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HomeMy WebLinkAboutMiscellaneous - 66 SPRING HILL ROAD 4/30/2018 66 SPRING HILL ROAD 210/107.A-0235-0000.0 I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU -ez This certifies that ...' Q......1 ......... has permission for gas installation P- in the buildings of.................LA ........................................................................ at......�D y..... ..............I North Andover, Mass. Fee....w....... Laic. No. .'72.,;1-15 ..................................................................... GASINSPECTOR Check# r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I I rsr'l A?-J0V,,1 -- MA DATE PERMIT# C JOBSITE ADDRESSI S�r,,.,5 NV � , 1OWNER'S NAME I GOWNERADDRESS SIP 5 I TEt 969•�'t(((•)7ta/ IFAXI TYPE OR OCCUPANCYTYPE COMMERCIALI EDUCATIONAL)_.' RESIDENTIACK PRINT CLEARLY NEW: ? RENOVATION:) .} REPLACEMENT:�<I PLANSSUBMITTED: YES) NO'54 CJ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER I CONVERSION BURNER l COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER I LABORATORY COCKS i MAKEUP AIR UNIT I (� OVEN POOL HEATER ROOM/SPACE HEATER -� ROOF TOP UNIT + _ TEST UNIT HEATER UNVENTED ROOM HEATER ! WATER HEATER OTHER I yes I,ri-e hbq INSURANCE COVERAGE I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I ' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ! OTHER TYPE INDEMNITY ) 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 I , AGENT I 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 best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance all Pertin(n rovlsion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t� PLUMBER-GASFITTER NAME I K.eo�,i Sri e.S LICENSE#I L3� SIGNATURE MPI MGF I JP JGF I LPGI) CORPORATION 1 #i !PARTNERSHIP) LLC I. #j COMPANY NAME:) Peq -L' r I P':ADDRESS I lq,,,6 S H* Sh e CITY ����(cs�c�- STATEIMA ZIPI Q(gyg ITELI 779=77L/-/6Z/ FAXgl,7)? Wj CELLI IEMAILI g�11 The Commonwealth of Massachusetts Department of IndustrialAccidents -- d 1 Congress Street,Suite 100 Boston,ALL 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual):_ A J E�•EP �/V(4� Address: rn11 1A 1 f Z" City/State/Zip: M t VOC L'T d N 1.4 6�- Phone#: Z U 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. F1 New construction 2. 1 am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.F1I am a homeowner doing all work myself.[No workers'comp.insurance required.]i 9. El Demolition ❑4.F1 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. 12Plumbing 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.instuance.1 6.F1We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.FJ Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is pioviding workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name:_(J/?(2(. Policy#or Self-ins.Lie.#: /�// $ 3 Q 4, 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 DIA for insurance coverage verification. I do hereby certify un the p ins and penalties ofperjury that the information provided above is true and correct. Signature: f Date: Phone#: f `I y- 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 v Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 t�f NEFPINC-01 LCARUSO A�ORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `--� 9/21/2015 THIS CtRTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Salem Five Insurance Services,LLC PHONE 781 933-3100 FAX 445 Main Street AIC No E:t:( ) A/c No:(781)933-9048 Woburn,MA 01801 E-MAIL-ADDRESS: -MAILADDRESS:insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Citizens Ins Co of America 31534 INSURED INSURER B:Allmerlca Financial NEFP Inc dba Yankee Fireplace&Grill City INSURER C:Hanover 22292 140 South Main St. INSURER D: Middleton,MA 01949 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE AI SD WVD POLICY NUMBER MM/DDIIYYYY MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR OBN8980442 12/31/2014 12/31/2015 DAMAGE F.REN PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F PRO-JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BIANY AUTO AWN8988013 12/31/2014 12/31/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X NON-OWNED PROPTY DAMAGE HIRED AUTOS AUTOS Per acciERdent $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE OBN8980442 12/31/2014 12/31/2015 AGGREGATE $ DED I X I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN C ANY PROPRIETOR/PARTNER/EXECUTIVE WHN8939903 01/05/2015 01/05/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Insurance Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i Commonwealth of Mas usetts y Division of Regist ati f Board of Plumb' �I t w - Kevin P 20 South 3 m r j O Bradford, 4 ti Joumeyma <<,u e� PL33257-J 05/01/2016 �M see 005879 License No. Expiration Date. Serial No. 8 Date..,. �.. .... >..... r10tiTIy ora TOWN OF NORTH ANDOVER PERMIT FOR WIRING �ss�c14U This certifies that ............. .................................................✓ %^.. — t- .... ............................... has permission to perform ....... .C� .lJ.< T ;f 5c wiring in the building of....... ......l e........ at ...... .&....... .:P.�.....n.�.......... ii ........I............ .................>North Andover,Mass. Fee....7..��/...............Lic.No. ................. ...... G'r'�+ .......... ELECTRICAL INSPECTOR Check# 6 S Z � � y J r, oe �J k t (� �,j`' ,,aa Official Use Only \ {.�ammon�area& a/l�[tsaacl ccda Permit No. �CJafaarllm�r aira eruzca� Occupancy and Fee Checked BOARD OF FIRE PREVENT ONREGULATIONS [Rev. 1/07] leave blank) d 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: August 10,2015 City or Town of: North Andover,MA_ 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) 66 Spring Hill Rd Owner or Tenant Buckley Barrett Telephone No. (909)844-1701 Owner's Address 66 Spring Hill Rd Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building- . .l t i o 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: _Installation of a low-voltage, wireless burglar alarm system. Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA_ No.of Luminaires Swimming Pool Above In- No.of Emergency Lighting nd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS o.of Zones No.of Switches No.of Gas Burners o.of Detection and _Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers eat Pumpumber ons W o.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers pace/Area Heating KW Local Municipal Other Connection No.of Dryers Security Systems:* Y eating Appliances KW No.of Devices or E uivalent No.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP relecommunications Wiring: 4 No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: $850.00 (When required by municipal policy.) Work to Start: August 10,2015 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND OTHER (Specify:) I certify,under the pains and penalties of perjury, that the information on is app ' ation is true and complete. FIRM NAM • Defendgr SScuritv Com n LIC.NO.:C 1355 Licensee: 7� Signature LIC.NO.: D 434 (If applicable, enter"exempt"in the license number line.) Bus.Tel.No.: 800-689-9554 Address: 3750 Priority Way S Drive, Suite 200 Indianapolis IN 46240 Alt.Tel.No.: 866-502-3559 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety "S"License: Lic.No. SSCO-001258 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 Telephone ERMIT FEE: $ Signature No. r 4b �r The Commonwealth of Massachusetts Depar•ttttent of lndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 tvluly.ntass.gov/dia Wol•l:ers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �licant Information Please Print Legibly n le (Business/Orgaization/Individual); Defender Security Company ress: 3750 Priority Way S Drive Suite 200 /State/Zip:Indianapolis, IN 46240 Phone #:800-68.9-9554 ou an employer? Check the appropriate box: Type of project(required): I am a employer with 3 4• ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time). have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.t S. ❑ We arc a corporation and its 10.* Electrical repairs or additions rcquirzd.] I 1 am a homeov✓ner doing all work right have exercised their 1 l.❑Plumbing repairs or additions right of exemption per MGL 12.[]Roof repairs myself. [No workers' comp. insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] -jplicant that checks box N I must also GII out the section below showing their workers'compensation policy information. owners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new afridavit indicating such. ciors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have ccs. L the sub-contractors have employees,they must provide their workers'comp.policy number. m employer that is providing workers'coarpensatiou insurancefor my employees. Below is the policy and job site nation. trice Company Name: MJ Insurance Inc _ r or Self-ins. Lic. r — TC2JuB1108L22613 E.kpiration Date: 10/7/�•r# 2_0 / : — ice Address: _ City/State/Zip: I� t���1\ l ��� �A�/ �i v> l�` �C t .h a copy of the workers' compe sation policy declaration page(showing the policy number and expiration date). -c to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a :o to S 1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a Fine to 5250.00 a day against tale violator. Be advised that a copy of this statement may be forwarded to the Office of cigations of the DIA for insurance coverage verification. 'iereby certify under the pains and penalties of perjury that the information provided above is true and correct, C tturc: Date ( 2' 8665023559 jclal use only. Do ti0t Write in dii i area,io be completed by city or town official. �I tv or Town: PermitJLicense 4- suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector Other ontact Person:-- Phone R: COMMONWEALTH OF MASSACHUSETTS CONTROL# BOARD OF ILECTR I C ANS IMPORTANT -`ISSUES THE F O L L QW I NG L I CENSE A If your license is lost,damaged or destroyed;is inaccurate;or VREGISTERED SYSTEM CONTRACTOR , ""' needs to be corrected,visit our web site at mass.gov/dpi for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. DEFENDER SECURITY CO / PROTECT Y STEPHEN C. EHRL),CH �w This license is subject to Massachusetts General Laws and .:SOUTH regulations.Your license is a privilege,and cannot be lent or 3750 PRIORITY WAY assigned to any person or entity under penalty of law.Keep this STE 200a license on'Vour person or posted as required by law and/or 1$111 ANAPOL I IN 46240-3815 regulations. 1355 C 07/3.1/16 38220 7 COMMONWEALTH.OF MASSACHUSETTS CONTROL# J �J J zi It: 1 787;1) t5 M. M a t BOARD OF IMPORTANT tLECTRICIANS r I SSUES­ THE FOLLOWING LICENSE If your license is lost,damaged or destroyed;is inaccurate;or A REG HSTERES SYSTEM TECHNICIXneeds to be corrected,visit our web site at mass.gov/dpl for N4, instructions to ensure the proper mailing of your Renewal Application and any other correspondence. . STEPHEN C EHRLICHts General Laws and This license is subject to Massachusetts regulations.Your license is a privilege,and cannot be lent or 369 CENTRAL RAL STREET. assigned to any person or entity under penalty of law.Keep this !Q&'k LU license on your person or posted as required by law and/or UNIT,9 regulations. OXBOROUGH MA 02035-2637 434B 0/31/116 45560 Employer: DEFENDER SECURITY COMPANY Ur SS(;0-001258 STEPHEN C EHRLICH 3750 PRIORITY WV S DR 9200 INDIANAPOLIS IN 46240 12/03/2016 For DPS Licensing information visit: www_Mass-Gov/DPs e NOTICE OF COMPLETION OF ELECTRICAL WORK Pursuant to M.G.L. c. 143, § 3L, Stephen Ehrlich hereby provides written notice to the inspector of wires that the electrical work outlined in the preceding permit application has been completed. s Date........ .................. NORTH Ot�..ao`•'�ti TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS� This certifies that " has permission to perform a -- ................ i wiring in the building of . .:�...................................................... ate'G ..... North Andover Mass. 77�[ Fee/`/O.............. Lic.N6 d� ..;....... %:- .. . ......... ....... ELECTRICALINSPECTOS Y Check # 6127 Commonwealth of Massachusetts Department of Fire Services )ccuraw ind Fk:Q Ch�:ckvd BOARD OF FIRE PREVENTION REGULATIONS [Rev. o ()i APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 11 -,ork to I'c ini.-A:.1 !(:Cc'--,I:I I,C�!.N I III III e PLL r II.N 1.1K()R TYPE ALL I.VoR.If ITW.V' Date: Ci h- 'Or Town of: No,l At fil",jo I-,C.,_ -SI.,mcd llj�cs lk,jicc k)t Iji.s Intention to J�el tiorill ille Jectrictil this��Pphcllkoll the uIldel 01 01,11CI Location(Street Sr Number)- ( Nvilier or Tenant Owner's address 44 /7/')/ P0 Is this permit in conjunction with a huilding permit? Yes ❑ Vo 0 (Check Appropriate Box) Purpose of Building Ltili(y Authorization No. Existing Service Amps Fr its Overhead 11 U n d g rd 1:1 No. of Meters New Service Amps Volts Overhead El UndgrdF_1 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical %kork: No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.ol TWA Transformers KNA No.of Luminaire Outlets No.of Hot Tubs Generators a0 KIVA No.of Luminaires Swimming Pool 'kbove E] in- F NO -o mergency ughting 2riid. Battery Uilits No.of Receptacle outlets 16 No.of Oil Burners I FIRE ALARNIS [No. ofTones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges 2 No.of Air Cond. ------�If"I ;' Ht Pump Number Fo Tons No.of Alerting Devices No. 4)f Waste Disposers eaTotals: I ns No.of Self-Contained Detection/ lerting Devices No. o(Dishwashers '2- SpaceiArea Heating KWL . . I eW F-1 Otherocal El Connection No. of Dirvers i Heating Appliances KWJecurify.S steins:* No. of Water 'No.of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No, Hydromassage Bathtubs No. of Vlotors; Total tip (-(Tic—communications Mring: OTHER: No.UfDevices ur Equk.AM 1 tiin;tt,:d V,ilue,J1 FILCtI'iCAI ',V��rk: Vk l.b oi k to ',tart: 0 -e-4) Fections to be I'U.ILICatCd in ac,a,rd;IIILC 44th EIEC Rule 11). and upon cuilipli.:tioll. C(.f_. ( ,,, tkc imlicr. I(., I-Lim, it tur Ihe v,;i-k wdti I .L.c fit. 111-' 1 .11-1 ;1:1.,% !1i:)Ifcd If � E Idr(.-ss: N kA IFR S I\Sl 14A"( F h%, ;,LW. ;3v 111% R: Irt: 'Ilat ill:: CC 1' 12 11 ,1), flli: 1*1.dLIiA.;II,. Date. ! . :p&. TOWN OF NORTH AN VER o PERMIT FOR PLUMBING 41 SA US This certifies that . . . . `.19.e . has permission to perform . . .>3 . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at . l`' (�.- -tel. � ,� . � . . . , North Andover, Mass. Fee--.- Lu. ,?, �L�*-� . . . . . . . �UMBING � CTOR Check 9 ���/� � ' f %® *i 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS r Date Building Location , Owners Name C_ e/� Permit# go,11 Amount / Type of Occupancy New ri Renovation �/ Replacement Plans Submitted Yes Q No ❑ FIXTURES Q z w a a o w a rx o Q z z a E"' A SLR a � FW MSW ISr.FLOOR M FLOOR 3M FLOOR 4IR FLO R 51H HDOR 61R FLOOR TIH MOOR 91H FLOOR a (Print or type) Check one: Certificate Installing Company Name c��7 ,., Corp 1 Address 6 � Partner. r4- Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the ty e surance coverage by checking the appropriate box: Liability insurance policy13 Other type of indemnity 11 11 ❑ 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 F1 Agent I hereby certify that all of the details and information 1 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 Plumbing Code andt7hapter 142 of the General Laws. By: y SignafurFur Title Type of Plumbing License &3S,Z City/Town tcense um er ­' Master ❑ Journeyman APPROVED(OFFICE USE ONLY LJ Date.. . .�s': .� . .. .. ORTH TOWN OF NOR, ANDOVER • . PERMIT FOR G S INSTALLATION . � - . SACMUSE�A This certifies that . . . .C..% . . . . . —� v " has permission for gas installation . . . 4 . . Q in the buildings of . . ' � -� �.� . . . . . . .. . . . . . . . . . . . . . . . . . . . at l�'l� . . . ,. . . . . .�t:. -* . . . .. North Andover, Mass. Fee ./.. Lic. , - .. . . . . . . . . GAS INOFE/C/ R Check# /19 v 5644 MASSACHUSETTS UNIFORM APPUCATON FOR PERN9r TO DO GAS F rFrING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations �� �,o�—:r� Q /,�i�( ��' • Permit# -:fb � Amount$� -L/7.��Z).Owner's Name New❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ v� f� U F � w � � W F � °• 04 � Q H Hz zz w w U o o Wz o a O `W.L' � z SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2 N D . F L O O R 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR ®u S, e (Print or type) n [/ / Check one: Certificate Installing Company Name Corp. :;address 3�Sn0�P �'' � Partner. a C O Business Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter ��r� �Yyob, f r INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked Yes,please indi a type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 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 13 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 undq Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 14 of the General Laws. B Signature of Licensed Plumber Or Gas Fitter Y n er c��S? 5 Title u City/Town El Gas Fitter 7-icense Nurn5er 0 Master APPROVED(OFFICE USE ONLY) �uneyman -//'7---SV L,ac,ation No. - Date NORT1y TOWN OF NORTH ANDOVER K y • i ; « Certificate of Occupancy $ �'s',^'•Eta' Building/Frame Permit Fee $ �ACNUS Foundation Permit Fee $ Other Permit Fee S5rf e.- $ TOTAL $ aLU Check # L ' Building Spector s e TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT&2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING It BUILDING PERMIT NUMBER- DATE ISSUED: SIGNATURE: Building Commissioner/IREeector of Buildings Date Z SECTION 1-SITE INFORMATION I 0 1.1 PropertyAddress: 1.2 Assessors Map and Parcel Nu Number WNu.ber 1.3 Zoning Information: 1.4 Property Dimensions: 14✓q Sid c1 ,q— Zoning District Pr os A Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of R Name(Print) Address for Service: y Signature V Telephone N 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Ap licable ❑ PWA 0 Licensed Construction Supervisor: 0 CJ aj �� License umber O Address 1✓ U/j,op Oe > Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number r Address Expiration Date �y Signature Telephone YI a 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. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check su a Ucable 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 f �^ Construction 3 Plumbing Building Permit fee te)x (b) zcor4 Mechanical HVAC 7�7 �- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER UTH RIZATION TO BE COMPLETED WHEN OWNERS AGEN ON ' qr APPLIES FOR BUILDING PERMIT �1'— -Xzl"" C 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. off' 0 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/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN s DIMENSIONS OF SILLS DIMENSIONS OF POSTS k� DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FELLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i t Driver's License 06-29-57 06-29-04 M 6'03"� Y D 267861218 Date of Birth Expires Sex Height Class Number CISSEL ��hiM � � ► PAUL C o €� W00p.c� No D� . .�+1� �►.> ,fir, Norfh Andover, M/� ,i►II6si;°„. � "gig NORT1y � Town ® _ E over - � •� -- ��r`•,. o� cocrn� ZY< lover, MISS., Oa oi3c72 / 7 ADQATED FPS\ t5 "♦ BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR ^� — / THIS CERTIFIES THAT. �.. �.. Z-.... ...p� 4.!C................................. .. Foundation has permission to ' ' on...... ?.... ......�.-�?rt ............... Rough .rNST L �.t�G� Chimney to be occupied as.................................................. ................. 15F. ...�...... .. ......... �..................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS _ ELECTRICAL INSPECTOR 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 Lathin or D Wall To Be Done 9 Dry FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Y SEE REVERSE SIDE Smoke Det. VAORTH 0 ® �_ ,. . over 0 o� CoCH,� 10 lover, Mass , n 7�ADRATED P? C7 7 S H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES ..... �TT�w,q,�7s°N� Foundation has permission to on ..... ............... Rough to be occupied as .. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS _ ELECTRICAL INSPECTOR 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. SEE REVERSE SIDE Smoke Det. NORTIy Town of E over v TTT Z �- T C COCMIC !� dover, Mass., Ja oA=W °RATED p? C7 S H E BOARD OF HEALTH Food/Kitchen PERMIT T Septic System /— BUILDING INSPECTOR / THIS CERTIFIES THAT. ( ..C�'.. t-.... ...p4 i.!G-... ...�T"s. w �. s�N Foundation has permission t0e voW...................................-- On ..... ....S��.l�c?.�--.f .� -....��t`%�............... Rough to be occupied as .NST .... . Chimney ...................................... . ... .................. .................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS _ ELECTRICAL INSPECTOR 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 NORT1y E ® ® _ over 0 o� �o��,�� y lover, Mass., ed o S=W ADRATE D ilk? C7 S H BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. ..C��.. Z-.... ...p� !6.........DwP?4e ��'S; w!q, 7 s'oN� Foundation has permission toerawl........................................ on...... ............... Rough to be occupied as .... ....... S'ti'STr4 -. Wcs� Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS _ ELECTRICAL INSPECTOR 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 s_ 14A,(=4 A,(=4 Street No. Smoke Det. SEE REVERSE SIDE 4 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1�1 BUILDING PERMIT NUMBER: DATE ISSUED: X T /7 0 A SIGNATURE: _ /L ! ov Building Commissioner/In ctor of Buildings Date SECTION I-SITE INFORMATION 1.1 Pr ttyyAddress: 1.2 Assessors Map and Parcel Nu er: opet � / 1 WP / U 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Rec rd �} ,L(C Name(Print) I �� 7 Address for Service Signature Telephone N 2.2 Owner of Record: Name Print Address for Service: z�q M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed•Construction Supervisor: Not Applicable ❑ <, y: _3!�% � Q Licensed Construction Supervisor: jr '1/ -) l,, f C) °,-,jt License Number -1- yF �.,s ; �� i Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone Date.,:- .......... ........ NORTH TOWN OF NORTH ANDOVER OF�.,,ao ,c 1ti0 3? PERMIT FOR GAS INSTALLATION O S F p I • �1SSAC,4u5ES4 This certifies that . . . . . . .:.: . . . . . . . . . . . . . . . .�. . . . . . . . . . .%. . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . .� . �. . . . . . . . . . . . . . . . . . . . . . . . . . . at .�. — �.r��r`-� �'�J (f. : �:. . . ,—North Andover, Mass. Fee. ". . . . . . Lic. No.. .'. . . . . . �:,. - ,r; . . . . . . . . . . GAS,INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MAP PARCEL a � a (r tW MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO :GASITTING A' (Type or print) Date A 3 It i'o.00 NORTH ANDOVER,MASSACHUSETTS Building Locations (a6, S P R w G N i t.L R D• Permit# Amount$ PAW— CIS561. Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ o o w d > w r GG7 F Z J d x W W ; O F t J rrA W d z d W mi d E' > m m Z O Z O d o w d oG d O O w O aG 3 0 �7 U a > G a H O 9UB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) k one: Certificate Installing Company Name /Yl A R K LEWIS PL U Y"t3:na G Cd Corp. c Address P.O- Boy, 4105, ❑ Partner. AUoov&A_ MA. 018io Business Telephone (q'8 (o 14 _ Ooq_3 Firm/Co. 04 3wassa. Name of Licensed Plumber or Gas Fitter MARK I-sw t s INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes ff No❑ If you have checked M,please indicate the type coverage by checking the appropriate box. Liability insurance policy 10Other type of indemnity 1:1Bond ❑ 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 C apter 142 of the General Laws. =q6466 91 By: Signature of Licensed Plumber Or Gas Fitter Title Plumber I 19 City/Town ❑ Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman