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HomeMy WebLinkAboutMiscellaneous - 66 LONGWOOD AVENUE 4/30/2018 210106.0
h
Location C(o Ca L CNU e-r co O Q-6 A U E
No. 5Jr 6 d�O 1 ? fi J Date
. - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $-9-6 ,
= Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
1230 Building Inspector
R
~ OCT 2 4 2016
1OWNOF tJORTN AN00\1ER
HEALTH DEPARTMENT
j IIF MMM 0 XM9T °� 2HM=
r
Environmental/Demolition Contractors
r Commercial/Industrial/Residential
October 17, 2016
Town of North Andover
Health Department
1600 Osgood Street, Suite 2035
North Andover, MA 01845
RE: 66 Longwood Avenue, North Andover, MA
Dear Sir/Madam:
Please find enclosed a copy of the Notification filed with the MASS
DEP regarding the above captioned project. We will be at the location
on October 26, 2016.
Kindly review and contact us with any questions or comments you
may have.
Very truly yours,
Susan A. Pappalardo
/Enclosures
I
7 Puzzle Gane, Unit 2, Newton, NN 03558
Office: (603)97q-2503 FAX 603 974-2877
Massachusetts Department of Environmental Protection
100252865
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form
Project Revision
r" [ Project Cancellation
A. Asbestos Abatement Description
1.Facility Location:
RESIDENCE 66 LONGWOOD AVENUE
Instructions 1.All a.Name of Facility b.Street Address
sections of this form NORTH ANDOVER MA 01845 5085099430
must be completed in
order to comply with c.City/rown d.State e.Zip Code f.Telephone
MassDEP notification MARK RAE OVMIER
requirements of 310
CMR 7.15 and 9•Facility Contact Person Name h.Facility Contact Person Tile
Department of Labor
i p Worksite Location: OUTSIDE,BASEMENT
Standards(DLS) i.Building Name,Wing,Floor,Room,etc.
notification
requirements of 453 2. Is the facility occupied? r%_0 a.Yes r b.No
CMR 6.12
3. Is this a fee exempt notification (city,town, district, municipal housing authority, state facility, or
owner-occupied residential property of four units or less)? W a.Yes 17, b.No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
2.Submit Original if applicable: Approval ID#
Form To:
Commonwealth of
Massachusetts 6.Asbestos Contractor:
P.O.Box 4062
Boston,MA 02211 E&F ENVIRONMENTAL SERVICES LLC 86 CAROtAN AVE
a.Name b.Address
HAMPTON NH 03842 6032345581
c.City/Town d.State e.Zip Code f.Telephone
AC000767 h.Contract Type:r 1.Written 2.Verbal
g.DLS License#
7. GUILLERMO A MARGARIN FRIAS AS060373
a.Name of Contractors On-Site Supervisor/Foreman b.DLS Certification#
N/A
8
a.Name of Project Monitor b.DLS Certification#
ASBESTOS NOTIFICATION LABORATORY AA00208
9
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
10/26/2016 10/28/2016
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYY`)
7-330 N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
r a.Demolition 1- b.Renovation c.Repair r, d.Other-Please Specify: REMOVAL
Revised: 11/13/2013 Page 1 of 4
Date. . . .1!' ;?Il Z'. .. . ...
NORTH
3j 0ry`,sae ,+�,ypL
TOWN OF NORTH ANDOVER
• - PERMIT FOR GAS INSTALLATION
9SSACMU5Et
This certifies that . . . . . . . . . . j
Q
has permission for gas installation
in the buildings/of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . ../ . . � ref '. . . . North A do er, Mass.
Fee. �� Sv. Lic. No..•.�. Z. ?T
GAS INSPECTOR i���
Check# .3 z ll
8125
w
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE PERMIT#
JOBSITE ADDRESS _,OWNER'S NAME �O I►' � /
GOWNER ADDRESS TE FAX
TYPE OR OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL
PRINT
CLEARLY NEW:E] RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YESE] NO
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 T6 7 8 9 10 11 12 13 14
BOILER - -- - - --
BOOSTER
CONVERSION BURNER
COOK STOVE
E
DIRECT VENT HEATER _I __ - - -- - -
DRYER
FIREPLACE - - -- - - - - -- -
FRYOLATOR - - - - - - - -- - - - --
FURNACE -- -
s '
GENERATOR -_--
GRILLE -- - -- - - - - -
INFRARED HEATER —
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN - _ - --
POOL HEATER
ROOM/SPACE HEATER -- - -- _f -
ROOF TOP UNIT _ - --- - - ---
TEST -- - ' -- -
_J
UNIT HEATER - - - -
UNVENTED ROOM HEATER -
WATER HEATER --' - --
OTHER I - - -
I
INSURANCE COVERAGE
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ]NO
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW \
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND
OWNERS
' INSURANCE WAIVER:I am aware that the Ii ensee 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 E3 AGENT Ej
SIGNATURE OF OWNER OR AGENT
-Thereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the es y knowl
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with I Pertin t p /b t
Massachusetts State Plumbing Code and Chapter 142 of the General Law—s. �`-
PLUMBER-GASFITTER NAME f�� I I _ __ �I LICENSE# _ y� S A R
MP 0 MGF E-1 JP JGF E] LPGI® CORPORATION[:]# PARTNERSHIP O# LLC Q#
COMPANY NAME: __ __� ADDRESS .
CITY — STATE I_/33 ZIP TEL
FAX CELL EMAIL
9383 Date. 4niv. . .
TOWN OF NORTH ANDOVER
0
0 PERMIT FOR PLUMBING
ss�CHUS� -�' f f
This certifies that . ./.!���/-� . . 1"�. . . . . . . . . . . . . . . . . .
has permission to perform
plumbing in the buildings of . . . . . . �9.U% . . . . . . . . . . . . . . . . . . . .
at . . .�P. .[a �.� . ?"v��. . . . . . . . .., No :hh}Andoveei, Mass.
PLUMBING INSPECTOR
szla
Check #
J
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- CITY MA DATE __-. _-:_. _,!a_--------, PERMIT#
JOBSITE ADDRESS OWNER'S NAME�—t.l.0 J_fy 5r,
POWNER ADDRESS " ._ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIALE]i EDUCATIONAL El RESIDENTIAL f
PRINT
CLEARLY NEW:E] RENOVATION:El REPLACEMENT:M PLANS SUBMITTED: YES NOM
FIXTURES 1 FLOOR— BSM 1 2 3 4 5 1 6 7 8 1 9 10 11 12 13 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/AREA DRAIN
INTERCEPTOR INTERIOR _ ..
KITCHEN SINK - - -- - - - - - - 0 - - - - -- ---- --
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET -
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES i
WATER PIPING
OTHER r -- {-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESP NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND
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 E] AGENTE]
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the es of m wledge
and that all plumbing work and installations performed under the permit issued for this application will be in c pliance with all P ' nt ovis' ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
oL,726 �,
PLUMBER'S NAME �" _ _- ,LICENSE#MG ATURE
MPD JP CORPORATION S# PARTNERSHIPFJ#OLLCQ#�
COMPANY NAME _1.� TJ U_M ADDRESS1
CITY -CIY�_. _�1.__. --_ - _ - STA E _ ZIP _d (� --- TEL Cj 2-0-a.L
FAX CELL EMAIL �� '`� �`1 S�(' W)'1 TS ,f7
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/lndividual): —�
Address: /Ok Lila
City/State/Zip: -��e#: ,
Are you an employer?Check the appropriate box:
Type of project(required):
L❑ 4.I am a employer with ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. �Iarn a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
p and have no employees These sub-contractors have g• ❑Demolition
workingfor me in an capacity. employees and have workers'
� y p � comp.insurance.t 9• E]Building addition
[No workers comp.insurance P
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#I 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address:_(' \ ' _ VCity/State/Zip:V &_J_t 61W
Attach a copy of the workers'\�§mpensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certi under lite pains and enalties o er'u that tl:e in ormation provided above is tare and correct.
Si ature: 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#:
f�10R7/r�
-W. • "° Zoning Bylaw Review Form
t Town Of North Andover Building Department
27 Charles St. North Andover, MA. 01845
Sys°.r."..•'j,�9
s"`Husx Phone 978-688-9545 Fax 978-688-9542
Street: X
Ma /Lot: C
Applicant:
Request: /& K '3 -t —
Date: '-711S 0 Y'
Please be advised that after review of your Application and Plans that your Application is
DENIED for the following Zoning Bylaw reasons:
Zoning it'-3 a 3v00LI-zja5 rNv4/3r>1�0 - 30 i` s 1-,Q-
Item Notes Item Notes
A Lot Area F Frontage
1 Lot area Insufficient 1 Frontage Insufficient
2 Lot Area Preexisting Lj r- 2 Frontage Complies
3 Lot Area Complies 3 1 Preexisting frontage e
4 1 Insufficient Information 4 Insufficient Information
B Use 5 No access over Frontage
1 Allowed G Contiguous Building Area A) .a
2 Not Allowed 1 Insufficient Area
3 Use Preexisting 2 1 Complies
4 1 Special Permit Required 3 Preexisting CBA
5 Insufficient Information 4 Insufficient Information
C Setback H Building Height
1 All setbacks comply 1 Height Exceeds Maximum
2 Front Insufficient Act oN 2 Complies
3 Left Side Insufficient 3 Preexisting Height e
4 Right Side Insufficient 4 1 Insufficient Information
5 Rear Insufficient I I Building Coverage
6 Preexisting setback(s) S A a oea r- 1 Coverage exceeds maximum
7 Insufficient Information 2 Coverage Complies
D Watershed 3 Coverage Preexisting Lf -e
1 Not in Watershed L e 4 Insufficient Information
2 In Watershed j Sign fV
3 1 Lot prior to 10/24/94 1 Sign not allowed
4 1 Zone to be Determined 2 Sign Complies
5 Insufficient Information 3 Insufficient Information
E Historic District K Parking
1 In District review required 1 More Parking Required
2 Not in district S 2 Parking Complies e
3 Insufficient Information 3 Insufficient Information
4 Pre-existing Parkin
Remedy for the above is checked below.
Item # Special Permits Planning Board Item # Variance
Site Plan Review Special Permit -a Setback Variance
Access other than Frontage Special Permit Parking Variance
Frontage Exception Lot Special Permit Lot Area Variance
Common Driveway Special Permit Height Variance
Congregate Housing Special Permit
Variance for Sign
Continuing Care Retirement Special Permit Special Permits Zoning Board
Independent Elderly Housin S ecial Permit Special Permit Non-Conforming Use ZBA
Large Estate Condo Special Permit Earth Removal Special Permit ZBA
Planned Development District Special Permit Special Permit Use not Listed but Similar
Planned Residential Special Permit
Special Permit for Sign
R-6 Density Special Permit 1�: -jA Special permit for preexisting
Watershed Special Permit nonconforming-
The above review and attached explanation of such is based on the plans and information submitted. No definitive review and
or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to
Provide definitive answers to the above reasons for Any inaccuracies,misleading information,or other subsequent
changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the
Building Department.The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein
by reference. The building department will retain all plans and documentation for the above file.You must file a new permit
application form and begin the permitting process.
✓ Building Department Official Signattfae Application Received. Application Denied
Plan Review Narrative
The following narrative is provided to further explain the reasons for DENIAL for the
APPLICATION for the property indicated on the reverse side:
fiM• d"' 1 �yWl a (i � ! s t ,s 2 Y^P _s�s'V�7Yt, nc a q a .y.
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Vz
a .. tr n S+�s t F4 7<..-: 5d r N:?C .,�`;'}'...s, �''s,.�: ;�Sn M4:.: 't•Y 33�{�.d�.t< _
A So e c 143� ��r�n�c T ICU o" d 10r,e ' c F�677
o,v rm SJ�rvc ort q-
�1/ CvNlbrMr:� �t9 /S r� Utr o� VV0
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a
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d2 .14 t1,4 R!AV<<e Zv— i-c,-4 Ac k
S r—C 401L) i`j st 'T-4-
Referred To:
Fire Health
Police Zoning Board
Conservation Department of Public Works
Planning Historical Commission
Other Building Department
IF NORTH ANDOVER
ZING DEPARTMENT
APPLICATION TO OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Sedim f6T fleC tlai'
BUILDING PEINI.0. DATE ISSUED: M
_ X
SIGNATURE:
Building Commissioner/Ingwor of Buildings Date Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Ej g LoNCs woo� tom,
Coo C S t
P(of AA- �r acN�+( -1,A P 0�2 L1 Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
f02So
Zoning District Proposed Use LA Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide ReqWred Provided Reqwred Provided
v
1.7 Water Supply M.G L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 J
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT l: r C L I I : C-5
2.1 Owner of Record
C 4US r'rt —5 qVA, LG-1USL PP1Ar t SAV1
Name(Print) � ) Address for Service
7 --7 4 —3/-8.0
St Telephone
2.2 Owner of Record:
O
Name Print Address for Service:
Z
Le.o. q -78- 1qct—368 v
Signature Tele hone M
SECTION 3-CONSTRUCTION SERVICES 9"
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone r
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name M
Registration Number r
Address r
^
z
Signature Tel Expiration Date hone G)
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check su applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Completed by permit applicant
I. Building (a) Building Permit Fee
Multi lier
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
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
g J
property
Herebv 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 iST 2 ND 3Ku
SPAN
DD64ENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING x
MATERIAL OF CHD4NEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
i
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
� Uie On
WELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/12EQmtor of Buildings Date Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
L©N CT Woo-1N N-J,
' (DO C _ s �
AA' 1`r a�` P `'$ [�r Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS(ft)
Front Yard Side Yard Rear Yard
ReqWred Provide R red Providd R red
Provided
1.7 Water Simply M.GL.C.40Zone1.5. Flood Zone Information: 1.8 Sewerage Disposal stem:
D
Public ❑ Priate ❑ v
Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
�y� L
" LG- PP IA(A sAvl
_
Name(Print) Address for Service
l� r1 4 /-;9 u
St Telephone
2.2 Owner of Record:
4co ``��-, ,v,-- CLEEn f=oRooH.A(L7
Name Print Address for Service: O
Z
Signature Telephone R{
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: _ 0
• License Number
Address
Expiration Date
Signature Telephone r..
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name
Registration Number r
AddressWORM
r
Expiration Date n Zz
Signature Telephone Y♦
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 it.
Signed affidavit Attached Yes.......0 No.......❑
SECTION 5 Description of Proposed Work checkapplicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN -T
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
1, as Owner/Authorized Agent of subject
property
Herebv 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/A ent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS I 2 ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS 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
A SUN
FORM U - LOT_ RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT G i U 5 PP, 1\)f- S I PHONE q O
LOCATION: Assessor's Map Number 6 C PARCEL
SUBDIVISION L Q+ LOT (S) 1
STREET 6� DOMLT"�®(�L� ��� ST. NUMBER
.**********OFFICIAL USE ONLY * ***********
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED.
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
_DA E
Revised 9197 jm
rDate. ...4141.............
MORTM
Of<•••'��,�O
TOWN OF NORTH ANDOVER
o
PERMIT FOR WIRING
Thiscertifies that ............................................................. ................................
has permission to psrform --/°•I.-.1- I.Y-�'
:,. .:.s ............................................................
k
wiringin the building of..::.... ...........................................................................
at
-� ';�, . ... ... ........... .North Andover,Mass.
Fee.�U..... I .No:� -. . ...... . /L: �c/........
ELECTRICAL INSPECTOR
Check # �
5515
N
J
d
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Date d ' /' 19 Permit # ✓ J
Building Location�L 4L,0ygU_;P"nl. *Ja Owner's Name
Type of Occupancy 'Tri
New ia--Iol Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No pg�
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Installing Company Name 215 BOSTON ST,,P ® BOX 999 Check one: Certificate
Address TOPSHEW,MA ©1283 ❑ Corporation
❑ Partnership
Business Telephone-, (� Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑
• No ❑'
If you have checked yes, please Indicate the type coverage by checking lire appropriate box.
A liability Insurance policy ❑ Other type of Indemnity❑ I Bond ❑
I '
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.
'I r
t _ I Check one:
LSrgnalure of Owner or Owners Agent Owner❑ Agent ❑
I
. I
I hereby certify that all of the details and information I have submitted.(or'enlered)in above appli ion are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for IN application w' be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge era aw .
By T pr,of Ucense:GasliUer
Title Plumber Si'gnat o cense P m er or Gas ilt
j -
City/Town
Master License Number
' APyFiONE OF C .ON Journeyman ; t'I
111E(,'UMMUIV Wt ALI H UP' JACHUNW I N' Office Use only
D+ OFPUB CSAFEIY permit No.
BOARDOFFB?EPREVF1V770 RBGIIIAT7OWrCW 12:010
Occupancy&Fees Checked
APPLICATTONFOR PERMIT T PERFORMELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH T 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)
Owner or Tenant S
Owner's Address �/�
Is this permit in conjunction with a bui ding permit: Yesimm No (Check Appropriate Box)
Purpose of Building vt�;L �/ 5 `/ S �' 'Pee�� C.JU/kJG GSM. Utility Authorization No.
Existing Service 1= Amp '2�Volts Overhead Underground No.of Meters
New Service ✓ Amps �?U/ /Z2eNolts Overhead Underground No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work 4r _.G {fl/!n 1�►
No.of Lighting Outlets / No.of Hot Tubs No.of Transformers Total
(� KVA
No.of Lighting Fixtures U Swimming Pool Above 0 Below Generators KVA
round eround
No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units
No.of Switch Outlets
No.of Gas Burners
/20 vo /7S
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
Plumps Tons KW Initiating Devices
Of No.of Dishwashers Space Area Heating KW No.of Sounding Devices
No.of Self Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal � Other
Connections
No.of Water Heaters KW No.of No.of
Signs Bailasis
No.Hydro Massage Tubs No.of Motors Total HP
OTHER•
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IbawaamerALdxUyh>u o=PohcymchdTCoplee Covaaworitsakst chalegtuvalart YES NO
Ihayssubrniwdvalidptcofofsametot rOffi=YESM Ea
Y)wha%wire Ed YES,pp=mdc rethetypeofoovaageby
dvda<lgthe brut
INSW� ANCE BOND r7 OrIIEZ (f�f� (P1ea9eSpecity)
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Estimated VahleofFbddcal Wolk$ �j U U d
WOJIDSW kq)ectimEkiteReque9ed Rough Final
Sigrwun rTrPaVffi sOfperjury:
FIRMNAME LioffWNo.
C1*p2&'-
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LicerwNo 0 3
BusirmTelNb.
A l V CJ ///h` t Alt Tel No. `1''-7Sr—
OWNER'SINSURANCEWAIVFR;IamawmetridieLiowdoesnothawthemrdnceeovaageoritsmbstx leqrivalartasWmedb,Nha xu GalaalLaws
andthazmy . Onthis' 'applicati«Iwaivestfrislagtlrtanai '
(Please ec e) r f Agent d(.N 7�&- a a�
Telephone N PERMIT FEE$ �V�
signature of Owner or Agent
a Date. . .
Of NORTH TOWN OF NORTH ANDOVER
.'QED 'a9ti0
PERMIT FOR,GAS INSTAhLATION
T
29
3SNCHUSE
This certifies that . . _16. . . . ... . . . . . .
�J
has permission for gas installation . ..t.�+�;:!v
in the buildings f
at , North Andover, Mass.
Fee. -r� Lic. Nq�� .2.7 S.1 . . . —. . . . . . .t. . . . . ,T .
GASINSPECTOR
WHITE:Applica RtZ;Rit�ANARY: Building Dept. PINK:Treasurer GOLD: File