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2101098.A-00558-08_0 000.0 \\
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North Andover Board of Assessors Public Access Page 1 of 1
NORT„ North Andover Board of A.ssessors,,
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'SSwcMuget roperty Record Card
Click Seal To Return Parcel ID :21.0/098.A-0058-0000.0 FY:2012 Community :North Andover
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Summary
Residence -1
Detached Structure
Condo
66 JAY ROAD
Commercial
Location: 66 JAY ROAD
Owner Name: ALPUERTO,CARLO
ALPUERTO,KIMBERLY
Owner Address: 66 JAY ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood:6-6 Land Area: 1.23 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 1971 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 412,500 412,500
Building Value: 203,800. 203,800
i
Land Value: 208,700 208,700
Market Land Value: 208,700
Chapter Land Value:
LATEST SALE
Sale Price: 530,000 Sale Date: 10/26/2005
Arms Length Sale Code: Y-YES-VALID Grantor: SULLIVAN,PHILIP
Cert Doc: Book: 9845 Page: 33
I
http://csc-ma.us/PROPAPP/display.do?linkld=1893796&town=NandoverPubAcc 7/16/2012
Residential Property Record Card
PARCEL ID:210/098.A-0058-0000.0 MAP:098.A BLOCK:0058 LOT:0000.0 PARCEL ADDRESS:66 JAY ROAD FY:2012
PARCEL INFORMATION Use-Code:_ - 101 g Sale Price: 5301000 Book: 9845 g RoadlType: T Inspect Date: 04/30/2008
Tax Class T Sale Date 10/26/05 Page_ 33 Rd_Condition P Meas Date: 04/30/2008
Owner. - mM _ .� _
ALPUERTO,CARLO Tot Fin Area. 1971 Sale Type A_P Cert/Doc: Traffic M�Entrance X
ALPUERTO, KIMBERLY Tot Land Area. 1.23 Sale Valid Y Water Collect Id RRC
Address: T Grantor: SULLIVAN;PWILIP Sewer � �Inspect Reas: C+�-'_v__�
66 JAY ROAD Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
NORTH ANDOVER MA 01845
RESIDENCE INFORMATION LAND INFORMATION
Style: CP Tot Rooms: 7 Main Fn Area: 1250 Attic: NBHD CODE 6 NBHD CLASS: 6 ZONE: R3
^ _ . r _ — -
" '" Method
540 S Ft Acres Influ-Y/N Value Class
Story Height: 1_75 Bedrooms:_ 3 Up Fn Area: 721 Bsmf Area 1250 Seg Types Code
'� G Full Baths: 2"'Add Fn Asea: Fn Bsmt Area_:
1 P 101 S� 43560 1.000 206,910
Ext Wall: AV Half Baths: f Un in Area: Bsmt Grade: 2 R 101 A 0 0.230 1,748
Masonry Trim ` Exf Bath Fiz_ 0� Tot Fm Area 1971 _ DETACHED STRUCTURE INFORMATION
Foundation CN Bath C ual T _ RCNLD. 183325 Str Unit" Msr-1 Msr-2 E YR-BIt Grade Cond."/oGood P/F/E/R Cost' 'Class'
Ketch QualT Eff Yr Built 1975Mkt Adj:,
° -- �-�'
SE—S- 100 0.00 %//
1988 A A 88'�y�-�'- '�-200
Heat Type: HW Ext Kitch Year Built: 1971mSound Val ��
ue: PC S 512 0.00 1988 A A 50///50 20,300
Fuel Type: O _� m,_" Grade..—A Cost BI'dg:183,300
Fireplace.�rN E 6�- Bsmt Gar Cap Condition A -Att'Str Val1 VALUATION INFORMATION
Central AC: Y�Bsmt Gar SF: Pct Com tete: Att Sty Val2 - '�` Current Total: 412,500 Bldg: 203,800 Land: 208,700 MktLnd: 208,700
P
Aft Gar SF: 462%Good'P/F/E/k-- /100/100/78-' Prior Total: 412,500 Bldg: - 203,800 Land: 208,700 MktLnd: 208,700
Porch Type Porch Area Porch Grade Factor
E 213
W 132
SKETCH PHOTO
sz 1`6x8 S' Ft i
?Sq.Ft 9 1442
, x
FU'.75/FM/B FM/B 112 G 22
8
26 962 Sq.Ft 288 Ft 462 Sq.1-t
37
66 JAY ROAD
Parcel ID:210/098.A-0058-0000.0 as of 7/16/12 Page 1 of 1
ra �
1 Date.. .... ........ ......
TOWN OF NORTH ANDOVER
9 PERMIT FOR WIRING
l c , D
., This certifies that6 VA e
................................`7.
.......................................................................................
has permission to perform ....�4.P,„ G 022o r� --ls.............
winng,in the building of......... ... ..................................................................................
at .... .�.....4�...('�............�d'4.�................. ........:..........Nh
r
f'
363 !2
Fee.............................. ic.No.
a ELECTRICAL INSPECTOR
Check# ��
12465- n\
Commonwealth of Massachusetts j Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
,M BOARD OF FIRE PREVENTION REGULATIONS
[Rev-1/071 (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(WC),�27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gi es notice of his or her intention to perform the electrical work described below.
Location(Street&Number) �6 -1 a-
Owner or Tenant CO,< O v x 0 Telephone No.
Owner's Address
Is this permit in conjunctio with a building permit?, Yes run
No ❑ (Check Appropriate]Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 2 e Co\,k44
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires Lf No.of Ceil:Susp.(Paddle)Fans /� No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Abovr _ 7�
�---�
No.of Luminaires Swimming Pool rnd. �I� `�
No.of Receptacle Outlets ( �j No.of Oil Burners
No.of Switches No.of Gas Burners
No.of Ranges No.of Air Cond.
Heat Pump I.NmmbiiTo
No.of Waste Disposers Totals: I II
M
No.of Dishwashers Space/Area Heating
No.of Dryers Heating Appliances ,
No.of Water Tom' No.of rq
,.j Heaters Signs I i
No.Hydromassage Bathtubs No.of Motors ,
OTHER:
Attach a Yt'res.
Estimated Value o Electrical Work: =00 (When re�
Work to Start: 7 /� I Inspections to be requested in accoraance witliMEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [� BOND ❑ OTHER ❑ (Specify:)
I certify,under thepai andpenalties ofperjury,that the information on this application is true and complete—
FIRM NAM (l,6 Q'Q_c :C.NO.: 30�
Licensee: �Ve_A GO vae-,Y t— Signature LIC.NO.:
(If applicable, me "exempt"in the li mbe line.) Bus.Tel.No.• 7 a t a 3_
Address: I fes--Z-,PQ V` t< Tse nzzSCZA-ot h"_ Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Dep ent 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:$ 5�—
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed '
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,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.
Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8-Permit/Date Closed: **Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments: .
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments: p
Y
Inspectors Signature: Date:
ROUGH INS CTION: lJ
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date: S
FINAL INSPE ON:
Pass Failed 0 k-1; - 6 5 e-Inspection Required($.)
Inspectors Comments: .E
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
r Commonwealth of Massachusetts i Official Use Only
Permit No.
a Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07]
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code�( ;,j27 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: 1/ ( am
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gi es notice of his or her intention to perform the electrical work described below.
Location(Street&Number)
�
Owner or Tenant Co< O v Telephone No.
Owner's Address
Is this permit in conjunctiou with a buildinK\-
mit?® Yes M No ❑ (Check Appropriate Box)
Purpose of Building L �° ` 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: e Co V1
(oo� �?�. f oo•u5 Q�d 5 U,,O V- c
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires L( No.of Cell:Susp.(Paddle)Fans01, No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- 1-1o.o mergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets 15 No.of Oil Burners FIRE ALARMS No, of Zones
No.of Switches 5 No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No
Tons .of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: "'""..."""'""""'"""'"""'.."" Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value o Electrical Work: _00 (When required by municipal policy.)
Work to Start: rd I Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [ 9 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pai and penalties of perjury,that tl:e information on this application is true and complete
FIRM NAM ` `e-c-1 G,8 Q'GLc`f :C.NO.: � 3o-2
Licensee: Signature LIC.NO.: kj
(If applicable, me ,"exempt"in the liQ�se�numbe line.) Bus.Tel.No.• , ` � t°2
Address: ��e 1h \'cs— 662A d W, 019 (;,0 Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires DepartrAnt of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAVER: 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. $ 5J"
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed '
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the L
notification of completion of the work as required in M.G.L.c.143,§3L, f
Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8-Permit/Date Closed: ***Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required ❑
r
Inspectors Comments:
D
Inspectors Signature. Date:
ROUGH INS CTION:
Pass M LZ Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: raja, Date: S
FINAL INSPE ON:
Pass Failed � • CS e-Inspection Required($.)
Inspectors Comments: .0
4 4a
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massa.chusetts
Department of IndustrialAccidents
- 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name(Business/Organization/Indivi(ival):
Address: G_ �� e
City/State/Zip: (q
.0 one#: L7 7% T
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am.a.employer with employees(full and/or part-time).* 7. ❑New construction
2,❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
❑
4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other
152,§1(4),and we have no..employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who subinif'this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not,those entities have
employees. If the sub-contractors fiave employees,`they must provide their workers'comp.policy number.
Iain 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA.for insurance
coverage verification.
Ido hereby c�un r thepains andpenalties ofperjury that the information provided above is true and correct
Si nature: Date� -
Phone#: �
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract'£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 foi•confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
I i
'COMMONWEALTH OF MASSACHUSETTS
o • • e •
BOARD QF
ELtCTRICIANS
ISSUES. TME FOLLOWING LICENSE
AS ;.A REfa JOURNEYMAN ELE/CTSRI C AN S
ALFRF-b:' GOVAERT
4 LAKEVfEW ROAD
MI.DOLETON f"tA 01949 1444
36308 07/31/11; 70327
Date /..Gl �........
` 10341
TOWN OF NORTH ANDOVER
° PERMIT FOR PLUMBING
o,,r.rA`.�0
�,... gsAC14Us�
This certifies that.................... " t c s
............................................................................................
i. has permission to perform....... .. .. ........41 ............................................
plumbi
ng in the buildings of.... ..[10QAA.6...........................
Y
at.:....... ? ...... ...��c ...............................I......... North Andover, Mass.
Fee'..?.-'.. .'.....Lic. No. AZ4.1. M4..................................................................
PLUMBING INSPECTOR
Check# 167 115'
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE _ I PERMIT# t
JOBSITE ADDRESS ZO OWNER'S NAME M [ter it:
POWNER ADDRESS I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:® RENOVATION: REPLACEMENT:[] PLANS SUBMITTED: YES❑ NO®
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL —
SERVICE I MOP SINK
TOILET-
URINAL
WASHING MACHINE CONNECTION
c-
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES +'NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El"' OTHER TYPE OF INDEMNITY ® BOND® C4_—
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 ® AGENT
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are truend a rate to the best of my knowledge d�
and that all plumbing work and installations performed under the permit issued for this application will be in co nc h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME (�(lec:F��c _tiS_o_�^rtG LICENSE# � i1-7_/ GNATURE
MpM"" JpE] CORPORATION# PARTNERSHIPFI# - LLC E]#
COMPANY NAME. ADDRESS a3 wo {- S� ._
CITY Z .Z ." _ STATE ZIP ®[8�. �. _ TEL
FAX qy - 7i,) CELL EMAIL _5G .!5— !_
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ S S
FEE: $ PERMIT#
PLAN REVIEW NOTES
f �—
Depanment of lndusMd Aeeidents
.✓ Offlee of rnvesgtgarao' s
604 W�shlng foes Steet-
Boston.,MA'0. 111
WWW.MdS&g0V1d1,a
Workers' Compensation insurance davit: Builders/ContraiLtors/Ele�eri�ia�lPla�
h� bcant Informatio ��ers
Please Prat
I-JaMle(Business/orgaolzation/Mvidual): _
address: - b
City/State/Zip: Phone #•
--7F1yrfG; 7/�
Awe po employer? Check the•appropritfltt: `�-
1• I ain a employer with �4. TYPe of project(re?gt�ed :
_ I am a general cotitrac�or and I )
employees(full and/or part-time). have hired the stib-contractors 6. Cl New constructiola.,
2.❑ I ani a sole.proprietor or partner- listed ori the attached sheet t �. ® Remodelizag
ship and have no employees These subcontractors have
working for the in any capacity. workers coup. $ ® Demolitiorl
insttaarace. Building addition
(No workers' corp. ® �ar
insurance* 5. Wet;a corporation and its g.
required.] Officers have exercised their. 14❑ Elec 'cal repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL. I I,Q- g Yepairs or additions
j thyself. (No workers' comp. C. 152,§1-(4), and we have no
insurance required.) t• a to ees. 12.® Roof repairs
P Y [No workers=
carrrp. msivance Yequired.) 13.M Other
'rVt y applicant that checks box$1 must also fill out the section below showing their workers'�mpeoss6on policy infortnatioa:
1 Ho meownets who submit this affidavit indicating they are doing all work and th
'Contractors that check this box mast attached.8p additional sheet showen brae outside copa8ctots mast suing tho nine of the su bmit a pew davit indicating such.
b-coptMctots acid their-Wo**ets'comp.policy infottttation..
I arse an employer that is providing workers'ctimPMatdon Insurance for tray etrrpdaiyeej.:.Bjrlow.is the policy aced,jmb site
injormatdon.
Insurance Cotupany Name:`
Policy.R or-Self-ins.Lic. #: - G y _
. Expiration Date:v
Job.Sitc Address:
city/State/zip:
Attach a copy of the workers' coanp¢ASAdOla policy declaratdon page(sh®wind the otic raux3t
P Y [lumber and expirntlon date).
Failure to secure coverage as required under Section 25A of MMGL c. 152:can lead to the imposition of crimin
fine up to S1,500.00 and/or one-year i>atprisotaiaten�as wen as Civil Penalties of a
enalties
P iii the
of to 5250.00 a day against the.violator. Be advised thata' form of a STOP WORK ORDER and a fine
Investigations'of the DIA for ' ce coverage verification.�Py of t stat cut may be fotWarded.to the Office of
7 do hereby cerci der . dans aped pen antes of pedury thas thre Irafory9aatiora pPovtdrad above,is trtace and correct
attire:
Pho c�
Official use only. Do iaot wrtge ise this area,to be cotsipleted by city or town offickL
City or Town: FermiVUeense.M .
Issulug Authority(circle one):
1..Board of Health. 2.BuildingDeparttaaent 3. CltylTowu Clerk 4
6. Other .Ela tical Inspector 5• lntutnbittg Inspector
Contact Person: P'hotae
4
COMM( MWEALTH OF, MASSAC USETTS.W �'
LICENSED AS A'MASTERtPL'UMBER r �
" ISSUESeTHE ASB VE UCENSE 70
*�.
jL,
M=I CRAEL:G AORA�CG
J
23'5" WALNUT STREET ;
t
r'MA 40+1867 3952
.' Y. X124 , '., 05/•01/14 ,142718`
71
I '
I
Date.... ...........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... Ile
..................... .... .................. ....... ... ............
r- 'k I k 4"1 1QJ",
has permission to perform ................. ..................... ...................
of......... 0
wiring in the buildig .....
71�
at ...... Va Poo �L
. ......................I... ...... ....................................Arth Andover,M s.
Fee' .........Lic.No.
.i--.--i4
ELECTRICAL INSPECTOR
Che4ok#
12083 657� e
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. � �
Occupancy and Fee Checked
4 6 BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07]
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) ��. fold
Owner or Tenant k�tet, }� pu►rb Telephone No.
Owner's Address
Is this permit in conjunctiotl with a building permit? Yes D"'No ❑ (Check Appropriate Box)
Purpose of Building Qr" t%(e_ Utility Authorization No.
- Existing Service 26o Amps 1'7® / 2 W Volts Overhead❑ Undgrd 1011**, No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: K 4%17 c,,,
Completion of thefollowing table may be waived by the Inspector of Wires.
! No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs . Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No. of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p Totals: — • • •• ' •• Detection/Alerting Devices
No.of Dishwashers ) Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances ger SecuriNo o De Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Tnres.
-'Estimated Valueof Electric Work: (When required by municipal policy.)
Work to Start: f �( /Y 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 cover e is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE POND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: . 1" LIC.NO.:
Licensee: Mu rL- a `� Signature LIC.NO.: 211 tlB—til
(If applicable,eafr "exempt"ij the license nWnper line) Bus.Tel.No.:
Address: !� ��l Gr'3chy'` �/�' ✓✓ LAI 8 d 1�l Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE:$
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the ,
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed f j
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 Y
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall.be limited as to the time of.ongoing construction activity,and may be.deemed by the.Inspector-of-Wires abandoned-and invalid ifhe_. .
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: **Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments: .
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors ments:
i
Inspectors Signatur : Date:
FINAL INSPECTION: a- - Z- Z -/ Pm 2P�r
Pass❑' Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
IN 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual); MCA V- Ayzlptt 1
Address: (.rJCl,�;s�-• ��/'•
City/State/Zip: t/t/c1 U✓tePhone#: 7�j " 3 3- egg
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
2. 'lployees(full and/or part-time).* have hired the sub-contractors
am a solo proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
10. Electrical repairs or additions
required.] officers have exercised their
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' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the.section below showing their workers'compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached 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 anal job site
information. ,l'
Insurance Company Name:. Yy C-M T"r C-�-A e
Policy#or Self-ins.Lie.#: 0 ? l 1&-�01� Expiration Date: 211 V11,
Job Site Address: /=�' City/State/Zip: �' 4.1 o iyP
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
frpe 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
Itivestigations of the DIA for insurance coverage verification.
.l
I do hereby certo under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: 1�/ �C�
Phone#: 7g7_
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other - - -
Contact Person: Phone#:
Y
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or.written."
An employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a 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 confumation 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 M
year,Where a home owner or citizen is obtaining a license of-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 ConaMOUWealth of Massa husetts
Department of industrial Accidents
offlee ofInvestigations
6.00 Washington Street
Boston}MA.02111
Tei,#617-727,4900 at 406 or 1-877:MASSAFB
Revised 5-26-05 Faz,##617-727-7749
www..mass.gov/dia
.y .
� r
I
'tWOMM�NWEALTH OF.IVIA$SACHMET�S
w�
15SUE'S THE FOLLOWING LE>=NSE ASA
"AE0t53TEREDeMASTER' ELErRTE°l'A rr�
t j !�
i1ARC b `ACME LDA
20 HENDER,- RD I i
IWOBtFRN
��x- �114o A �07/31 �1� '94992 ,
Date. . :,��".�c1�.
RTM TOWN OF NOR 14 ANDOVER
PERMIT FOR PLUMBING
'@ ,SSACHUS�
This certifies that
has permission to perform ,,� '� - -:: --. . . . . . . . . . . . . . .
plumbing in the buildings of .. . s - . . . . . . . . . . . . . . .
at .f. .�. . . . . . ��`� >T ';
. , North Andover, Mass.
Fee •. . . .Lic. No . . . . . . . . . .
PLUMBING S ECTOR
Check .N
8135
�h
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS -711
/dAFq
//"" k Date /Building Location `Q a Owners Name �Io t rA 0f�-f Permit# /Js
` Amount zZ
/
Type of Occupancy I ' F f"11(x/ ''��
New Renovation ® Replacement 1:1Plans Submitted Yes ® No ❑
FIXTURES
¢�
a � �
O W a rA LnU W WO z A,
x
co
z A a0SL
d
x z
Z H �
� � w o v x
3 a as A a 3 H a x oa -72-
RASE" vr
In FLOOR
MH-DM :
3MIt"
41HMOCIR
M H-oma
6MH -
7M MOOR
gmH-0m
(Print or type) Check one: Certificate
Installing Company Name irr S' Corp.
D iP
Address ip
❑ Partner.
usmess Telephone J 7 i 51 [] Firm/Co.
� N
Name of Licensed Plumber: Ivy er
Y
Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box:
Liability insurance policy r( Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature 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 inst ations perfo nder Pe Issu for this application will be in
compliance with all pertinent provisions of the M tts iftod of the General Laws.
By: igna re o icense um er
Title
Type of Plumbing License Ci /Town O�-
icense UMDer Master ❑ Journeyman
APPROVED(OFFICE USE ONLY
The Common wealth of Massachusetts
^j 1 Department of Industrial Accidents
t#• Office of Investigations
600 TAT
rashington Street
44 ,� Boston, MA 02111
www_mass.
Applicant Information v/dia .
Workers' Compensation Liseu-ante Affidavit: B�nilders/Contractors/Eiectricians/Plambers
Please Print L'bl
NaIne (Business/OWiratiowlndividual):_
Address:
City/state/Zig: (VtAct - tOG?7Phone#: . 7PI •--?11q,`d'7V.
Are you an employer?Cheek.the appropriate box: .
1.❑ I am a employer wi#h 4, 77. deiing
ject(required):
❑ I am a.general contractor and I
employees(full and/or part-time).* have hired the sub-contractorsconstruction
2. I am.asole proprietor.or partner_ listed on the attached sheet x
ship and have no employees These su&contractors have 8. ❑Demolition
working for me in any capacity, workers' comp.insurance.
[No workers'comp.insurance 5. 9• ❑ Building addition
❑ We are a corporation and its
required.) officers, have exercised their 10•0 Electrical repairs or additions
3.❑ I aim s homeowner doing all work right of exemption par MGL 11.7 Plumbing repairs or additions
myself.[No workers'comp, c. 152, §1(4),and we have no
insurance required.]t em to ees, 12.[] Roof repairs
• P Y [No workers'
comp. insurance require&] I3.Q.Other
*Any applicant that checks bo)l lF t must also fill out the section below showing theirworkerc'oompmsation policy information
t homeowners who submit this affidavit indicating they am doing all work.and then hire outside contractors must submit a new affidavit indiaatiag such.
=Contntctors that check this box must attached an additions:sheet showing.Ehe name orthe sub-contractors and their work='comp.polic,;inf ntmuion.
1 ar an employer that is provi fMr:workers'compensation insurance for nV employees Blow is the policy amd job site
.
information
Insurance Company Name: '
Policy#or Self-ins.Lic. #:
Expiration Date:
Job Site Address:
City/statrzip;
Attach a copy of the workers' compensationii decla
Po cy ration page(showing the policy number and expiration d
P site
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
` ear imprisonment, and
o
fine up to$1,500.00 and/or one- f i
y prisonment;as well ss civil penalties in the form of a STOP WORK ORDER and a fine
of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der the p a o u that the information provided above ' true amd ronaet
Si Lure: -✓
Date:
I
Phone ff. 70
Officiat ase only. Do not write in this area,to be conrplet.--d by
city or town offlaW
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2-Building Department 3.City/Town Clerk 4.Electrical Ins eetor 5
6.O P. Plumbin
Other g Inspector
Contact Person: Phone#:
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp 3 overs 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 wr'itten"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mom
of the foregoing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,associatiozr or other legal entity,employing employees. 'however the
owner..of a dwelling house having not more than three speartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maiintenance,construction or repair work on such dwelling house
or on the grounds or building a urtenarrt thereto shall not "
gro g pp because of such employment be deemed to be an employer.
MGL chapter 152,§25C(6)also states 6W"every state or-local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or *o 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 perforrrrance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been preserrted to the corttracting authority."
Applicants '
Please fill out the workers'compensation•affidavit comple✓toly,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. ifan 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 lbe 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'
oompensation policy,please call the Department at the nurnber listed below. Self-i'+sured mppri chnild P.nrPr t4,
self insurance-Iicense 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 A-ilI 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
policyinformation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A of-the affidavit that has been
copy i officially stamped or merited by the city or town may be provided to the �
applicant as proof that a valid affidavit is an file for futon permits or licenses. A new affidavit must be filled out each r
year. When:a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a flog license or permit to bum leaves etc.)said person is NOT required to complete this affidaviL
The Office of Investigations would lr'ke 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 IndustrW Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL#617-727-4900 ext 406 or 1-977-MASSAFE
Revised 5-26-05 Fax 4 617-727-774
www.mass.gov/dia
FORM U - LOT RELEASE FORM Poo
0"
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT O L/C`2 V �l[ V.A PHONE / 9 � b,?S' 9,5S 6
LOCATION: Assessor's Map Number PARCEL 2_
SUBDIVISION LOT (S)
STREET ST. NUMBER
******************************'OFFICIAL USE ONLY********'k**"**
R gMMENDATIONS F TOWN AGENTS:
ONSERVATION ADMINI RATOR DATE APPROVED
DATE REJECTED�a
r
COMMENTS e res Aka
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS -SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zwk$0*W AW 00 bilit 026
BUDLDING PERMIT NUMBER: DATE ISSUED: r
M
SIGNATURE:
Buildint Commissioner/I r of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number: C
!N
ap Number Parcel Numb
� er
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frotrta ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided R red Provided
1.7 water supply M.GL.c.4o. sal 1.3. tined Zone Ir fomstim: I.s seweragDisposal SystemC
Public ❑ Private ❑ zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT n
2.1 Owner of Record
RC
ame(P t) Address for Service:
Signatu Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone R
SECTION 3-CONSTRUCTION SERVICES Qa
3.1 Licensed Construction Supervisor. Not Applicable ❑ 0000
Licensed Construction Supervisor:
License Number
Address
Signature Telephone Expiration Date
r
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name
Registration Number r
Address r
^
Signature Tel Expiration Date Z
Telephone �Y/
1 /
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
--Siltned affidavit Attached Yes.......❑ No.......0
SECTION 5 Description of Proposed Work check ail applicable)
New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) 0 Addition ❑
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
K2 0 d L42d Lf r/d G�5
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Completed by penhit applicant
i. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a) x (b)
4 Mechanical(HVAC)
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
RS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Here y 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
Si ature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDMERS 1 2ND3RD
SPAN
DIMENSIONS OF SILLS
DN ENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
North Andover Building Department
ETel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
The debris will be disposed of in:
(Location of Facility)
i ature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector