnd. rnd. BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones of No. of Switches No.of Gas Burners No. InDetection and Initiatin Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons J.KW No.of Self-Contained P Totals: Detection/Alerting Devices Space/Area Heating KW Local❑ Municipal El Other No.of Dishwashers S P g Connection No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent t No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent ' OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: , _ (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 covera is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under the ants and penalties of perjury,that the infor//m��ation on this application is true and complete. FIRM NAME: . �/ � R+ C C V LIC.NO.:9 Licensee " 11 �. Signature LIC.NO.: (If app lica Ze, ent r " empt"in th license nzz er line.) Bus.Tel.No. ` 3 Address: 3J LaR AM- LAAe,__ d S6 4 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. s - a<'�ssec�--•[ � --�+'ailefl•-•I J �e-7nspectzoxt xequuzec7($�O.OQ)~I � inspectors'CID vxue;ats: (JCnspeeforilisignature-9zo finials) •^ abate SRO, CxOI�, 3'asse � +afiec7--r Aa-inspectiottxequired($50.00)-•I � 7stspectozs' mh�eats: Q:Aspector$l gignature•-)I()jurtials) Pate �'assetl—[ � �+'a�Iet�--[ � �Zeinspectio�aet�urrer�($�OAQ)�[ � • Inspectors'comments: • (�n sp ectoxs'signature no tiiuftals) Pate NX-fri,CAI,I&A Mfi±OX'lJ�tai 11 : WA-AE: P- assed- [ afled- [ rhe-nspecftonxequire ( 50.OD) I !s�pecfbrs'eoynm.e�fs: . guspectors'olgnaturo-io Wtials) Data I�7�]PEOz'.Io2d'-•Okla:' . .sed I pailec [ )- 'XLe-:inspectioxtxeauired($50.0D)•-[ o ectors' cozum.ents: _ . Lisp ectoxa' ignattare 3adnitials} ,plate -1�1rMP rP A O.V A*DV r Vn VV'Pi77.'(' 7!n'fTrP AVn T'PVrV n-Nr ClTrPV W 3rrrV A'D*W A rVrh'n !MSi'P7 CITIT"TO WY,n*n �y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leibly Name(Business/Organization/Individual): a -C� r Address: L,A►n R I') City/State/Zip: &LAN/t, Phone#: Are you employer?Check the appropriate box: Type of project(required): 1. 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. F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in an capacity. workers'comp.insurance. + g Y ]? h'• 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F]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' 13.❑Other 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name:—t—A p�✓1 -I—/(i Policy#or Self-ins.Lic.#:(A IA/ V Expiration Date: 2— 1 . ' Job Site Address: IW eEity/State/Zip: Attach a copy of the workers'compensation policy' claration 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby rtif and the sins andpenalties ofperjury that the information provided above is true and correct. Si ature: Date: Phone#: _ 0 ^ 3 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 ...eve every person in the service of another under any contract of hue,- 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 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 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 GonupoRwealthofMassachusetts Department of Industrial Accidents (office of Investigations 600 Washington Street Boston,M.A.0211.1 TeX,#617-7274900 ext 406 or 1-877rMASSAk'B Revised 5-26-05 Fax#617-727-7749 www.mass,gow`dia 37 e-1 e,"--;t— Date.................................. NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING SAcmU This certifies that ........... .............!: .........�............................... has permission to perform ...... ....................................................... wiring in the building of......................... ................... at...... ....................-r'..../.........:..1�. f.:.................... .North�zover,Mass. Fee.�. ............... L i c.No. /n.y-,� . ....................... ..................................... ELECTRICAL INSPECTOR Check # ! Date. . �?'G-U. E A NOR7p "'° '•�" TOWN OF NORTH ANDOVER To f PERMIT FOR PLUMBING SSACHUS� r• 4 This certifies that _ . . .. . . .. . . . . i — -- has permission to perform . . . .:'` ,• . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . F ; at. . . 0" f ' Norlt Andover,Mass. � FeJ&f. ' .Lic. No. I!G,� .�. . . 1 Check � —�f (% PL17M61 IN CTOR � _ s E 5311 MASSACHUSETTS UNIFORM APPLICATION FOR PERMITJO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location Ln-i is- j A t Q w/t-y Permit# Amount Owner C 3 e,o.��� New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES N Cn a � .7 a w SM-ME >49Mvr ► 1 IST HDM ZD DDM j 1 �mFIDW 4M)FLOOR 5M HDM 6M HjOCI t 7M KOM 8M>EIDOI2 (Print or type) Check one: Certificate Installing Company Name P At'S 3,-, S L V 3 L ❑ Corp. Address LTJ, El Partner. Business Telephone FD/Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the ty0eof insurance coverage by checking the appropriate box: ,Liability insurance policy Other type of indemnity ElBond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner E Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma sachusetts State Plumbing Code and Chapter 142 of the General Laws. �ti�✓ BY Signature Of ,cense um er Type of Plumbing License Title i-..)4 City/Town ,cense UMDer MasterEd Journeyman E]APPROVED(OFFICE USE ONLY Date. ./.7. Z ° .Z. . ... NORTH pf „ao ,^,ti0 3� 'a TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION e, C� '�S,9SSAC HUSEt 9 i This certifies that . . . has permission for gas installation . . . .,f1 .� . . . t ; ,... . . . . . in the buildings of . . rpt : . ��.� . , J3 ; r <<.�� t at . ./c,: f. }� . . S.14;./ , , ,�� , North Andover, Mass. Fee. Lic. No.. !?.`r'. :. . ...% i.J�Az GAS INSPECTOR 1 Check# ) `/ i 4089 171 xZ�^c MASSACHUSETTS UNIFORM APPLICATON FOR PERN Ur TO DO GAS FITTING (Type or print) Date / ,� 1,3 NORTH ANDOVER,MASSACHUSETTS Building Locations > L t �'R/ Permit# 1/,0 S-2 Amount$ is t _Owner's Name New[3/ Renovation Replacement Plans Submitted m m O m C C. w a m e a H W a x p3 A [7 OU a > 0 t SUB-BASEMENT BA SEM ENT 1ST . FLOOR R2ND. FLOOR 3RD. FLOOR V 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH . FLOOR (Print or type) p one: Certificate Installing Company Name t P 6. 4 %A<( Corp. Address Z ►'✓`t 3 J ;` ❑ Partner. C N✓ .l M/! Business Telephone _1 t FimiJCo. Name of Licensed Plumber or Gas Fitter � 14 P", 3 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy [:]--' Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and 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. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber l"1 y I -I City/Town ❑ Gas Fitter License er �Iaster APPROVED(OFFICE USE ONLY) ❑ Journeyman • The Commonwealth of Massachusetts Pt.,ni, N.. OlFice Use Onh�U�" Department O Ptlb1;C .$a Occupancy & Nt Checked D epa f Safety 3/90 (kaw blank) BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date '-I-q-©`A- City or Town of +w0cve�— To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. c Loation (Street & Number) �_ I S 5 P' 1 R C{Ji Owner or Tenant Cpn-VCCX_! R f )dt�� I'cur ` Owner's Address 2clo PsP_V- _57— Tor ri Cf'cdi,r Is this permit in conjunction with a building permit: Yes D No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization N0. <D Cd Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service 160 Amps ;Ib /�/Q Volts Overhead ❑ Undgrd� No. of Meters_ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work I No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA Z No. of Lighting Fixtures Swimming Pool Ab ❑ grnd. ❑ Generators KVA i No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Batte Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones s No. of Ranges No. of Air Cond, Total No. of Detection and i tons Initiating Devices m No. of Disposals No. of pumpTotal Total No. of Sounding Devices W s Tons KW g D No. of Dishwashers Space/Area Heating KW No. of Self Contained ¢ Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal [:]Other Connection CL LL No. of WaterlHeaters KW No, of o. _67- Low Voltage f Signs Ballasts Wiring o No. Hydro Massage Tubs No. of Motors Total HP OTHER: I INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current liabilitInsurance Policy including Completed Operations Coverage or_.ts substantial equivalent. YES NO[J I have submitted valid proof of same to this office. YES E]NO If you have checke YES, please indicate the type of coverage by checking the appropriate box. INSURANCE [�[ BOND ❑ OTHER ❑ (Please Specify) (Expiration ate Estimated Value of Electrical Work S �� /I Work to Start V"'Inspection Date Requested: Rough (,V4inal 1 Signed under the penalties of perjury: FIRM NAME_ ���'�',��xtt, )c�T� LIC. HI). Licensee cl ��� C. SQ>4� Signature LIC. NO. Address & gat T4 C��SLt t`� 40,"15 Bus. Tel. No. <9a;— Alt. Tel. No. cj/ & OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this perm t application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent I i .ation //ti) -, F, (, "'..a . .o. Date i MORTM TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ /5 sscMus' Eta' Building/Frame Permit Fee $ Foundation Permit Fee $ " Other Permit Fee $ TOTAL $ c Check # d 5z G0 Inspectb� 'r � v i 1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING , BUILDING PERMIT NUMBER: �� +� DATE ISSUED: Al /gy ,ted O 49 0 e - a SIGNATURE: Building CommissionerofBuildings Date - SECTION 1-SITE INFORMATION c 1.1 Property Address: 1.2 Assessors Map and Parcel Number- Map umberMap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ZoningDistrict Pr U Fronto ft 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide Required. Provided Provided 1.7 water Supply MCxLC.40. 34) 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 n 2.1 Owner of Record Name(Print) Address for Service A&A, L" 7 Signature hon i 2.2 Owner of Record: C Name Print Address for Service: S n Signature Telephone Q SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ "As Licensed Construction Supervisor- 0 5 C License Number Address Expirrahon Signature leph e r 3.2 Registered Home Improvemept Contractor Not Applicable ❑ C Company Name Registration Number r Address v 62 'd"A' qff U-T- 'J617 EiAfationate Sin ture le one r' r SECTION 4-WORKERS COMPENSATION(ALG.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 it. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Descri tion of Pro sed Work check ad n ble New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: r e ;yCXc.4(alo dy oa TrA.-J 'RA^) 0teUI%e w 4 1 �b1S ' �� ���� (3�J145 C q14A 'l Ag c �4 Gzrz � SECTION 6-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollar)to be .. Completed by permit applicant 1. Building (a) Building Permit Fee /'a P""y � u c� 3 - Multiplier ES/�• 1 2 Electrical (b) Estimated T'otal;Cost'of Construction & 3 Plumbing Building Permit fee x (b) _ (� 4 Mechanical HVAC A50, � / � 5 Fire.Protectioti 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this%building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject. property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS isr2ND 3RD SPAN ' DIMENSIONS OF SILLS DIMENSIONS OF POSTS 1 DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE e A) FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used.to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from .......1.....�....� complince with any applicable requirements. ...... APPLICANT " A-W, t, PHO 7 -3, 7 ASSESSORS MAP NUMBER i LOT NUMBER S SUBDIVISION!� /"(?� ��-�ia LOT NUMBER r STREET 1 D J STREET NUMBER 65 CIAL USE ONLY RECO ATION TOWN AGENTS DATE APPROVED I O Z C S A ON Ai TRATOR Q DATE REJECTED � n / CON EN fS A!a' DATE APPROVED '/ri `U� T' I (J DATE REJECTED COQ DATE APPROVED FOOD PE TOR-!!FAL DATE REJECTED v "DATE APPROVED SE ECTOR-HEALTH DATE REJECTED COAQVIENTS PUBLIC WORDS-SEWER/WATER CONNECTIONS DRIVEWAY DRIVEWAY PERMIT �'-Z-d Z DATE APPROVED FIRE EPAR DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE a The Commonwealth of Massachusetts Department of Industrial Accidents Office or'Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phones Y am a homeowner performing all work myself. =1 am a sole proprietor and have no one working in any capacity I am an employer rovid' g workers'compensation for my employees working on this job. Goma name: pp Address `� P4 /n ' r Cf Y / Insurance Co. Policy Comnanv name: Address City: Phone#' lnsuracice Co. Policv# Failure to secure coverage as required under Lection 25A or MILL 152 can leas!to the Imposition of criminal penalties-of a fine up to$1,500.0o and/or one years'imprisonment as well as dW penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. i understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. !do herby certify under the pains and allies of perjury that the information provided above is hue and correct Signature Dat < ` Print name Phone# J Official use only do not write in this area to be completed by city or town official' E] Building Dept OCheck if immediate response is required Building Dept p Licensing Board p Selectman's Office' Contact person: Phone# ❑ Wealth Department ❑ other VORKMANIS COMPENSATIOM GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVER BUILDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section 8.7.6 of the Town of North Andover Growth Management Bylaw.The applicant shall provide all of the necessary information as requested below. ��A, ma�� bw -K-5- SA/Y�,(-,JAU 6 3 Permit Applit Property address Map/Parcel 92k.)6�g- Sig 7Y Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 ofthe Growth Management Bylaw.I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the building permit.Further I understand that my interpretation of the exemption status is subject to review by the Budding Department and is only officially accepted when the building permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot,in the building permit application and associated attachments,complies with one or more ofthe following sections as indicated by a check mark. This is an application for a building permit for the enlargement,restoration or reconstruction of a dwelling in. existence as of the effective date of this bylaw,provided that no additional residential unit is created The lot(s)was/were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and or moderate income families or individuals,where all of the conditions of 8.7.6 are met and or represents dwelling units for senior residents,where occupancy of the units is restricted to senior citizens through a properly executed and recorded deed restriction running with the land For purposes of this section"senior"shall mean persons over the age of 55. This application is part of a development project which voluntarily agreed to a minimum 40%permanent reduction in density(buildable lots)below the density permitted under zoning and feasible given the environmental conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open space or farmland The land to be preserved shall be protected from development by an Agricultural Preservation Restriction,Conservation Restriction,dedication to the Town,or other similar mechanism approved by the planning board that will ensure its protection This application represents a had of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a one time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. e This application represents a lot which is ready for a building permit(all other permits from all other boards and commissions have been received and the project is in compliance with those permits),and the Development Schedule does not accommodate issuing a building permit in that year.One building permit will be issued per year per Development until such time as the development schedule accommodates issuing building permits.Applicant must submit an approved FORM U with this EXEMPTION. PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS. BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED BUILDING PERMIT IS ALLOWED AN EXEMPTION AS CITED ABOVE. FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE CHECKING OFF OF A ABOVE EXEMPTION WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR NOT IS GROUNDS FOR REFUSAL BY THE BUILDING DEPARTMENT TO ISSUE A BUILDING PERMIT. J Ah / -f APPLICANTS SIGNAYDOIJEDA E THIS FORM TO BE ATTACHED TO BUILDING PERMIT APPLICATION TOWN Off'NORTH ANDOVER vE HnaTk q Office of the.Building Department Community Development and Services � p 27 Charles Street :o o North Andover,ver,A a.ssadiusetts 01845 9SS^GtiUS�� D. Robert Nicetta, Telephone(978)6188-9545 Building Commissioner F-AX(978)684-9542 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, s 150a. The debris will be disposed of at/in: (Site location) Signature of permit applican Date Michael McGuire,Local Building Inspector James Deeola,Electrical Inspector James Diozzi,Gas/Plumbing Inspector m I .. ► DATE(MMIDACO�n DPIY) t1�rrAi iiJ # L. .. ..:: .:: 4/02/02 . � PRODUCER I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND .CONFERS NORIGHTS UPON THE CERTIFICATE ! A 6 K Fowler Insurance Agency I HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR I 200 Park Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NorLh Reading, MA 01864 COMPANIES AFFORDING COVERAGE I COMPANY I A Zurich Insurance Co. INSURED Cvinrinivi B Travelers Insurance Co. I Contawnperari Builders Inc. 200 Park St_ Mn�cenY N. Readina, MA 01864 I C Liberty Mutual Ins. Co. I I COMPANY D v4lfEitAtsE:R ....... -: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.AK?TWTHSTenlnlnlr_ANY REOLI)REMERIT.TERM OR CONDITION OF ANY CONTRACT OR OTHER.001CUMENT.A.nTH RESPECT TO I H:CH T"S I CERTIFICATE MAY 13E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, tXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO I TYPE OF INSURANCE I POLICY NUMBER POLICY EFFECTIVE I POLICY EXPIRATION I LIMITS LTR D.Te.uu�D,N+n yw C�ri:T:AL LIAOaTY I 13ciuET2AL+wGnEGATc' a 600,0 n 1 v{ .a' . " (�� JdV L ! +inV/inGnG/fnV+i I iWV/inLnL/V2 n.e..vn✓„vevg.vo-..n.+....n..,vn...n.,v o eVnVnV Ann MMEoInron0421 v C-1 AtMR MADE u nm lq I I ( PF_pglN.gL S nny lnr iL�Py a 3i1 C1 'In" VMTER'SSCONTRACTOR'SPROT l I I EACH OCCURRENCE S *Ann.nnn iI I I FIRE DAMAGE(Any one fire) S 50.000 I I I MED EXP(Any one Person) S 10,000 AUTOMOBILE LIAR ILm I _ � ANY AUTO I I I fwiviS iJe�i Sii3iLE u niT 1 3 ALL OWNED AUTOS I I ! lpLYINJURY i I B II_X,I— SCHEDULED AUTOS I I810971K8980 I 1/27/02 I 1/27/03 � s 2nnn (Yef person) --- ' I HIRED AUTOS I I I BODILY INJURY I S 500.000 HNON VAIED AUTOS I I I H I I PROPERTY DAMAGE I S 100,000 H•ANYIAIrtO� I I I nruFR TueN el rrn nNl`V� 1 I I ��ACCIDENT I S f l I AGGREGATE S Excess LIABILITY I EACH OCCURRENCE S Iu UMBRELLA FORM I ( I AGGREGATE S ! I I OTHER THAN UMBRELLA FORM I I I Is ! WORKERS COMPENSATION AND + VN:JIAI JL UIH- TORY LIMBS ER i I E "t4.....AO....'TY EL EACH ACCIDENT Is 1,000,000 f C ?nvrrclelnc Uw i"MP I_I INCL i WC131S315646 1 7/19/01 1 7%19%02 �EL DISEASE-POLICY LIMIT j S 1,000,000 I It—i PARTNET7SExECUTIVE UFHC:FJiS ARE: EXCL I £L DISEASE-EA EMPLOYEE S 1,000,U DO I ATY C_O_ 1 f I I DESCRIPTION OF OPERATIONS(LOCATIONSiVEHICLESISPEC)AL ITEMS ( insurance verification ! C 7l IGJkTE#II C2l1_! :: CfINCELLAT i+I > . ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of i38Y til AndoverI EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL I Attn: Mitre Magni-re — RlA- Tna 27 Charles St. I 1U 'DAYS WRITTENH NOTICE TO THE CERTIFICATE OLDER NAMED TO THE LEFT,� North Andover, MA 01845 BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY I OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. l li NARIFEn REPRESENTATMF K,arrM A ArnTtTTt CT-SA ctiiC�QR1 CCiRPi?F11T1{ih4:1988 z ,d dOt► :ZT 20 20 idd ORTIy Town o ' ". !0 - . Andover 0 rn No. 0 C ndover, Mass., C/ —C 00'C K E C I HEWICK ,or 4 0"� E D PV Cl SS CHUS IT FOR EXCAVATION AND F!7UNDATION THIS CERTIFIES THAT LOA?jj?fi�ArAy �� .....3 .j j .... �i�C. has permission to excavate and pour foundation at for the purpose of.....5-i-mal-s.....7A.."'A!Ay. .............'3>w I& I( iAJ Itor-a certifiedplot-otplashow - -n- - - The person accepting this permit must return to the office of the Building Ins, of building thereon before Foundation will be inspected. VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS The holder of this Foundation Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS assurance that a permit for entire building structure will be granted. BUILDING INSPECTOR NORTH Town of M0. over No ZL 's JK C% 44 a-o dover, Mass., � � COC MICMEWICK �oRATEO PPG��C V 4 BOARD OF HEALTH Food/Kitchen PERM. IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...4►��11.0.�.�e 1� O y!�1►� �V�.l��r�.......Z. .••••...••..•• Foundation 11WA has permission to erect.............�l......................... buildings on .. .5...........6.5.... .A.�.�L�...... Y Rough to be occupied as. 'l.koom5-5 F")I BA1Ns-�-Ya B�4�5-W S+a{(...�tT1'l�c.h ,slN (� cue{�iti� 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. 3/ ,3S53PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION T ELECTRICAL INSPECTOR TS � Rough ..... ... .................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Bureau of Resource Protection- Wetlands NACC # 9 WPA Form 5 - Order of Conditions for DEP use only and North Andover Wetlan Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Protection Bylaw. . ' -Applicant Information From: The Notice of Intent for this project was filed on: North Andover December 7, 2000 Conservation Commission Date For: The public hearing was closed on: NACC # 9 December '20, 2000 Project rile Number Date To: Eight Meadows Realty Trust Title and Date of final Plans and Other Documents: AppliramName Notice of Intent dated 12/7/00 700 Great Pond Road Plans entitled "Lot 5 Great Pond MailingAddtess North Andover Estates" dated 7/28/00 REV 11/13/00 City/T_ MA 01845 State rip Code The project site is located at North Andover City/Town 63-48 Assessors MoplPlat t ParcelAot t and the property is recorded at the Registry of Deeds for: Essex 3315 295 County Book Page Certificate(if registered land) Findings Furthermore,this Commission hereby finds that the project,as Findings pursuant to the Massachusetts Wetlands proposed,is: Protection Act: (check one of the following boxes) Following the review of the above-referenced Notice of Intent Approved subject to: and based on the information provided in this application and presented at the public hearing,this commission finds that the ® the following conditions which are necessary,in accordance area in which work is proposed is significant to the following with the performance standards set forth in the wetlands interests of the Wetlands Protection Act(check all that apply): regulations,to protect those interests checked above..This Commission orders that all the work shall be performed in ®Public Water Supply accordance with the Notice of Intent referenced above,the ®Private Water Supply following General Conditions,and any other special 14 Groundwater Supply conditions attached to this Order.To the extent that the ®Flood Control following conditions modify or differ from the plans, ❑Land Containing Shellfish specifications,or other proposals submitted with the Notice RI Fisheries of Intent,these conditions shall control. ®Storm Damage Prevention ®Prevention of Pollution 59 Protection of Wildlife Habitat Bureau of Resource Protection- Wetlands NACC # 9 WPA Form 5 - Order of Conditions I DEP and North Andover Wetlan Massachusetts Wetlands Protection Act M.G.L. c. 737, §40 Protection Bylaw. Findings (cont.) debris,including but not limited to lumber,bricks,plaster, Denied because: wire,lath,paper,cardboard,pipe,tires,ashes,refrigerators, motor vehicles,or parts of any of the foregoing. O the proposed work cannot be conditioned to meet the performance standards set forth in the wetlands regulations 7. This Order does not become final until all administrative to protect those interests checked above. Therefore,work appeal periods from this Order have elapsed,or if such an on this project may not go forward unless and until a new appeal has been taken,until all proceedings before the Notice of Intent is submitted which provides measures Department have been completed. which are adequate to protect these interests,and a final Order of Conditions is issued. 8. No work shall be undertaken until the Order has become final and then has been recorded in the Registry of Deeds or D the information submitted by the applicant is not sufficient the Land Court for the district in which the land is located, to describe the site,the work,or the effect of the work on within the chain of title of the affected property. In the case the interests identified in the Wetlands Protection Act. of recorded land,the Final Order shall also be noted in the Therefore,work on this project may not go forward unless Registry's Grantor Index under the name of the owner of the and until a revised Notice of Intent is submitted which land upon which the proposed work is to be done. In the provides sufficient information and includes measures rase of registered land,the Final Order shall also be noted_ which are adequate to protect the Act's interests,and a final on the Land Court Certificate of Title of the owner of the Order of Conditions is issued. A description of the specific land upon which the proposed work is done. The recording information which is lacking and why it is necessary is information shall be submitted to this Conservation attached to this Order as per 310 CMR 10.05(b)(c). Commission on the form at the end of this Order,which t form must be stamped by the Registry of Deeds,prior to the General Conditions commencement of the work. 1. Failure to comply with all conditions stated herein,and with 9. A sign shall be displayed at the site not less than two square all related statutes and other regulatory measures,shall be feet or more than three square feet in size bearing the deemed cause to revoke or modify this Order. words, 2. The Order does not grant any property rights or any exclusive privileges:it does not authorize any injury to NACC # 9 private property or invasion of private rights. Prgxtfileftmbg 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal,state,or local statutes,ordinances, 10.Where the Department of Environmental Protection is bylaws,or regu lations. requested to issue a Superseding Order,the Conservation completed within Commission shall be a parry to all agency proceedings and 4. The work authorized hereunder shall be com P hearings before the Department. three years from the date of this Order unless either of the following apply: 11.Upon completion of the work described herein,the applicant . (a)the work is a maintenance dredging project as provided shall submit a Request for Certificate of Compliance(WPA for in the Act:or Form 8A)to the Conservation Commission. (b)the time for completion has been extended to a specified date more than three years,but less than five 12.The work shall conform to the following attached plans and years,from the date of issuance. If this Order is intended special conditions: to be valid for more than three years,the extention date and the.special circumstances warranting the extended Final Approved Plans(attach additional plan references as time period are set forth as a special condition in this needed): Order. Lot 5 Great Pond Road 5.This Order may be extended by the issuing authority for Tine one or more periods of up to three years each upon 7/28/00 REV 11/13/00 application to the issuing authority at least 30 days prior to oate the expiration date of the Order. Dennis G. Quintal, P.E. 6. Any fill used in connection with this project shall be clean signed and stamped by fill. Any fill shall contain no trash,refuse,rubbish,or NACC on Re with i Bureau of Resource Protection- Wetlands NACC 11 9 WPA Form 5 - Order Of Conditions and North Andover Wetlai Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Protection Bylaw. Findings (cont.) Findings.as to municipal law,bylaw,or ordinance 13.Any changes to the plans identified in Condition#12 above Furthermore,the shall require the applicant to inquire of the Conservation North Andover Commission in writing whether the change is significant enough to require the filing of a new Notice of Intent. consetuationcommss;on hereby rinds(check one that applies): 14.The Agent or members of the Conservation Commission and Department of Environmental Protection shall have the ❑ that the proposed work cannot be conditioned to meet the right to enter and.inspect the area subject to this Order at standards set forth in a municipal law,ordinance,or bylaw, reasonable hours to evaluate compliance with the condi- specifically tions stated in this Order,and may require the submittal of I any data deemed necessary by the Conservation Commis- sion or Department for that evaluation. Name and atationotmuniapallaw,bylaw,or ordinance Therefore,work on this project may not go forward unless 15.This Order of Conditions shall apply to any successor in submitted which and until a revised Notice of Intent is sub interest or successor in control of the property subject to provides measures which are adequate b meet these this Order and to any contractor or other person perform- standards,and a final Order of Conditions is issued. ing work conditioned by this Order. [j� that the following additional conditions are necessary to 16.Prior to the start of work,and if the project involves work comply with a municipal law,bylaw,or ordinance,specifi- adjacent to a Bordering Vegetated Wetland,the boundary of cally the wetland in the vicinity of the proposed work area shall be marked by wooden stakes or flagging. Once in place, Ch. 178 of. the Code of North Andover the wetland boundary markers shall serve as the limit of Name and atat;onof municipal law,bylaw,orord1wnce work(unless another limit of work line has been noted in the plans of record)and be maintained until a Certificate of The Commission orders that all the work shall be performed Compliance has been issued by the Conservation Commis in accordance with the said additional conditions and with Commis- sion. the Notice of Intent referenced above. To the extent that the 17. All sedimentation barriers shall be maintained in good following conditions modify or differ from the plans, specifications,or other proposals submitted with the Notice repair until all disturbed areas have been fully stabilized with vegetation or other means. At no time shall sediments of Intent,the conditions shall control. be deposited in a wetland or water body. During construc- tion,the applicant or his/her designee shall inspect the Additional conditions relating to municipal law,bylaw,or erosion controls on a daily basis and shall remove accumulated sediments as needed. The applicant shall ordinance: immediately control any erosion problems that occur at the See attached Conditions site and shall also immediately notify the Conservation Commission,which reserves the right to require additional erosion and/or damage prevention controls it may deem necessary. Special Conditions(Use additional paper if necessary) See attached Conditions //lQJ�Q4//YiGLl7 YGrO/{f/1611a V1 Lu w11 vgnl4u•a11 1 v..vuvi, ` PA Bureau of Form Resource Protection- Wetlands NACC # 9 ' I� 5 " Omer Of.Conditions and North Andover Wetlar Massachusetts Wetlands Protection Act M.G.L. c. 131, YO Protection Bylaw. Findings (cont.) This Order is valid for three years,unless otherwise specified On this as a special condition pursuant to General Conditions#4, 3rd from the date of issuance. January 3, 2001 day of January Dare Month This Order must be signed by a majority of the conservation 2001 commission.The Order must be mailed by certified mail Yom' ! (return receipt requested)or hand delivered to the applicant. before me personally appeared A copy also must be mailed or hand delivered at the same Scott Masse time to the appropriate regional office of the Department of ' Environmental Protection. + ,r to me known to be the person described in and who executed Signatures: the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. Bary Pontic pl�,c-��'1��t�• �f�.�:�-cam - `-�'f'I�f�C.h.(°�i J �. , ��`.U D�. My commission expires r✓(� L This Order is issued to the applicant as follows: ❑ by hand delivery on Dare , j by c.M on January 5, 2001 Date Appeals The applicant,the owner,any person aggrieved by this Order, The request shall state clearly and concisely the objections to any owner of land abutting the land subject to this Order,or the Order which is being appealed and how the Order does not any ten residents of the city or town in which such land is contribute to the protection of the interests identified in the located,are hereby notified of their right to request the Massachusetts Wetlands Protection Act(M.G.L.c.131,§40 appropriate Department of Environmental Protection Regional and is inconsistent with the wetlands regulations(310 CMR Office to issue a Superseding Order of Conditions.The request 10.00).To the extent that the Order is based on a municipal most be made by certified mail or hand delivery to the bylaw,and not on the Massachusetts Wetlands Protection Act Department,with the appropriate filing fee and a completed or regulations,the Department of Environmental Protection has Appendix E:Request for Departmental Action Fee Transmittal no appellate jurisdiction. Form,as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Order.A copy of the request shall at the same time be sent by certified mail or hand delivery to the conservation commission and to the applicant, if he/she is not the appellant. Bureau of Resource Protection- Wetlands s WPA Appendix E .Request for Departmental Action Fee Transmittal Form and North Andover Wetlar, Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Protection Bylaw. Please type or print clearly all Mr Request Information information requested on this form. 1. Person or party making request(if appropriate,name the 2. Applicant(as shown on Notice of Intent,Abbreviated Notice citizen group's representative): of Resource Area Delineation,or Request for Determination of Applicability): Name Name Mailing Address Mailing Address City1W City/rown state Zip Code state Zip Code Phone Number Phone Number Fax Number(if applicable) Fax Number(inapplicable) Project Location: DEP File Number: RrWAddress Ciovr-n Instructions 1. When the departmental action request is for(check one): 2. On a separate sheet attached to this form,state clearly and concisely the objections to the Determination or Order ❑ Superseding Order of Conditions which.is being appealed.To the extent that the Determina- ❑ Superseding Determination of Applicability tion or Order is based on a municipal bylaw,and not on the ❑ Superseding Order of Resource Area Delineation Massachusetts Wetlands Protection Act or regulations,the Department of Environmental Protection has no appellate Send this form and a check or money order for$50.00, jurisdiction. payable to the Commonwealth of Massachusetts,to: 3. Send a copy of this form and a copy of the check or money Dept.of Environmental Protection order with the Request for a Superseding Determination or Box 4062 Order by certified mail or hand delivery to the appropriate Boston,MA 02211 DEP regional office as listed in Appendix A. 4. A copy of the request shall at the same time be sent by certified mail or hand delivery to the conservation commis- sion and to the applicant,if he/she is not the appellant. n.,....I ..c I NACC#9 Therefore,the North Andover Conservation Commission(hereafter the "NACC") hereby finds that the following conditions are necessary,in accordance with the Performance Standards set forth in the State Regulations, the local ByLaw and Regulations,to protect those interests noted above. The NACC orders that all work shall be performed in accordance with said conditions and with the Notice of Intent referenced below. To the extent that the following conditions modify or differ from the plans,specifications or other proposals submitted with the Notice of Intent,the conditions shall control. GENERAL CONDITIONS 1) Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this Order. 2) This Order does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of property rights. However,the NACC, agent of the NACC or the Department of Environmental Protection(DEP)reserves the right to enter and inspect the property at all reasonable times until a Certificate of Compliance is issued, to evaluate compliance with this Order of Conditions,the Act(310 CMR 10.00), the North Andover Wetland ByLaw and Regulations, and may require any information, measurements,photographs, observations,and/or materials, or may require the submittal of any data or information deemed necessary by the NACC for that evaluation. Further,work shall be halted .on the site if the NACC, agent or DEP determines that any of the work is not in compliance with this Order of Conditions. Work shall not resume until the NACC is satisfied that the work will comply and has so notified the applicant in writing. 3) This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state or local statutes, ordinances, by-laws or regulations. 4) The work authorized hereunder shall be completed within three years from the date of this order. 5) This Order may be extended by the issuing authority for one or more periods of up to one year each upon application to the issuing authority at least thirty days (30)prior to the expiration date of the Order (Refer to Section VIII (B)(p.33)of the North Andover Wetland Regulations). C:\Winword\OOC\NACC#9 1 NACC 01/03/2001 NACC#9 6) The NACC reserves the right to amend this Order of Conditions after a legally advertised public hearing if plans or circumstances are changed or if new conditions or information so warrant. 7) Where the Department of Environmental Protection(DEP)is requested to make a determination and to issue a Superseding Order,the Conservation Commission shall be a party to all agency proceedings and hearings before the Department. i 8) The conditions of this decision shall apply to, and be binding upon,the applicant, owner, its employees and all successors and assigns in interest or control. These obligations shall be expressed in covenants in all deeds to succeeding owners of portions of the property. 9) The term"Applicant" as used in this Order of Conditions shall refer to the owner, any successor in interest or successor in control of the property referenced in the Notice of Intent,supporting documents and this Order of Conditions. The NACC shall be notified in writing within 30 days of all transfers of title of any portion of property that takes place prior to the issuance of a Certificate of Compliance. 10)The proposed work includes: Construction of a single family dwelling within the buffer zone to an isolated wetland subject to protection under the North Andover Wetlands Protection Bylaw and Regulations. 11)The work shall conform to the following(except as noted in the remainder of this document where revisions may be required): Notice of Intent filed by: Eight Meadows Realty Trust 700 Great Pond Road North Andover,MA 01845 Site Plans prepared by: Civil Construction Management,Inc. 8 Merrimac Road-Box 225 Newton,NH 03858 Dated 11/13/00 Stamped by Dennis G. Quintal,P.E. . CAWinword\OOC\NACC#9 2 NACC 01/03/2001 NACC It 9 12)The following wetland resource areas are affected by the proposed work:. Buffer Zone to a Freshwater Wetland. These resource areas are significant to the interests of the Act and Town ByLaw as noted above and therein. The applicant has not attempted to overcome the presumption of significance of these resource areas to the identified interests. 13)The NACC agrees with the applicants delineation of the wetland resource areas on the site as shown on the plans dated referenced herein. 14)The NACC finds that the intensive use of the upland areas and buffer zone proposed on this site will cause further alteration of the wetland resource areas. In order to prevent any alteration of wetland resource areas a twenty five foot(251 No-Disturbance Zone and a fifty foot(5(Y) No-Construction Zone shall be established from the edge of the adjacent wetland resource area. The Conservation Administrator and/or other agents of the NACC do not have the authority to waive these setbacks as established under the local bylaw_ No disturbance of existing grade, soils or vegetation is permitted in the No-Disturbance zone. (See Section III(D) &Appendix G of the local Regulations).- 15) egulations).15)There shall be no increase in the post development discharges from the storm drainage system or any other changes in post development conditions that alter the post development watershed boundaries as currently depicted in the Notice of Intent and approved by this Order of Conditions, unless specifically approved in writing by the Commission. 16)This document shall be included in all construction contracts,subcontracts, and specifications dealing with the work proposed and shall supersede any conflicting contract requirements. The applicant shall assure that all contractors, subcontractors, and other personnel performing the permitting work are fully aware of the permits terms and conditions. Thereafter,the contractor will be held jointly liable for any violation of this Order resulting from failure to comply with its conditions. CAWinword\OOC\NACC#9 3 NACC 01/03/2001 NACC#9 17)The owners of the project and their successors in title,in the event they proceed to alter areas subject to the Commission's jurisdiction under the order, agree that the Order does not in itself impose upon the Town any responsibility to maintain the proposed drainage system and that said Town shall not be liable for any damage in the event of failure. By acceptance of this Order, the owners agree to indemnify and hold harmless to the Town and its residents for any damage attributable to alterations undertaken on this property pursuant to the Order. Issuance of these Conditions does not in any way imply or certify that the site or downstream areas will not be subject to flooding, storm damage or any other form of water damage. Maintenance of the drainage system,if accepted by the Town as part of a public way, becomes the responsibility of the Town. 18)Issuance of these Conditions does not in any way imply or certify that the site or downstream areas will not be subject to flooding,storm damage or any other form of water damage. C:\Winword\OOC\NACC#9 4 NACC 01/03/2001 NACC#9 PRIOR TO CONSTRUCTION 19)No work shall be undertaken until all administrative appeal periods from this Order have elapsed or, if such an appeal has been filed, until all proceedings before the Department or Court have been completed. 20)This Order shall be recorded by the applicant at the Registry of Deeds immediately after the expiration of all appeal periods. No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property. In the case of recorded land,the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of registered land, the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is to be done. The recording information shall be submitted to the North Andover Conservation Commission on the form at the end of this Order prior to commencement of the work. Any Order not recorded by the applicant before work commences may be recorded by the NACC at the applicant's expense. 21)A sign shall be displayed at the site not less than two square feet or more than three square feet in size bearing the words"Massachusetts Department of Environmental Protection,File Number NACC#9." 22)Any changes in the submitted plans caused by the applicant, another Board's decision or resulting from this Order of Conditions must be submitted to the NACC for approval prior to implementation. If the NACC finds said changes to be significant, the NACC will call for another public hearing(at the expense of the applicant).Within 21 days of the close of said public hearing the NACC will issue an amended or new.Order of Conditions.Any errors found in the plans or information submitted by the applicant shall be considered as changes.The proposed project may be still under review by other local or state boards or agencies. This may result in changes to the project plans or wetland impacts. If any such changes occur a revised plan and an explanation of the revisions shall be submitted to the NACC for review and approval prior to the start of construction. No work shall begin on a project until written approval has been granted by the NACC. C:\Winword\OOC\NACC#9 5 NACC 01/03/2001 NACC#9 23)It is the responsibility of the applicant, owner, and/or successor(s) to ensure that all conditions of this Order of Conditions are complied with. The project engineer and contractors are to be provided with a copy of this Order of Conditions and referenced documents before commencement of construction. 24)Prior to any work commencing on-site,the applicant shall submit to the NACC for approval,a detailed sequence of construction,including the construction of compensation and retention areas,installation of sedimentation/erosion control devices and re-vegetation to be completed before other work begins on-site. 25)Wetland flagging shall be checked prior to start of construction and shall be re-established where missing. All wetland flagging shall remain visible and enumerated per the approved plan(s)throughout the life of the project and until a Certificate of Compliance is issued so that erosion control measures can be properly placed and wetland impacts can be monitored. The proposed limit of work shall be shall be clearly marked with stakes or flags and shall be it by the NACC. Such markers shall be checked and replaced as necessary and shall be maintained until all construction is complete. Workers should be informed that no use of machinery, storage of machinery or materials, stockpiling of soil,or construction activity is to occur beyond this line at any time. All flags used for the above purposes shall be of a color,different from other flagging used on the site. 26)A row of staked hay bales backed by trenched siltation fence.shall be placed between all construction areas and wetlands. The erosion control barrier will be properly installed and placed as shown on the plans approved and referenced herein and shall be inspected and approved by the NACC prior,to the start of construction and shall remain intact until all disturbed areas have been permanently stabilized to prevent erosion. All erosion prevention and sedimentation protection measures found necessary during construction shall be implemented at the direction of the NACC. The NACC reserves the right to impose additional conditions on portions of this project to mitigate any impacts which could result from site erosion, or any noticeable degradation of surface water quality discharging from the site. For example,installation of erosion control measures may be required in areas not shown on the plan(s)referenced in this Order of Conditions. Should such installation be required by the NACC, they shall be installed within 48 hours of the Commissions request. CAWinword\OOC\NACC#9 6 NACC 01/03/2001 NACC#9 27)The applicant shall have on hand at the start of any soil disturbance, removal or stockpiling, a minimum of 20 hay bales and sufficient stakes for staking these bales (or an equivalent amount of silt fence). Said bales shall be used only for the control of emergency erosion problems and shall not be used for the normal control of erosion. i 28)A check payable to the Town of North Andover shall be provided in the amount of$3,000 which shall be in all respects satisfactory to Town Counsel, Town Treasurer, and the NACC, and shall be posted with the North Andover Town Treasurer through the NACC before commencement of work. Said deposit of money shall be conditioned on the completion of all conditions hereof, shall be signed by a party or parties satisfactory to the NACC, and Town Counsel, and shall be released after completion of the project, provided that provisions,satisfactory to the NACC,have been made for performance of any conditions which are of continuing nature. The applicant may propose a monetary release schedule keyed to completion of specific portions of the project for the NACC's review and approval. This condition is issued under the authority of the local ByLaw. 29)The applicant and/or the legal owner of that portion of land upon which these Orders of Conditions have been placed shall provide to the NACC prior to transferring,or assigning any portion of said land to another party, subject to said Orders of Conditions,the"Compliance Certification Form Affidavit" attached via"Appendix A"signed under the pains and penalties of perjury,stating that said applicant and/or owner has read these Orders of Conditions and is in compliance with each and every condition. This document shall apply to each of the conditions referenced herein and shall be provided to the Conservation Department at least five (5) business days prior to the closing of said land transaction. CAWinword\OOC\NACC#9 7 NACC 01/03/2001 NACC#9 30)Once these above mentioned pre-construction requirements are complete, the applicant shall contact the Conservation Office prior to site preparation or construction and shall arrange an on-site conference with an NACC representative,the contractor,the engineer,wetland scientist and the applicant to ensure that all of the Conditions of this Order are understood. This Order shall be included in all construction contracts, subcontracts, and specifications dealing with the work proposed and shall supersede any conflicting contract requirements. The applicant shall assure that all contractors,subcontractors and other personnel performing the permitted work are fully aware of the permit's terms and conditions. Thereafter, the contractor will be held jointly liable for any violation of this Order of Conditions resulting from failure to comply with its conditions. The applicant or contractor shall notify the NACC in writing of the identity of the on-site construction supervisor hired to coordinate construction and to ensure compliance with this Order. A reasonable period of time shall be provided as notice of the pre-construction meeting(e.g. 72 hours). NACC#9 DURING CONSTRUCTION 31)IMPORTANT: Immediately upon completion of the dwelling foundation, and prior to further construction activities associated with the site,the applicant shall complete a plan prepared by a Registered Professional Land Surveyor of the Commonwealth(R.P.L.S.)which accurately depicts the foundation location and ifs proximity to wetland resource areas as approved under this Order of Conditions. Said plan shall be submitted to the Conservation Administrator for approval. 32)Upon beginning work,the applicant shall submit written progress reports j every week detailing what work has been done in or near resource areas,*and what work is anticipated to be done over the next period. This will update i the construction sequence. 33)Any fill used in connection with this project shall be clean fill, containing no trash,refuse,rubbish or debris,including but not limited to lumber, bricks, plaster,wire,lath,paper,cardboard,pipe,tires,ashes,refrigerators,motor vehicles or parts on any of the foregoing. 34)No exposed area shall remain unfinished for more than thirty (30)days, unless approved by the NACC. 35)No re-grading in the buffer zone shall have a slope steeper than 2:1 (horizontal:vertical). Slopes of steeper grade shall be rip-rapped to provide permanent stabilization. 36)There shall be no stockpiling of soil or other materials within twenty-five(25) feet of any resource area. 37)Washings from concrete trucks, or surplus concrete, shall not be directed to, any drainage system, or wetland resource area. 38)All waste generated by, or associated with,the construction activity shall be contained within the construction area,and away from any wetland resource area. There shall be no burying of spent construction materials or disposal of waste on the site by any other means. The applicant shall maintain dumpsters (or other suitable means) at the site for the storage and removal of such spent construction materials off-site. However, no trash dumpsters will be allowed within 50'of areas subject to protection under the Act or local SyLaw. CAWinword\OOC\NACC#9 9 NACC 01/03/2001 NACC#9 39)Accepted engineering and construction standards and procedures shall be followed in the completion of the project. 40)During and after work on this project, there shall be no discharge or spillage of fuel, or other pollutants into any wetland resource area. If there is a spill or discharge of any pollutant during any phase of construction the NACC shall be notified by the applicant within one (1)business day. No construction vehicles are to be stored within 100 feet of wetland resource areas, and no vehicle refueling, equipment lubrication, or maintenance is to be done within 100 feet of a resource area. i i I I CAWinword1OOC\NACC#9 10 NACC 01/03/2001 NACC#9 AFTER CONSTRUCTION 41)No underground storage of fuel oils shall be allowed on any lot within one- hundred (100)feet of any wetland resource area. This condition shall survive this Order of Conditions and shall run with the title of the property. This condition is issued under the authority of the Town's Wetland protection ByLaw. 42)Fertilizers utilized for landscaping and lawn care shall be slow.release, low- nitrogen types (<5%),and shall not be used within 25 feet of a resource area. Pesticides and herbicides shall not be used within 100 feet of a wetland resource area. This condition shall survive this Order of Conditions and shall run with the title of the property. This condition is issued under the authority of the Town's Wetland Protection ByLaw and shall remain in perpetuity. 43)Upon completion of construction and grading, all disturbed areas located outside resource areas shall be stabilized permanently against erosion. This shall be done either,by loaming and seeding according to SCS standards. If the latter course is chosen, stabilization will be considered complete once vegetative cover has been achieved. '44)Upon completion of the project the applicant shall submit the following to the Conservation Commission as part of a request for a Certificate of Compliance: a) WPA Form 8A-"Request for a Certificate of Compliance." b) A letter from the applicant requesting a Certificate of Compliance. c) The name and address of the current landowner. d) Signed statements from the individual property owners shall be submitted with the request for a Certificate of Compliance indicating ,that they read and understood the recorded Order of Conditions prior to purchasing their property. e) The name and address of the individual/trust or corporation to whom the compliance is to be granted. f) The street address and assessor's map/parcel number for the project. CAWinworW0C\NACC#9 11 NACC 01/03/2001 NACC#9 g) The DEP file number. h) A written statement from a Registered Professional Civil Engineer of the Commonwealth certifying that the work has been conducted as shown on the plan(s) and documents referenced above,and as conditioned by the Commission. i) An"As-Builf' plan prepared and signed and stamped by a Registered Professional Civil Engineer of the Commonwealth, for the public record. This plan will include: ➢ "As-Built' post-development elevations of all drainage.& stormwater management structures constructed within 100 feet of any wetland resource area. NOTE: If portions of the stormwater systems exist partially within the Buffer Zone than the entire structure must be depicted to accurately verify compliance. ➢ "As-Builtr'post-development elevations and grades of all filled or altered wetlandresource areas including the encompassing buffer zone which is regulated as a resource area under the local Wetland Protection Bylaw. ➢ Distances from structures to wetland resource areas. Structures include(but are not limited to)septic systems, additions,fences, sheds,stone walls,pools,retaining walls, subsurface utilities and decks. ➢ A line showing the limit of work and the extent of existing erosion control devices. "Work"includes a___y disturbance of soils or vegetation. ➢ Location of all subsurface utilities entering the property. CAWinword\OOCWACC#9 12 NACC 01/03/2001 J NACC#9 45)The following special conditions shall survive the issuance of a Certificate of Compliance(COC)for this project: ➢ 25' No-Disturbance Zone and a 50' No-Construction Zone shall be established from the edge of adjacent wetland resource areas except in those locations approved under DEP#242- Future 42 Future work within 100' of existing wetland resource areas will require a separate filing with the NACC(refer to Section XI (page 18) of the Regulations for performance standards within these zones)The Conservation Administrator and/or other agents of the NACC do not have the authority to waive these setbacks as established under the local ByLaw; ➢ Discharge or spillage of pollutants (Condition#40); ➢ Prohibition of underground fuels (Condition#41); f ➢ Limitations on the use of ferUlizers,herbicides, and pesticides (Condition#42). CAWinword\OOC\NACC#9 13 NACC 01/03/2001 NACC#9 APPENDIX A-AFFIDAVIT I, on oath do hereby depose and state: (authorized agent applicant and/or current owner) (PLEASE CBECK AT LEAST ONE BLOCK) 1. I am the of (position with applicant) (applicant name or company name) the applicant upon whom Order of Conditions have been placed upon by (DEP or NACC number) the North Andover Conservation Commission. &/or 2. I am the of (position with owner) (owner name) the owner upon whose land Order of Conditions have been placed up by (DEP or NACC number) the North Andover Conservation Commission. & I hereby affirm and acknowledge that I have received said Order of Conditions and have read the same and understand each (NACC#) and every condition which has been set forth in said Order of Conditions. & I hereby affirm and acknowledge that on this day of 19 I inspected said property together with any and all improvements which have been made to the same and hereby certify that each and every condition set forth in Order of Conditions are presently in compliance. (NACC#) & I hereby affirm and acknowledge that this document will be relied upon by the North Andover Conservation Commission as well as any potential buyers of said property which is subject to said Order of Conditions (NACC#) Signed under the pains and penalties of perjury this day of 20 (Signature-authorized agent of applicant or owner) C.Minword\OOC\NACC#9 14 NACC 01/03/2001 Location - k"T 'S No. 2Z Date NORTH TOWN OF NORTH ANDOVER Of+" O •,h0 i • ; , Certificate of Occupancy $ �'�s''••°'Etn Building/Frame Permit Fee $ SgCMUs Foundation Permit Fee $ Other Permit Fee $ DO TOTAL $ 3SS3 Check # 15 6 % ! ilding- spector r� Civil Construction Management, Inc. FOUNDATION PLAN 8 Merrimac Road, Box 475 Newton, N.H. 03858 Lot 5 — Saile Way Tel (603) 382-7650 n North Andover, MA P ,-A 0 PLAN REFERENCE: "GREAT POND ESTATES", A DEFINITIVE SUBDIVISION PLAN IN NORTH ANDOVER, MASSACHUSETTS, PREPARED FOR EIGHT MEADOWS REALTY TRUST", SCALE: 1-=40'. OCTOBER 7, 1991, REVISED DECEMBER 11, 1992, BY DEFEO & WAIT & ASSOCIATES, INC. PLAN # 12515. S05'31'31"W 33.12' S03'21'25"E S02'10'44"E S08'1 1'26"W 173.03' 87.58' S�) 16.50 6578 44'{1, sS LOT 5 111,420 S.F. 2.6 Ac. rn -' L !y LOT 4 col z LOT 6 La 1.P. s i.N C' EXISTING FOUNDATION 45.8' Go 43.7' L=18.80' I.P. o) R=60.00' G.B. G.B.0N� 128.80, 9 24 44 E I.P. L=27.40 R=30.00' `� j,E W A y_ Scale: 1" = 60' I certify that the foundation is located on the lot as shown and that it does conform a 4, 2002 with the Town of North Andover Zoning Regulations regarding setbacks from the street and lot lines. I further certify that the dwelling is not located in a federal flood hazard zone. ZH OF �,tv� This plan does not represent a property survey. SLI NTAL r Zoning: R-1 avn. Na 37427 MINIMUM SETBACKS: �' � FRONT: 30 Ft. SIDES: 30 Ft. REAR: 30 Ft. Civil Construction Management, Inc. PROPOSED 8 Merrimac Road, Box 475 FOUNDATION PLAN Newton, N.H. 03858 ' Tel (603) 382-7650 LOT 5 SAILE WAY NORTH ANDOVER, MA REFERENCE: 1. BPLAN *GREAT Y DEFER WAIT N AES RTES' FONC IGT MEADOWS REALTY TRUST MARCH /2, 2002 92 2. PLAN 'SITE PLAN" FOR DETERMINATION OF APPLICABILITY Scale: 1" = 40' FOR LOT 5 GREAT POND ESTATES, SAILE WAY BY CML CONSTRUCTION MANAGEMENT, INC. 5/13/97 BUILDING SETBACKS: FRONT = 30' SIDE 30' REAR 30' \A5 I � X A6 ALPHA-NUMERIC WETLAND -- — FLAG LOCATION (TYP.) W \ I A7 YL o � \ A8 r X TOTAL PARCEL M \\ LOT 5 \\ 63/48 4 111 ,420 S.F. As 2.5578 Ac. / ,o All / li I I A10 \ / Al2 R=60.00' \=18.80' ��^o,`y \� / A13 A14 O r� PROPOSED FOUNDATION 45.9 R = 30.00' \\1 O��G 46.8' ` `F� L = 27.40' 15 J'A OF ap )C R e(�� O 16 ICF GIUPNIAL Sts dyrL -+ \ \ �. fiQ Z�/p�, Na 374V, 1\ \ \ Ll yi pORTM of tie r.^k0 +►i y sSrlCHU96 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number �� Cti-i�-° Date `�` �O3 THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS v//� `e� IN ACCORDANCE WITH THE PROVISIONS O THE MASSACHU TTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.. 1 q s 4-a m �4c S CERTIFICATE ISSUED TO CaN V-e m Building Inspector 1 -_= NORTH Town E of _ Andover No. ,y _ .,9, _ o a dover, Mass., COCHIC W CR V ADRATE D BOARD OF HEALTH Food/Kitchen PERMIT T Septic System idrs C BUILDING INSPECTOR THIS CERTIFIES THAT.....600�i N1• r .. r ......................... Foundation has permission to erect.................I................... buildings on... Q ..i. ... ..�.� ...........a�C Rouged to be occupied as itt�� 5 FV.I�..�A . I..4s.. S' ..y.. ....... ... ..... ...�`�.... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final✓% G '"_ y/3�1� this office, and to the provisions of the Codes and By- ws relating to a Inspection, Alteration and Construction of Buildings in the Town of North Andover. �11rs �A� PLUMBING INSPECTOR �i 3 y '� 3 SS3 ,v3 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough x.01 PERMIT EXPIRES IN 6 MONTHS ELEC ICAL INSPE TO UNLESS CONSTRUCTION TARTS1110 . v ..... .................. ................. ........... BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough 34 141 � Display in a Conspicuous Place on the Premises — Do Not Remove na No Lathing or Dry Miall To Be Done FIRE DEP TET, Until Inspected and Approved by the Building Inspector. BurnerON Street No. Smoke Det. SEEREVERS =SIDE Town of North Andover V%ORTH Building Department ,�v.tt`$o ;,6„a4'o v 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax(978) 688-9542 [DCH,[NiWNN 1' APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS I� C LOT NUMBER SUBDMSI 4 DATE REQUEST FILED DATE READY FOR INSPECTION C TEN (10)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-INSPECTION FEE OF TWENTY-FIVE ($25.)DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE "d - FFICIAL UKE ONLY ROUTING D.P.W. —WATER METER DATE D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO THE INSPECTION REQUEST DATE. 77]�Z� a SIGNATURE/ W THORIZATION 4218 Date.. f NORTF�, TOWN OF NORTH ANDOVER Fr ..�yf. • LP PERMIT FOR WIRING SSACMUS� This certifies that .. ..:... ...'�-......?�1.n.5...... ..................... has permission to perform ......... l ." W /�v� ................. .......................................... e ging in the building of..... U..!. 62G/7 ..... l...`�..t... .......�..C ..s..�.�P..... .... ,North Andover,Yaw Fee.f yr.do Lic.No.............. ........ ...... ELECTR[CALI PECTOR Check # THEC0MM0NWEALTH0FA1ASS4CHUSETTS Office Use only DEPAffAfl11VT0FPUXJCS4FE7Y BOARD OFFIREPREVEMONRi�GUL4HONS527CMR12.00 Permit No. Occupancy&Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date_ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) #� -IC 5(�t^ Owner or Tenant �' e 6yv Owner's Address_ °�(5n 049 2)e STOER Is this permit in conjunction with a building permit: Yes NoCheck Appropriate ppropriate Box Purpose of Building Utih Authori tion No. Existing Service AmpsVolts Overhead Underground ��� � g No. of Meters New Service o �..f=n Amps Volts Overhead Under round g � No.of Meters J Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work W fT Y-J G^J ) P No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total No.of Lighting 41 ixtures Swimming Pool Above Below KVA QGenerators KVA ' round round No.of Receptacle Outlets 100 No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets 1 No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pum s Tons KW Initiating Devices No.of Dishwashers 1 Space Area Heating KW No.of Sounding Devices ` No.of Self Contained No.of DryeS- Detection/Sounding Devices Heating Devices KW Local Municipal Other No.of Watt'Heaters KeyConnections No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER FrMua=GC)raga Putsuargtothetecltmanayso�Ger flaws [haw aa a tLiabihtylrarulcepb)xy Coniple�,OPC � crAssubslafltWequivalal YES NO [havEsigth appted Td ptaofofsarnetothe Ofl>m YES �" FYCUhawdlackedYES,pk%eirdi�lhe ofw ED �adaf�gthe box � �bY NSURANCEE BOND OTHER may) vodctOSattL�pearonDateReq Rough - 1.1 l �`l I 12d a►ofFdet�acalW«k$ 36, 6 o o :igneduntiatTr, IRMNAME �7 •J1,JC � I �+ LiarmeNo. ioalsae r•S c C Scc� SigpakmLioaWNo �— (S� �^ �J BusnmTel No. S 7 S- 025oa WNER S INSURANCE W Alt Tel No. AI\Ut IamawarethattheLx=wdoesnothavetheinsurancecoverageoritssubsantialequivalaltasr 4wedbyMa%xhuretisGenerallaws dd-atmysignabueonthispem Lapp, d*fegtmanent 'lease check one) Owner Agent Telephone No. —PERMIT FEE Signature o caner or gen � 3 Date......// ,�ORTM °ft��`°;•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SSACMUSEt L • This certifies that �..S/ �� S ............................................................................................. j SPc /S,Ys/' has permission to perform ....................... ......... ... ............................ ..?...... wiring in the building of. P�tVLEiCrZC;A�L I�J....... a... � w Fee. v1..tA... Lic.No./...�s... ...... . TOR Check # a v� The Commonwealth of Massachusetts OLfice Use Only��"" '=r Department of Public Safety Permit No. r !! BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupanir/ 3 Fee Checked `- 3190 Qeave blank) 1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO An work to b•porron d In raord.n",.ft,M@ M•s.:•cnus•ns Et•m:st Code.527 CUR 12:00R K (PLEASE PAINT IN INK OR TYPE ALL INFORMATION Date /—` ------_ City or Town of - �" V e,/— The undersigned applies fora permit to perform the elecincal work — --To the It!s described below, pectcr of Wires: Location (Street d, Number) fal• l •,� Gti � �,•f Owner or Tenant Cnr� /]n✓'Q I c/ /� Jr�pfeU --- Owner's Address_ c/ n p a, C ire Wp� L Is this permit in conjunction with a building permit yes Cl no fa / (Mr—;k Appropriate Box) Purpose of Buildin Utility Authorization No. Existing Service Amps ! Volts Overhead ❑ Und rd ❑ 9 No. of Meters New Service Amps_ i Volts Overhead ❑ Und rd ❑ " S No. of Meters_._ Number of Feeders and Ampacity _ Location and Nat-e of Proposed E!ec:rical Work No. of fighting Outlets of Hot ITubs No. TOTAL�~of T'ranslormers � f,Vq No. of Lighting Fixtures Above In - — Swimmin Pool ornd.❑ rnd❑ Generators KVA No. of Recaotacle Outlets No. of Oil Burners No. of Emergency Lignting — Bane ry Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ran es TOTAL No. of Detec:ion and —" No. of Air Conditioners _ TONS Initiating Devirss No. of Disposals HEAT TOTAL TOTAL No. of Sounding Devices r No. of Pumps TONS KW No. of Self Contained No. of Dishwashers Soace/Area Heating KW Detection/Sounding Devicas No. of Dryers Heatinq Devices KyV Municipal . Local ❑ Connection ❑Other No. of Water Heaters KW Signs Bal of Law Voltage Signs Ballasts Whin No. of Hyda Massa a Tubs No. of Motors Total HP OTHER:" INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Uability Insurance Policy Including Completed Operations Coverage or its substantial valid proof of same to this office. YES O NO O equivalent. YES ❑ NOG !haave'su8r4(Ihed`` If you have-checked YES, please indicate the type of coverage by checking the apprepriate box: " INSURANCE ❑ SOND ❑ OTHER ❑ (Please Specify) J. (" Ezpi>a an-D) Estimated Value.of Electrical Work $ Work to Start" Inspection Date- Req(f606d: Raugh i Signed under the penalties of perjury: Fina FIRM NAM--77E- 14 Licensee f!�� —_LIC. NO. Signatt/r Address • 62• 0 LLC. .N Bus. lel. No� '...7Y�� OWNER'S INSURANCE WAIVER 1 am aware that the Licensee does not neve the insurance Covera a or its ;Alt. Tel. No. Massachusetts General Laws, and that my signature on this application wai-res this requirement. Owner 4 er_ n Agent ( equivalent as requtred by i (Please check tme) (Signature of Owner or Agent) PE imrr FEE S.