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Miscellaneous - 660 CHICKERING ROAD 4/30/2018
660 CHICKERING ROAD ? b 2101083.0-0003-0000.0 Date.......y:.. r10RTM °� "" '•��o TOWN OF NORTH ANDOVER jo* t PERMIT FOR WIRING CHU5��4 This certifies that ..... I...�J ............... .7`......................................................... has permission to perform ..3D# ��.... ........ .... ....Cw!. ..fi-.......................... wiring in the building of.........}M.e..b.�L., -s.......... .............. at .......(Ot ..L,...: � =f ......... A..... NorthAndover,Mass. Fee..�.2Lic.No. Jl ............ .......................'.Z �.................. ELECTRICAL INSPECTO. l� Check# © - Official Use /Only �\ l..o,nmonuealth o��//adeach.u�e� moi'/ Permit No. 13 2 eCJepartment o�.:tire�ervice� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) . APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ) 5 12.00 (PLEASE PRINT IN INK O T PELJVF0Rm4TIOA9 Date: 5 4City or Town of• a To the Inspector of Wires: By this application the under; ne gives np,,ti e of his or her i tention to perfo the electrical work described below. Location(Street&Number) 6 W U Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ 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: 3� ,- -�- �Jffcoe Completion o the followin table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA Generators KVA No.of Luminaire Outlets No.of Hot Tubs bove In- o.o mergency ig mg No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection an No.of Switches No.of Gas Burners initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices eat ump um...er ons KW o.o elf-Contained No.of Waste Disposers Totals: Detection/Alerti2 Devices Mumcipa Other No.of Dishwashers Space/Area Heating KW Local❑ Connection Heating Appliances KW Security Systems:* No.of Dryers g pp No.of Devices or E uivalent No.of atero.o o.o Data Wiring: Heaters KW Si ns Ballasts No.of Devices or E uivalent e ecommumcattons iring No.Hydromassage Bathtubs No.of Motors Total HP 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: (When required by municipal policy.)o Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of s e o the/� rmit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) � ,l�� I certify,under the pa' penalties of perjury,that the-information on this application is true and complete FIRM NA E: U G LIC.NO.: Signature na ture LIC.NO.: Licensee: � g 7 (If applicable ter "ezem " .n the 'cense number i .) Bus.Tel.No.: Address: ^jv Alt.Tel.No.: *Per M.G.L.c. 14 ,s.57-61,security w 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 rewired by law. By my sienature below,I hereby waive this requirement. I am the(check one)❑owner ❑owners agent. ' + Date... ?f-1-7-!`./... ...................... 4ORrs, TOWN OF NORTH ANDOVER �►; n PERMIT FOR WIRING tag 8`4ACHU5� This certifies that ................ v .................. has permission to perform .. n5,......... ; ..r.. -...................................... wiring in the building of.............►.!e....h)t�?-t.A/—",h..`,........ l�E at eLl�.�.rltel-�Kz.... �....................../EiCM .North Andover,Mas . U !r� Fee..�.Z. ....Lic. No. . .)...? .............. ............................r..:................ Ea INSPECTOR/ ,Check# � - commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] Geaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ),5 7 CMR 12.00 (PLEA SE PRINT IN INK OR TYPEALLINFORMATION) Date: L /7 City or Town of. NORTH ANDOVER To the Insp ctor of fres: By this application the undersigned gives notice of his or her intention to perfo the electrical work described below. Location(Street&Number) Leg CA �j &,1 Owner or TenantC 7 5 Telephone No. Owner's Address S Is this permit in conjunction with a building permit? Yes ❑ 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: Q i 544 ('2 J Completion of the ollowin table maybe waived by the Inspector o 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- ❑ No.of Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g 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. uivalentNo.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: — Ij� �f'�L t -e Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested ih accordance with MEC Rule 10,and upon completion. iE 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 sVapica he p rmit' uing office. CHECK ONE: INSURANCE tA do BOND ❑ OTHER ❑ (Specify:) X certify,under the pain a d p allies f perjury,that the information on flust on true and coripiEtE. FIRM NAME• V/ C c LIC.NO.: Licensee: Signature 117M LIC.NO.: (If applicable,enterr,, MPO"i a li nse member line. ! Bus.Tel.No.! Address: 9 G ,I q v J AW Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ M CTMALP RMTM. - _ E�ECT.�I[CA1G3[l��F�CTOJ�.-•.' .. ._ � � � -- I'asseit=L +'ailed--[ I ode-inspections required'($50.00)-L j inspectors'comweAts: - (X'usp ectore Signature-no bl itials) _ Pate rms—ea—[ ] v F'ailecl-j ] Re-Inspection required($50.00)•-[ Inspectors'co e spectors'Signa -)10' "tials) Pate 3.MOOR GROUND INUNCTION: passed--[ ] Failed—[ ?fie-inspection,required($50.00)-[ ] Inspectors'coznm.ents: (Inspectors},Signature•-no initials) Date A l i Cg:(,-Tri_0 NA fONS GR O Passed.—[ ) Failed--[ � �e-inspectionxequired($50.00)• [ ] hspectbrs'cornmoits: (Iuspectors'Rignature••bio Initials) Date r Passed—[ )FAiled--[ )- 'Re lusp ection reguirea($50.00)• [ j ► I'mpectors'coxaments: ` 01spectors'Signature no Initials) Date 1)0OR TAGS APX TO 13E FILLED ANDLEFT ON SITE IF THE AREA TO DE INSPECTED JB NOT ACCESSIBLE AND.A.SSE WSPECTION OF§50.0 0 IS TO BE CHARGED. - The Commonwealth of fffassachusetts - - Department of Xndustrigl Accidents Office of Invesfigaflons 600 Washington Street Boston,MA.02111 vmmass govldia W9rker$9 Compensation Insurance Affidavit:Builders/ContractorslEl Pctlic mb �x��u�elr A hcant Xnfoxmaixon Name,(Business/OrganizationlSndividual): .A.ddress: City/StatelZ, L Phone Are yo an employer?Check the appropriate box: 'Type of p ject(required): 4. ❑ I am a general contractor and I F 1, am a employer with J_time) 6.employees(full and/o .* have liiredthe sub-contractors artner listed on the attached sheet." 7. ❑Remodeling 2,El I am a sole proprietor or p These sub-contractors have 8. []Demolition ship an.d•have no employees workers'comp.insurance. ` working for me,in any capacity. P 9. ❑Building addition [No workers' comp.insurance 5. ❑We are,a corporation audits l�[ Electrical repairs or additions required.] officers have exercised their r A right of exemption por MGL 11.[(Plumbing.repairs or additions 3.❑ I am a homeowner doing all work c. 152,§l(4),and we have no 12.Q Roofrepairs myself.[No workers' comp. employees.pTo workers' insurancerequired.]" 1311 Other comp.insurance required.] Any applicant that checks box#1 mustalso fill outthe section below showing their workers'compensation policy information. 'Homeowners who submit this affidavit indicatmgthey ire doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that clzeckthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is pYovicling workers'cornpe�tsation insurance for any employees. Below is the policy and joh site infomation. Insurance Company Name% / D�yExpirationDate: l l Policy#or Ser-ins.Lic.#: n job Site Address: � .l ' . l� City/State/tip: Attach a copy of the workers'compensati01113011cy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.152 can lead to the,imposition of ermvnal 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 ofup to$250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Officer' f Investigations of the DIA for insurance coverage verification. Y'do lieYeby i d t ai s artcl penalties afperjury that the information provided above"`true rl correct. - Date: �/ ` Si ature• Phone 4: Offtcial use only. .Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbimglnspector 6.Other Contact Person: Thome 0: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation.for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,- express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two oxmore of the foregoing engaged in a joint enterprise,and including the legal repxesentatives of a-deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. Howaver 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 lobal He-ensing 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 tfie boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)along with theircertificate(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 LL C or LLP does have employees,apolicy is required. Be advised that this affidavit maybe.submitted to the Department of Industrial Accidents for confirmationof insurance coverage. Also be sure to sign and date the affidavit. he affidavit should be retumedto the city or town that the application for thepermit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or ifyou 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 0 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 ne cessary)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 b e provided to the applicant as pro of that a valid affidavit is on file for future p ermits or licenses. A new affidavit must be filled out each year.'Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)saidperson is NOTrequired 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 anal fax number: Tho GQ ozkweaxth ofMassachuse"tia Depajftent of MusWal A oddwta Off Ne Qf uvestxgWo 6QQ wat&a strut Boston, 02111 z- ` :1AS.F`B Revised 5-26-05 Fax#617-727-7749 wWW.M1Ma,gQV1di4 • Date OF N�RTh,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,s`SACHUS�t This certifies that ............. .[ 7T e!=.................................................................... has permission to perform .........:�.—Q. A...... eTz�r.7 wiring in the building of.......ktn(.. at .... GG'� �!7/llrGlli�C?.P............tt.<�........................ North Andover,Mass. .............. Fee„1 ZS�'p.......Lic.No. . . .�� � . .....-.....n.:.. ELECTRICAL INSPECTOR Check# r, Commonwealth of Massachusetts Official Use Only ` Permit No. Department of Fire Services ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ),5 7 CMR 12.00 (PLEASE PRINT INWK OR TYPE ALL INFORMATIOA9 Date: /� City or Town of: NORTH ANDOVER To the Inspec r of Wires: By this application the undersigned gives notice of his or her intention to nerforra the electrical work described below. Location(Street&Number) v �f i2 f►t Owner or Tenant c 4 cJ 174wt Telephone No. Owner's Address <'Qm"e Is this permit in conjunction ith a uilding permit? Yes ❑ No (Check Appropriate Box) Purpose of Building e5 Acy a/an I Utility Authorizatio}r 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: W)I'll Ang &L Pte Coley] 7— Completion of the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Cell: TranSusp.(Paddle)Fans s Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency ig ting No.of Luminaires Swimming Pool 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 Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW focal❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. ctrical Work: (When required by municipal policy.) Estimated Value of E� Work to Statt: Z 7 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO GE: Unless waived b .the owner,no permit for the performance of electrical work may issue unless the licensee provides proofof liability ins ce including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains and Penalties ofperjury,that the in rma�on this application is true and complete. do A FIRM NAME: .. �c> % LIC.NO.: Licensee: T h TU h,e Signature IIXf AP LIC.NO.: (If applicable, ter "exem t"in the license number 'n .) ' / AL Bus.Tel.No.: Address: i (,�C B✓L1 h N Alt.Tel.No.: ` *Per M.G.L c. 147,s.57-61,security won equines 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 P RwT FEE. The Commonwealth of:ZVIassachnsetts - Department of Inrlustrigl Accidents Office Of Investigations 600 Washington Sheet .Boston,MA 02111 www.massgov/clia Workers'Compensation Insurance Affidavit:BuildersfContractors/Electricians[Pliimbers Applieant-Wormatxon Please Print Legibly Name(B usiness/Organiization/Individual): y 1/�A �� 1 C Address: 5— 9 City/Staff do t I'M Phone Are 4 an employer?Check the appropriate box: Type of DrIaliect(required): 1. I am a employer with4. ❑ X am a general contractor and I 6, ew construction full � employeesand/or p -tinge) have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. El Remodeling ship and`have no.employees These sub-contractors have S. ❑Demolition working forme in any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance S. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised.their 3.El X am a homeowner doing all work right of exemption per MGL 11.[(Plumbing repairs or additions myself[No workers'comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurancerequixed.�? employees.[No workers' 13.❑Other ' comp.insurance required.] X.Any applicantthat checks box#1 mustalso fill out the section bel6w showingtheir workers'compensationpolicy information. I Homeowners who submitthis affidavit indicatingthey ate doing all worg and then hire outside contractors must submit anew affidavit indicating such. TContraaors that check this box must attached m additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees Bellow is the policy and job site infarmation. Insurance Company Name:. ` Policy#or Self ins.Lic.#: Expiration Date: rob Site Address: � 0 i29 City/State/Zip: Attach a copy of the workers'compensation-p ey declaration page(showing the policy number and expiration date). Failure to secure coverage as requnedunder Section 25A ofMGL o.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 fInvestigations of the DIA for insurance coverage verification. f do Hereby cerci der file 'ns and penalties of perjury tliat the information provided ab ve i true anti correct. - Signature: Da , Phone#: Official use oitly. .Do not write in this area,to be completed by city or town official. City or Towia: Permit/License# Issuing.Authority(circle one): 1.Board of Health 2.Building Department 3.CIWT. own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A Information and.Instructions Massachusetts General Taws 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 cr implied,oral or written." An employei is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo ox more of the foregoing engaged in a joint enterprise,and including the legal representatives of a:deceased employer,or the redeiver or trustee of an individual,partnership,association or other legal entity,employing employees. Iowever 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 employes." 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 produeed•acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have b con presented to the contracting authority." Applicants Pleasefll out the workers'compensation affidavit completely,by checking tfie boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)andphonenumber(s)alongwiththeircertificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the • members or partners,are notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,apolicyisrequired. Beadvised that this' affidavit may besubmitted tothe Department of Industrial Accidents for connrmation 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 theperni t 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*orkers' compensationpolicy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate he. City or Town Officials Please be sure that the affidavit is complete andprinted 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 necess ary)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-ii on file for fature permits or licenses. .A,new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone aid fax number: The Co onwealth off-amarhwetts - Dep fitment ofZxtdwWal.A,ccidonta 4�ce o�Tu���ti�atxox� ' 600 Was*&a ftoet Boston,MA 02111 T01 D 617-7.27,4.900 OA 406 Qx x-877-MA��A�� Revised 5-26-05 Fay,0 617"727'7749 WWW-Maagovaa, Date ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING I Io :P, 4rgo� If causs This certifies that ..............i? i-e eA0 ............... .................................. has permission to perform LL WC'*- /*, C**'*/*"**�'**'*'*'******"'**"**'*'**'***'*'*******"*"**'*'******, wiringin the building.....................—......................................................................................... at 66 o (1! 6, /0 " ��/ hAndover, . .. ....... .... ....;....... .../<fort Mass. Fee...{ .6 .......Lic. EL CTRICAL INSPECTOR Check# N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. I � 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(ME ),52Z CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspe orfWires: By this application the undersigned gives noticeof his er int ntion to perfo the electrical work described below. Location(Street&Number) j I `jl Owner or Tenant Telephone No. Owner's Address V Is this permit in conjunction with a building permit? Yes ❑ No V (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: , — L.-e,10 ..f:'l iP 4:es Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. 1:1 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 .................. 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 of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov age is in force,and has exhibited proof ofAsat)the enmt issuing office. CHECKONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) t'`j"J. I certify,sander the pain d penalties ofpe 'ury,that the 'nfornzaila,,on tltrs applicatton rs true and complet FIRM NAME: E ti°d h(C LIC.NO33 Licensee: STio let, jo w Signature LIC.NO.: (If applicable,en "e empt" - t lice"se number li .) Bus.Tel.No.• Address: S r Alt.Tel.No.: *Per M.G.L c. 147,s.57-61, ec surity work r quires epartment Public Safety"S"License: ,Lic.No.• OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,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 0 Failed ❑' 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($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass M ItFailed 0 Re-Inspection Required($.) ❑ Inspectors Com s: Inspectors ignature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Y • I ry The Commonwealth of Massachusetts _ Department of XndustrialAccule�ts office of.Tnvestigations 600 Washington Street Boston,MA 02111 www.massgov/iiia Workers'Compensation Insurance davit:Buil.ders/Cont°actors/Electr icians/Pliimbers A h Information Please Prim Le 'bZ Name(Businessiorgani'zatioa�lXndividual): �It� ► I (�G C yl Address: 1 - City/State/Z:ip: Phone#• Are y u an employer?Check t qui appropriate box: Type of project(re 1. I am.a employer with 4. ❑I am a general contractor and I 6. ❑New construction f employees(fulland/or p -time) h ve hired the sub-contractors 7. EJ 2.E1 I am.a sole proprietor or partner- listed on the attached sheet.T ship and'haveno.employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance, g, E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exereised.their 10.❑Electrical rep airs or additions am a homeowner doing all work right of exemption per MGL II.El Plumbing repairs or additions myself[No workers'comp. c.152,§1(4),and wehaveno 12.❑Roofrepairs insurance re employees.[No workers' �ired.a 13.❑Other comp.insurance required.] XAny applicantthat checks box41 must also fill outthe section below showingtheir workers'compensationpolicy information. T'Horneowners who submit this affidavit indicatingthey ke doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. f am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site infomation. insurance Company Name:. y f Policy/#or Self,ins.Lic.ff: DSD 1 OS,O Expiration.Date: Job Site Address: IL cif 14 City/State/Zip: k1d A" Attach a copy of the workers'contpensation-polley d14ration page(showing the policy number and expiration date). Failure to secure coverage as req A dander Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$7,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. X do hereby Certo e thean penalties ofperjury Mat the information provided ab a is;;andcorrect. - Si afore: Date: v Phone 0. Official use only. .Do not write in tliis 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 ContactFerson: 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 mother under any contract ofhire,- 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 employex,or time 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 employes." 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 fox any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been.presented to the contracting authority." Applicants Please 1111 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if aiecessary,supply sub-contractors)name(s),address(as)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other that the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Baadvised that thisaffidavit may besubmitted tothe Department of Industrial Accidents for conimation of insurance coverage. Also be sure to sign and date the affidavit: he 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 obtaia a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their sel-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete andprinted 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 thatmust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current PORGY information(ifnecessary)and under"rob Site Address"the applicant shouldwrite"all locations in (city or towu)"Acopy 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-ii on file for future Hermits 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 orpermit 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: Tho Co onwoalthofMom hv:&ettq - A-Tartmert offadustxial.AcddontE Moe of hwotzga-io n 600 WasiVon et Boston,MA 0211 X TO.#617-227-4900 W 406 or 1-877-M Revised 5-26-05 FaX 0 617-727-7749 WWW- us,gov1dia 5T-f#'NEN A JIM 11-f 555 SALE! S _ - NORTH .ANDOVER ,0 -31,99, _ I i Fold,Then Detach Along All Perforations; ;COMMONWEALT,H=OF:MAS�S1ECHl3S:ET� . BI kyl P-1 • • - • • ELECT li I C 1 ANS 1 SS11ES T1,{ FOLLOWING' f f;ENSE aS le V - . . 55 SACM S7 W J. U 3 10149 Date ... �. . . . . '-ON. TOWN OF NORTH ANDOVER to PERMIT FOR PLUMBING This certifies that . . . Gllto AA h,.'-? OG has permission to perform / �AS I s !' . . . ✓ S. . . S plumbing in the buildings of. .�,.?��- !1./.c .J. ��1 �- �• .P�L at . .6p(0©. . (_ 'L+ e l�t.+ !p . . . . . . . , North Andover, Mass., Fee ./0/7. . . . Lic. No. . . . ti PLUMBING INSPECTOR T Check# 1 S�3 9f/f x V." - yet°� 7Z7;t:L -e/'a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � hc CITY lap v MA. DATE - Y- PERMIT# 1 JOBSITE ADDRESS (,O OWNER'S NAME POWNER ADDRESS: ,t_ a t- TEL: _�a -tea FAX: TYPE OL OCCUPANCY TYPE: COMMERCIALID EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEAF LF NEW:❑ RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXUTRES 7 FLOORS- Bot 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS COIN DEVICE DEDICATEDSPECIAL WASTE SYS DEDICATED GASIOIUSAND SYS DEDICATEDGREASE SYSTEM DEDICATEDGRAY WATER SYS DEDICATEDWATER REUSE SYS DISHWASHER DRINKING F)UNTAIN FOOD WASTE GRINDER UNIT FLOOR/AREA DRAIN ILI INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY 1 ROOF DRAIN p- SHOWER STALL SERVICE/MDP SINK I TOILET URINAL WASHING MkCHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING S INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ ' 3 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND s 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 ❑ Ja SIGNATURE OF OWNER OR AGENT 6— 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 applicatio implian with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: I ROBERT M.DEMERS JR.- I LICENSE# 9737 IGNATURE COMPANY NAME: I APOLLO PLUMBING&HEATING INC. I ADDRESS:I 1 SHATTUCK ST.PO BOX 466 CITY: I LAWRENCE STATE: MA ZIP; 01842-0966 FAX: 978-683.5933___ _ TEL: 978-688-1755_ CELL: EMAIL: a olio lumbin comcast.net MASTER 0 JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# 3046 PARTNERSHIP❑#©LLC❑# � �,�OXO �� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES eam nos, /C9 (!3 Yes No :/:/T /-> THIS APPLICATION SERVES AS THE PERM ❑ ❑ FEE: I PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations kip I Congress Street,ISuite 100 Boston,MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Leidbly Name(Business/Organization/individual): l`'0He.4 ✓1/yG- Address: / _5Ah'1-rryC. 7- ,0 AoX 6 City/State/Zip: e.A)Ce. MA Phone#: ? 7 91-6 S 8-l'7 SS- Are you an employer?Check the appropriate box: Type of project(required): ❑er with 4 1. I am a employer I am a general contractor and I P Y * have hired the sub-contractors 6. E]New construction employees(full and/or part-time). - 2.❑ 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 workingfor me in an capacity. employees and have workers' X P h' 9. El Building addition. [No workers'comp.insurance comp.,insurance,t. 5_ e. e.�eorotatidals: 10.Q Electrical repairs or additions . required} __ _ _-_ -❑-W .. 3:❑ I am a homeowner domg'all work W officers have exercised their 11,Q Plumbing repairs or:additions myself.[No workers'comp: right of exemption per MGL 12.E]Roof repairs insurance required.]t c. 152,§1(4),.and we have no employees.:[No workers' 13.n:Other comp;insurance required.] 'Anyapplicant that checks box#1 must also:fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicatingthey 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 naive 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.policynumber. I am an employer that is providing workers'compensation insurance for.my employee& Below isthe policy and job site information. .InsuranceCompanyName: -e 'J4!J TFp1Lh Policy#or Self---ins.Lip.M 18W ec 3La7 Expiration Date: Job Site Address: 660 CJS i n.r n4 Q_CL City/State/Zip: !�. 4,)c10 ve, O t kt4 I- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$25000 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby cerci njer th-epains and enaldes ofp!!&M that the in ormation provided above is true and correct Si afore: Date 9 - Phone#: T79- 6 U—/7 -C- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License#. Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: !!' t; r �. ,il9• r. !rt s• it r4 y+✓, i�rr•irr j,:r•F1�1��/�± •j.,t:tl?G[{j�:±:,'-'•i.:.i jii'Sf+?;,i � .Y �'L j•i;��!�,�-1iK-�i 'ljRjr l/ctr�7jll�ti';��f 4F. q-3r'] � � '!'(i {lttlll7•:� Kl !�J��{ •{ 1#i'{ !•7.�' a Fts'•�Jti i'•r!s trrt' J'(j'j Y 'Ift1E r t �� f �! -fy r t. tl l! / � (1 � r ((�E t�i tr =(k••�{: 7.�� t ({r lt�f�:•'i!!i`� �y+c�{ � \���{tt s uY• 7 { •�t i1 ' ( � { {i j j � ! f{(1 f �i ri �e!t: .{' 1 , , , .i�r a{' -l s ,, y 5�'ltint. } j�\ �,`\1\ s'i����• i � �.t.� �' s, •t t s t ( ����� i i ��• � i t L` ., ti s 1.71S�y }y� s �� �1711]E�1 t ! 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F+�: t3� r �SE� 1 .�.':i_�!!• � � it • • .1 lE �`r `�t��)!i�!.�.[i{;•r�i•! !'�jit ..y t •,?, .�- !}�r�-•q' ., • • t �llFf'j j��,j� -�r.r •,=it;1 1, ,�{y;•`4�14, �! tt tit��� i 't • r r � t� t' �,�;���111`ty, t�(,,;111ilry� • 1•< s i�s•� ` •� L � •w,' 1 �\� t�.\'ck=s`t""11,.t�till�•3ltte E � � ,,,F�-�rty��� 1� R�Si� '��1 - ',E , • ``�.i�+ c�1��71>�.,,'.t.1` �A*.9t�li,��t'.,t•Vly-{}�_ 1= �, E j�yt:'"�jy i 4 �1' 1�7 j r t• , �t�ktg!i t ,'� ,7'^f',1{s1•^'tsi`t'.,'7tii M u. jj1 i t t•!j r, U,t{{.,,t! •�.n:l, r{s,•rj.<:,_, ,t :t/$L i:1;ti !•j+ .tl.• f tl.'. '�:lt j .�a'.7;:� �,'s:r;t.yr,.. ,; :Ir- :lc::l,.�{;.r,•{r.{r: .;.rFl:; .jt,4r:t t ,. �.-r j. i £i/rW i� "tar ;:;1 f-r,' ,.;, - ) •r;(.• !..f.syls.,. :1,..::•:i.• .. 1.1vEw. tr�,a�.. .,.. U#tj..,.ir'r,-.r•{; �,:...,��.. Town of North Andover r AORTil OFFICE OF ?o ``t. "..+ o 3 c COMMUNITY DEVELOPMENT AND SERVICES AO 40r 27 Charles Street North Andover, Massachusetts 018455 �9` �o• �` o r pp,� WILLIAM J. SCOTT SSACHUS� Director (978)688-9531 Fax (978)688-9542 May 3, 1999 Mr. Charles Lietz McDonald's Restaurant 660 Chickering Road North Andover, MA 01845 Dear Mr. Lietz: Please be advised that a complaint was received by the North Andover Health Department concerning your establishment and the outside trash disposal. The complainant stated that the parking and lot line areas consistently accumulate trash, which then blows into the neighboring lots. An inspection was performed on Thursday, April 29, 1999 by authorized personnel. See the attached inspection form for details. The dumpster area must be maintained free of garbage and the broken lids must be replaced so that the dumpster can be closed at all times. In addition, as we enter the warm weather seasons, increased monitoring of all trash areas should be addressed. Correction of all violations to the Dumpster Regulations must be completed by May 14, 1999. A re-inspection will be conducted at that time. Thank you for your cooperation in this matter. If you have any questions please do not hesitate to call the Health Department at 688-9540. Sincerely,, ousan Ford Health Inspector BOARD OF.APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover f NORT4 OFFICE OF 3� " '°1�00 COMMUNITY DEVELOPMENT AND SERVICES 13 t y 30 School Street = o North Andover. Massachusetts 01845 W LL.IAM J. SCOTT 9S3ACHUSE�( Director Establishment: Address: Telephone: `7 2 L7 Date Person Sroken With: Owner: : ,- /zf < _1- / �, On this day an inspection was made of your waste receptacle area. Your waste receptacle area was found clean dirty and the cover of your waste receptacle was found in good repair _ in poor repair and kept closed not kept closed. Other Comments : aa f ill 410 . 600 Storage of Garbage and Rubbish - Garbage/Rubbish shall be stored in watertight receptacles with tight-fitting covers . Said receptacles and covers shall be of metal or other durable, rodent-proof material . 410 . 601 Collection of Garbage and Rubbish - The owner cf any dwelling shall be responsible for the final collection or ultimate disposal or incineration cf garbage and rubbish by means cf a regular collection system approved by the Board of Health. 410 . 602 Maintenance of areas free from Garbage and Rubbish (A) - The owner of any parcel of land, vacant or otherwise, shall be responsible for maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish or other refuse. The owner of such parcel of land shall correct any condition caused by or on such parcel or its appurtenance which affects the health or safety, and well-being of the occupants of and dwelling or of the general public. Person in C:^ar;e _ SD.ector e NORrM TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUSE� This certifies that .................�!..G � -7— ........................................ has permission to perform .........L. 9 e-IT...�G{L. .. ................................ wiring in the building of..... C. I9.W?V AS... l..!. at......0^.. .. ?'/��rE �,�f�! ..... ............... .North Andover,Mass. Fee./.7r Lic.NoA. 4. ?.3............. . . . . .. ,!may... ..... ELECTRICAL INSPECTO_R �• Check # r G,* / 3 Date. �a.... ...... ..C.:......... NORTH °t<�`'°:•�"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSACMUSE� This certifies that ✓v .4...... .r.................................................. has permission to perform .. 1 r� ....................................................................... wiring in the building of. _ :..... . ��u.:���../ .. .......................... at...S �.......N�lip „ / ....... ,North Andover,Mass. Fee................b.. Lic.No..,� 9 v tl33............�..f......�r � ......... �yELEMICAL I PECrOR Check # s THFCOAMONWEALTf OFAlA,S,SACHUSETTS Office Use only DEPARINIEfirl'0FPUBL7CS4FL7Y Permit No. _4I.A 9 BOARDOFFIRMPREVEMONRWULAHONS527CMR12.-00 Occupancy&Fes Checked APPLICA77ONFOR PERMIT TO PERF0RAT ELECIRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 AL,61:5_(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) CA 1G Owner or Tenant �. S Owner's Address Is this permit in conjunction with uildin ermit: Yes m No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. ofMeters Volts Overhead Underground No. of New Service Amps / r�— 0 Number of Feeders and Ampacity �. -- Location and Nature of Proposed Electrical Work 2r% yi� 25e No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground round No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Sw,tch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total r� FIRE ALARMS No.of Zones Tons J Vo.of D1<sposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices — Io.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices `o.of Dryers Heating Devices KW Local Municipal Other o. of Water Heaters KW No.of No.of Connections Signs Bailasis �.Hydro Massage Tubs No.of Motors Total HP HER MX(e veraga Ptus O tIDdr1egA=)ff of Ma%adusetls C*ned UM acurTtLiabhtyhm anx%lwyurixiingC MonsCorwdgeoritssubstaryi epvaiffit YES NO �. ;subinit>edvalidproofof totheOffice YES �� /� F) hawcheckEd YES, irdcaiethetypeofcovt�by RANGE BOND LO'II3tCJ ���AW Fx�erdtionDa� /,q,- bqYY1irinT)r�RPq)esJDd Rcut EShrrl*dVahredB"1calW01k$ �sratt iunderMiel�es pecjtay "� Farb NAMELNee l l Li�No. �ht,, Z1 JSignature IioffwNo &>simmni No. I C )'VA�71Alt Tel No. f R'S INSURANCE WAIVER,lam awmdiat&16AwdoesnothavethCManrcecOvaageoritsabstantuleqwvaiErtasognedbyNL%Swhmzc-cneralLaws my signako on this petit application waives this roclumnent. check one) Owner Agent Telephone No. PERMIT FEE Signature ot UWner or Agent - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job_ Company name: Address City. Phone# Insurance.Co. Poli .# Company name: s Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposWm of criminal penalties of.a fine up to$1,5oo.00 andfor one years'imprisonment_as well-as_ciyg j enalties jn tbolam-faSTOP.VAM aRDF.R.and_a.fine_f.(a11t0.0A)_arlay againsf.m-_ I understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification. l do hereby eerily under Me pains and penalties ofperjury that the information provided above is drue and coned. Signature Date Print name phpne.# 1 Official use only do not write in this area to be completed by city or town officiar t City or Town Permit/Licensing El Building Dept El Check if immediate response is required E] Licensing Board F1 Selectman's Office Contact person: Phone#: 0 Health Department F, Other Permit No. _ 97 7C2 Department of Fire Services - Occupancy and Fee Checked - , BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] --�- - (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5)2 CIOR 12.00 (PLE•;ASE PRINTININK OR TYPE,AL.LIN 0 ATION) Date:_ City or Town of: _ Al/0To the Inspe to of Wires.- By %fires:By this application the undersigned gives notice of his or her rote tion to perform the electrical work described below. Location (Street &Number) Owner or Tenant M_C10 - Telephone No. - -- Owner's Address 0,hoC K A.I& ?� Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 1UV"V-Y/ Utility Authorization No. Existing Service Amps / _Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps t Volts Overhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1 yJ - Completion of the folio wing table may be waived by the Inspecto_r_of YY'ir�s. No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of 'Total 1 Transformers KVA ; No. of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o. o mer enc m --`--- - No. of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units _y Lighting No. of Receptacle Outlets No. of Oil Burners FIRE ALARMSo. of Zones No. of Switches No.of Gas Burners No. of Detection and _ Initiating-Devices No. of Ranges No.of Air Cond. Tonsl No. of Alerting Devices Meat Pump Number Tons KW No. of Self-Contained --- — ,I No. of Waste Disposers a Totals: ........... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other u _ Connection _ No. of Dryers Heating Appliances — KW Security Systems:* No.of Devices or Equivalent No. of Water KW No.of No. of Data Wiring: _ j Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent __ OTIIER: - ------ _- Attach additional detail if desired, or as required by the Inspector of]Vires. F'stimated Value of Electrical Work: '' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove;rx6 is in force, and has exhibited proof of same to the permit issuin office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) �, 9p✓ /Z j 0p I certify, under the p-a-in-s-and penalties o petjur that a information on thislipp (tion is true tuitl mplete. FIRM NAME: \/u �/�l� — LTC. 3j Licensee: S lh-eyl --jL,-'IDA Signature _ LIC.NO.: (If applicable, enter "exe t"in the license tium me.) Bus.Tel. Address: t �C do dAAlt.Tel.No.: *Security System Contractor License r&Juired for this work; if applicable, enter the license member here: 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 agre.r,t. Owner/Agent PERMIT FEF_: 3 Signature Telephone No. I -_____Jr �'�z 'Z- y -- ___� /J� _ _ F 0 19 6 Date...... '".arm... .. 4, TOWN OF NORTH ANDOVER PERMIT FOR WIRING S C14us ru 5............`G�.T�/cL 6V P This certifies that ..........................�� � .............................. c c). /77- has permission to perform ........... Me,, Do wiring in the building of.............................. ...... at.......6.60 )v 6 lel .... .. ...................................... . . ....... .yNorth Andover,mass, Fee.... Lic.NoA�S.3?.,1y............... .......................... ......... ELECTRICAL LEc icAL INSPECTOR Check # 3Z 11 11:1ya Jim(;onion 9789572389 p.1 errlACiut3Er6 official Useonly Ocmpancy and BOARD OF FIRE PREVENTION REGULATIONS Fee Ch • � � cave black APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK M work to be perfumed in mcordmcc With the Massa&=11 s Elecfricai Cods(MEC),52? 12-00 (PLE"PPXffffRff 0R. EALL ORMATIO,V Dste: --1 .1 1 City-or Town of: �^�� - To the Inspector of Wires: By this application thexndersigaed groes of his her interrtionto r�mf the electricalworkdescribed below. PA Location(Street& ��� (�C,/ r ' Owner or Tenant a-. Telephone Na - � Owner's Addt�ess - - Iv this permit in conjunction with a building rmit3 Yes ❑ No (Che&Appropriate Boz) Purpose of Utility Aa dilation Na Es sting Service Amps / volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Dolts Overhead❑ IInttgrd❑ Na of meters Number of Feeders and AmpaMy ` Location and Nature of Freposed Electrical Work:. Lighting Retrofit Comkdon oofW i table be waiwd by the r of Wires. No.of Recessed Lwmiasfnes Na.of Cad,-Sasp.(Paddle)Fans No.ofTotal Transformers KVA No.of Luminaire Outlets Na o€Hot Tabs Generallors - KVA No.of Luminaires ;r,g p0,d ❑ grnd ❑ t>:o ergency Lagliting Barite Units No.of Receptacle Outlets Na of Ort Burners FERE ALARMS No.ofZoaes No.of Switches Na of teras Burners . No.If Detection mtia Devices No.of Ranges No.of Air Coad. Tons No.of Alerting Devices No.of Waste Disposers T T� a of Self-Coitsined Detectioo/Alertin DevitSes Na ofDishvashers Spae dArea Heating KW Menicipal Conntx4ioa ❑ Other " No.of Dryers Resting Apptisae:es KW security S34ft-sm—Z Na ofDev.ces or aivalent a o Heaters KW rterlqo.S-� �� Data Wiring: No.of Devices or Fauhraient No.Hydromassage Bathtubs No of Motors Total im TdeoonumtioNaofftvicesn i =- ' t OTHER: Agar*addi iiwW&Aad ifdesire4 or ar requW by tare inspector of Wires Estimawd value of Ekxniesl Wal11 2.3 (When regfrved by mvimcq al policy) work to Start: 7%8=// Inspeefi=m be requested in accoraanm with UMC Rale Io,and upon complexion: INSURANCE COVERAGE: Unlew waived by the owner,no permit for the performaocx of electrical work my issue unless the licensee provides proof of fiability insmauoo nw4udwg"co�mPlewd operation"eu veraW or its sul�tial equwwe&- Tae undersigned oerlifies that such is is force,and bas exhibited proof of seine to fie permit issuing offim CHECK ONE INSURANCE L'T DOND ❑ oriffiR I cerftfy,tnrder the pains aad pmaUies ofperjrny,that the igfvnnation on t&is aP1FTicmtan is trrie mrd co pleie FUM NAME: Focus Electrical Corp. LIC-N©.. A153 94 Licensee: James M. Conlon Signatu _f-7C,Np; E33632 (If applecabk enter'-wwPP'n,floe/iaenm moaber Ue.) - s 62 irA Va 1 A Bns.TeLNo.:978-957- -� Addre89 � yDr�ve. B ar-„r p g2� A1tTel No.:9R-12S-1 901 *Per UQ c-147,s`57-61,security wodc requires Depatrmneut ofPublic Safelty"+License: Lia No. OWNER'S INSURANCE WAIVER I am aware fiat the Licmw does riot have the liability r oe coverage nomfally required by law. By my sigoam below,I hely waive this regtth=exrt I am the(check one13owner ❑owner's ant Owner/Agent Signature TdephoaeNo.978-957-2389 PEJLWTTFEF,-$ I Date.................................. NORTF, °�<"`° '•1"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING . N s' r ��Ss�cwUSE� This certifies thatR e.... :.Y.......:.......................................................... has permission to perform - ................ ........... ^........................ ....... ...... wiring in the building of............`........................`.............................................. at................................................. ...... ,North Andover,Mass. Fee.. ., .. ........`.. Lic.No!'.. r?................. .......... \`. ELEcrRICALINSPECTOR � v Check # .f , Commonwealth of MassachusettsIM�g Ci Official Use Only Department of Fire Services Permit No. �VjOccupancy 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(MFC), 27 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: /fl" City or Town of. NORTH ANDOVER To the Ins ector of Wires: By this application the undersigned gives notice of/ s�,;her' tention to perfo a electrical work described below. Location(Street&Number) i v e'4i rnk Owner or Tenant ffic ;TA41-n T-T one No. Owner's Address a L' - Ae, Ti Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boz) 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: Completion of the ollowin table may be waived by the InIpector 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 _End. 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 g No.of Waste Disposers Heat Pump Number Tons KW o.of Self-Contained Totals: .. . ...... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ElOther Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: a No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: ` (When required by municipal policy.) Work to Start: (_` Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability i J ce including"completed operation"coverage or its substantial equivalent The g q undersigned certifies that such cove is in force,and has exhibited proof of s to the mut issuing office. CHECK ONE: INSURANCE BOND El OTHER ❑ (Specify:) ���' � I certify,under the pains andpenalties of erju that the in ormA iogn on this application is true and complete.,�j FIRM NAME: LIC.NO.: Licensee: �' ' Signature LIC.NO.:" (If applicable, eq1e�_ emp "e the li nse number liny.? Bus.Tel.No.:1 Address: S U 32 1,")v V"E✓ Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work rekluires 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 age t. Owner/Agent Signature Telephone No. PERMIT FEE: $ S"r'3 & Official Use Only -� Commonwealth of Massachusetts Department of Fire Services Permit No. q� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Ins ector of Wires: By this application the undersigned gives notice ois r her intention to pea electrical work described below. Location(Street&Number) �a t�L f 6 it eA) rfo Owner or Tenant Iff M TA1-4 T T one No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ 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: kJ Completion of the ollowin table may be waived by the I ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and —Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g 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:31 No.of Water No.of Devices or Equivalent KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: L----"' 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 i rance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove is in force,and has exhibited proof of sato the rmit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) //4P( I certify,under thepains and enttalties of erju that the in orm�ttio.;t on this application is true and complete FIRM NAME: t/b I LIC.NO.: � Licensee: Signature LIC.NO.: (If applicable, ent emphj�V"t the li .nse number lin //]]�� Bus.Tel.No.:1 s)-t Address: w U n &"D A Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work retluires Department oTPublic 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 age tt Owner/Agent Signature Telephone No. PERMIT FEE: $ r NORTH Town of 0 dover No. 0 C L CO - dover, Mass.,— J/ ORATED ?� BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT.... ...... 4) d7 kh BUILDING INSPECTOR Foundation ........... . k has permission to 9".j4d.?Ift 00 1)�UMigs on ...... A1.00%puA..........C..... .. .. ..... .....a................. Rough OK to be occupied as..... .... ........W........ ......... 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 , # K Re to &14 PERMIT EXPIRES IN 6 MONTHS Final 1 .10 UNLESS CONSTRUJ4C_Tn1 N S ELECTRICAL INSPECTOR Rough . ..... . .. ....... ..................... . ........ ...... ... . ... .. ... .............. Service BUILD G INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. L 1 0 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING f ype or print) Date 19 / NORTH ANDOVER, MASSACHUSETTS 2 Building Locations G��O �RL//C.�l.�'i y6-- Permit# 2/5 v Amount S Owner's Name A'C� A< New❑ Renovations Replacement ❑ Plans Submitted ❑ w x w W Cn N Z z C w N C C C zcn w C L = m T_ U zz ^ z SUB -aAsENt ENT BASEMENT 1sT. FLOOR 2N D . FLOG R 3RD . FLOOR 4 T H . F L O O R 5TH . FLOOR 6T 11 . FLOOR 7T 11 . F L O O R LLLL FLOOR (Print or type) Check one: Certificate Installing Company Name ;Z /Iy z. CIO IniG ❑ Corp. Address 0-7— ❑ Partner. C 9 Business Telephoney,�� •/�Q . O ,,*/ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one- 1 have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked ves,ple e i cate the type coverage by checking the appropriate box. Liability insurance policyOther tvpe of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Aizent 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 as Co e and 9hapter 14') of e General Laps. Bv: ature of Licensed Plumber Or Gas Fitter Title Plumber �D��� City/Town Gas Fitter (cense Nurnoer aster APPROVED(OFFICE USE ONLY) urneyman Date.'-.•?5!:. 5:5s i 4144 i Ho°TN 1'tip TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �Ss�cHUSE� This certifies that ✓ . U L.l�. . . .�� .�?. . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . J4/. - . P !. at. . . .,,North Andover, Mass. Fee. S. ' . .Lic. No.. S . . . . . . �`-. . . t_�-C �� .•. . . . . . . (f PLUMBING INSPECTOR @ 9�9 tis ✓ %w PIIS;` WHITE: Applicants CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) s��N. A;y [ovP� Mass. Date 9-a i 191 Permit #_&Z` L r Building Location- Aa_22,V,4 d� r�� � — Owner's Name a , > d Q CN r r Yr�z 1•v �od Type of Occupancy New ❑ Renovation ❑ Replacement ® Plans Submitted: Yes ❑ ❑ i FIXTURES B.P. # SEWER # SEPTIC # �50 z rn z a' z z w 3 z � aw. � _ � z Z � aD a. oy W F- y t- U w y a. Z ? MPQ V Z it Co rn W } H _z ° u, Zo o CL O iz °C w0 cc w 3 0 ° i 3 J `� Q Y ° c U cc Q w u. w P PRCE 3 x m ai o o g 3 = n i. o a 3 g i o r SUB-BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR LL Installing Company Name APo,C.Co P ` �TT� 11yL Check one: Certificate # Address I ���7Tvc ST .U. 80 X y6 6 CO Corporation !D 57 L k ig L4-,0- VLP_ '277,1, 01kya —096 G ❑ Partnership Business Telephone (77h) &89"/7SS ❑ Firm/Co. Name of Licensed Plumber 1 WALb NS/'VISSCAUx INSURANCE COVERAGE: I-have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes (X No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy. 0 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and Installation performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Signature of Licensed Plumber Title Type of License: Master V,�' Journeyman C] City/Town License Number 6 q q APPROVED (OFFICE USE ONLY) sa ' BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR R�v I Building Permit Number 35 Date November 28, 1983 THIS CERTIFIES THAT THE BUILDING LOCATED ON Lot B Chickerin Road IN ACCORDANCE MAY BE OCCUPIED AS WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO McDonald's .Corp. Westwood Ma. ADDRESS 420 Providence Highway. 0 o s i '• :: Building Inspector ;,SSACHUS* PERMIT-VO. L. �) APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PACE I ' MAP NO. LOT NO. 12 RECORD OF OWNERSHIP DATE (BOOK PAGE SUB DIV ( ZONE I . LOT NO. I -- LOCATION PURPOSE OF BUILDING jCl � � a&( i n AA OWNER'S NAME .7 G �,, r ,fir` (\ NO. OF STORIES X11 SIZE OWNER'S ADDRESS r BASEMENT OR SLAB ARCHITECT'S NAME vG p- SIZE OF FLOOR TIMBERS IST-Er 2ND 3RD A/L BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET (� POSTS 1f !I DISTANCE FROM LOT LINES—SIDES(9Gr�. / ((f REARj2 GIRDERS f q AREA OF LOT ��h; a. —3 �a FRONTAGE //�- CI. HEIGHT OF FOUNDATION THICKNESS f 7 J f !I IS BUILDING NEW SIZE OF FOOTING X (! ,. IS BUILDING ADDITION MATERIAL OF CHIMNEY - IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND Cr WILL BUILDING CONFORM TO REQUIREMENTS OF CODE .7 IS BUILDING CONNECTED TO TOWN WATER may/ • BOARD OF APPEALc er•r,^�• •- - ,+ F �� IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE ,y4. Frederic P. York 3 PROPERTY INFORMATION _ Construction Engineer LAND COST MCD�Onald IS EST. BLDG. COST �{ ®� EST. BLDG. COST PER SQ. FT. McDonald's Corporation EST. BLDG. COST PER ROOM 420 Providence Highway Westwood, Massachusetts 02090 SEPTIC PERMIT NO. " 617/329-1450 4 APPROVED BY • EGULATIONS vrrvG'I NSPECTOR ' BOARD OF HEALTH SIGNATURE OF O NER OR AUTHORIZED AGENT F E E 'A-90 C-0— U•1 O PERMIT BOARD GRANTED 19 BOARD OF SEL ECTMEN BUILDING IN P CTOR �- /4-f�...�" o'MOICt--IARD P. k A►✓11NSILI ArJD ASSOCIA�"ES,I�C, l - q��/� tiI o �-r E-I ,4 ►�D o v E=2. M,c�. / l4 i rt II � v N If f i Q i I t Do ZTO .00 ' P;ZOPEr-TY LINE A,FID ST 2E ET LINE OF+=SI=TS ' P�.EPd�ED1=01z:1JIL�32.GEAU Co►.tsT.CO• S►-tCwN ONTF-{ISPL.[�N l�rzE. SREcI�EGa.LL`f �o�T►��, D�TE2M1►1 d-rlonl Or- Z01 IMG I?EQUIZEM>r►3TS C>tJLY. r oN: Lo-r6 WrsL� Fg 2!7� 4r,> D4,TE: � `� � zle LOT _ONa, PLAN i5Y1-� o�-fRleEX Gout.rTY �� Q. �st. , S�_� '' ,�sSrio I� CTD irlg1 ;(�j c�ch(oJ 17CF�9 For�r.1faf 1� 7c-010vl-A�JScFTH� �671JLI nr,t{,-'ri� �Jho/r;Il_ r+1n A-S , PLOT P \_&W 0;: LAND Q1Ct-IARp P. kAMIN51L1 At-�D ASSOCIAI�S,I C, f W O 2TN Q►JDO�/E2. MA. i �o * Ott c� Jil he N eo t` t N 00 ON � v - v�/o���t� �2odo PRoPEfZTY LING Q►�o ST2EET LINE OFFS>=TS PZEPo�D FQ� Co►.isT•�' DETE2MIAlAT110T�1 OF ZONING �EQUIK EMENTS Ort YHF LoT � Wa�►�-�� 2n. l_OGATIO N:_ r oMa ., � DAVID 7l /�1.1 QE FEr-ENGE: s cgg m\, 6EIr.1G Lo-r'_ON A PLAN 15Y o Np. 7 r, !S4 sCLe—ImC-. �a 1a�� c��n��T►����►��I�i�IIl.Giaesl�o�1, l�.-rED: 7 ( l�ND IZECOFZ DED 11.1 DsTE���. p�1Tl�IsPLq�1 �sLocq Eoo�1Tl��G1►1D GG CS$F-X Cour.�-rY p' February e�r 1933 Mr. Frederic F. York MdDoxuildte Corporation 420 Providence Highway Wastuoodt MI. 02090 Pae: McDonald's Restaurant, Chickering Roads North Andover Dear Sirs The mended plans for the facility described above have been received aa3d appr ovadt with the corrections, as notod bolow, by this department as of this date. These amended plans replace the original na.l plans filled with Building Verrait zt35 and are made a Part of this application. Corrections to plans 1. Sig -age is limited to the ground si&m and the roof sign as shot* along writh dirsctionsl si . No additional logos or advertising signs will bs allowed. 2. The roof of a�o building must be covered with wood shakes and the thermopane uird=3 must have grills to ,give the appearance of smaa panes of glass (condition #9 of the North Andover Licensing Commission). Very truly yours, CUR-ILS if, Fos%T INz3?L PCR OF BDILDIMS CHF»af Copy to Board of Selectmen OFFICE OF LICENSING COMMISSIONERS NORTH ANDOVER, MASSACHUSETTS July 12 , 1982 . McDONALD ' S CORPORATION COMMON VICTUALER LICENSE At their meeting on July 12 , 1982 , the North Andover Licensing Commiss- ioners took the following action on the application of McDonald ' s Corp- oration for a Common Victualer license : VOTED : To ensure clarity and precision with respect to terms and conditionE imposed on the common victualer ' s license to be granted to McDonald ' Corporation , all prior votes of the Board are hereby rescinded , and in place thereof the following is substituted : That a common victualer ' s license be granted to McDonald ' s Corpora- tion for use on the site located on Chickering Road , at the corner of Walker Road , as shown on the Site Plan as filed with the Board of Selectmen ( entitled "Site Plan , McDonald ' s Corp . , Chickering Roac North Andover , Mass . " ) , in accordance with the provisions of Ch . 140 of the General Laws of the Commonwealth of Massachusetts , subject tc the following terms and conditions : `t 1 . That on the northerly boundary of the site ( facing Meadowview Apartments and on the easterly boundary of the site , a six foot stockade-type fence wil be constructed by McDonald ' s . On the westerly boundary of the site (facing Walker Road ) , a split rail type of fence will be constructed by McDonald ' s . 2 . That the curb cuts on Chickering Road and the corner at Walker Road will be as approved by the Massachusetts Department of Public Works . 3 . That McDonald ' s provide adequate trash containers on the site and a dais litter pickup within 300 yards of the premises in all directions , including the high school grounds and the adjacent brook , provided permission is given to McDonald ' s by the property owners to enter on their grounds . 4 . That a private duty policy officer or security guard be on duty at the site at all times when the high school - is in session , between the hours of 2 : 00 p .m. and 4 : 00 p .m. and from 5 : 00 p . m. to closing any night that does no precede a school day ; that such officer or guard be provided at all other special event times such as an athletic event at the high school which is ap to attract patrons to the restaurant ; and that this condition be reviewed by the Board of Selectmen at the end of the six month period following the opening of the restaurant so that the Board may review the necessity of McDonald ' s continuing to provide such officer or guard . 5 . McDonald ' s will pay for the installation of a traffic control signal at the intersection of Chickering Road and Walker Road as approved by the Dept . of Public Works , with the understanding that the Town shall prepare and process the application for approval by said Department . A McDonald ' s Corporation _ 2 - July 12 ,, 1982 Common victualer License 6 . That McDonald ' s erect the building and improve the site inocom- �-�`- —pliance with the Town Zoning By-Law . a 7 , That a single ground sign be built near the intersection of Walker Road and Chickering Road , as shown on the Site Plan submitted by McDonald ' --`—The sign will be a Cape Cod or Nantucket type ( namely , carved , inlaid lettering against a different color background ) . The sign would not be self-illuminated but would be illuminated by exterior lights only ; in all other respects the sign will be erected in accordance with the sign by-lar 8 . That a single roof sign consisting of the word , "McDonald ' s , " be a lowed , with internal neon-type lighting , white only , O-L 9 . That the roof of the building be installed with wood shakes ; that he exterior walls be of natural colonial brick and thermopane type Ne<oWilwindows , having the appearance of colonial small -paned glass . H (�'` �10 . That outdoor parking lot area lighting be steady , stationary and &A- ;.LX" shielded so that the light will shine onto the parking lot area ; and that ° no poles on which the lights will be positioned be no higher than 14 feet . That on the Walker Road side of the fence , McDonald ' s plant bushes enhance the appearance of that side of the site . N 12 . That business hours be limited to 7 : 00 a . m. to 11 : 00 p . m. Sundays through Thursdays and to 7 : 00 a .m , to midnight on Fridays and Saturdays . Vic13. That the major trash receptacle , commonly called the dumpster, be ��encl osed . 14 . That McDonald ' s provide materials and labor at least once every thref months to paint out the graffiti on the nearby overpass . McDonald ' s will not be obligated to do so for portions of the overpass not reachable by standing workmen . 15 . That no exterior eating tables be allowed , �16 . That deliveries and trash pickups at the premises be limited to regular open-for-business hours , 17 . McDonald ' s may have one or two curb cuts , at its option , on Walker -�� Rd . , which may be used for either entrance or exit purposes , or both . 18. McDonald ' s shall be permitted one curb cut on Chickering Rd . ( Rte 125 for entrance purposes only , 19 . That such lane markings on Chickering Rd . ( Rte 125) in front of , or proximate to , the site , as may be approved by the Dept . of Public Works , shall be installed . MORRELL ASSOCIATES CURRENT DATE: } AW - P.O. BOX 268 Marshfield, MA 02050 DATE SAMPLES TAKEN: (781) 837.1395 www.morrell-associates.com G� C L L 0 C E A _ N T T I O N BACTERIA COUNT CSample Standard Plate Count/g Coliform/g STANDARDS:SPC-Less Than 50,000/g Coliform-Less Than 10/g LAB ANALYST -- METHOD REFERENCE:Standard Methods For The Examination of Dairy / Products, 16th Edition,American Public Health Association, 1992 (/ 1. MORRELL ASSOCIATES CURRENT DATE: P.O. Box 268 Marshfield, MA 02050 DATE SAMPLES TAKEN: (781) 837.1395 www.morrell-associates.com C L L 0 I C A N T T I 0 .. - N BACTERIA COUNT Sample Standard Plate Count/g Coliform/g f . � 202 STANDARDS:SPC-Less Than 50,000/g u Coliform-Less Than 10/g LAB ANALYST METHOD REFERENCE:Standard Methods For The Examination of Dairy Products, 16th Edition,American Public Health Association, 1992 Date.. ".11..G.G........ V NORTH TOWN OF NORTH ANDOVER pF4��ao ,s,h0 0 -1 PERMIT FOR GAS INSTALLATION s' y � s '9SSACNUgEt This certifies that = ,��� l l.: . . . . .'.. . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . `. �.'�': :. . . . . . . in the buildings of . . �L: . ::. . r..: . . . . . . . .. .�..:. . . . . . . . . . at North Andover, Mass. Fee. !. . ... . . Lic. No.. !. . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . ,/GAS INSPECTOR' WHITE:Applicant CANARY: Building Dept. PINK:Treasurer �( MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) N Mass. Date 179- Permit# `�l J - Building Location `` C e�. S �� `� _ Owner's Name r� � X 6 0 �I�i C K c R S N C `c>T*",( �-�'vType of Occupancy New ❑ Renovation ❑ Replacements" Plans Submitted Yes ❑ No 2'-- 2 'Z Y W W Z (r y) 7t W 0) tr O U) JU w 0 U m = cn I Q O w Q cr Cc 0 0 Z W �y a: m (n f- W W O ( W Q W Q S Z l- U) > ^� 1 i W (r 0 0 0 W (n Q W 0 p W (n W co W Z Q 2 a W W Wa: W W ~ _ Lr Z Q W Q tr W } 0 O Z O ~ O J W W > W D z Q m Q m O O w m 0 w � is fr z O 0 = W D 3 0 0 U rr > o m F- O t SUB-BSM T: t BASEMENT. 1ST FLOOR_ i 2ND FLOOR I 3RD FLOOR • 4TH FLOOR { 5TH FLOOR i it 6TH FLOOR 7TH FLOOR I STH FLOOR I InstallingCompany Name APOLLO PLG & HTG INC p Y Check one: Certificate Address. 1SHATTUCK ST PO BOX 466 X Corporation 1097 C I LAWRENCE, MA 01842-0966 C Partnership Business Telephone 978-688-1755 e -0 Firm/Co. Name of Licensed Plumber or Gas Fitter t I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. i Yes [X No ❑ t If you have checked yes, please indicate the type of coverage by checking the appropriate box. t A liability insurance policy X Other type of indemnity ❑ Bond ❑ I OWNERS 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 the permit issued for this application will I be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142.of the General Laws. i By Type of License n (� ❑ Plumber Title ❑ Gasfitter Signature of Licensed Plumber or Gas Fitter Masr City/Town � Journeyman License Number 8699 APPROVED OFFICE USE ONLY) BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES NO. PROGRESS INSPECTIONS MERCURY TEST FEE FINAL INSPECTION APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE 19 GAS INSPECTOR W %s i9 ° 1 Jul Date.................................. �•ORTI, °<< :•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CMU`+� r - Thiscertifies - ....... . ........e... ............................... has permission to perform,��, 1......, f :!�.�.�......................... wiring in the building of............:.... .- r:r. ......... ............... at .......... at ....... .f ...... '.l. -:c/...i'`��)r,North Andover,Mass. Fee("._�?..-f.......... Lic.NgVY .;.11'� ..!-, -:T;':�.... ......,. ............ ' ELECTRICAL INSPECTOR 04/20/99 14:31 100.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer S1a5c� UO�' i91-),qa_J Office Use Only 04C Gmmonwealo of Mao u uoetto Permit No. 8epttrttnent of Public Bttfe Occupancy,& Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR2:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town of. 2 To the insp for f Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) U Owner or Tenant C D l S Owner's Address S C_m 4,9- Is Is this permit in conjunction watt? a building permill:it: Yes 0 No El (Check Appropriate Box) Purpose of Building re-, Son .r y r�� ?T Utility Authorization No. Existing Service _&OA Amps 420_nlOVolts Overhead ❑ Undgrnd ❑ No. of Meters r New Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Irv. grnd. ❑ grnd. ❑ Generators KVA No.of Emergency Lighting No.of Receptacle Outlets No. of Oil Burners Battery Units No.of Switch Outlets No. of Gas Burners FIRE ALARMS No.of Zones No.of Ranges C_ No. of Air Cond. Tonal No.of Detection and Ions Initiating Devices No. of Disposals No.of Heat Total TotalPumps Tons KW No.of Sounding Devices No.of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices No.of Dryers Heating Devices KW Local ❑ Connection Municipal []Other No. of No.ofLow Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tube I No. of Motors Totai HIP � I OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Compi ed Operations Coverage or its substantial equivalent. YES � NO O 1 have submitted valid p v li roof of same to the Office. YES 2NO O If you have checked YES, please indicate the type of coverage by checking the appropriate box. 01-01-2000 INSURANCE X BOND O OTHER ❑ (Please Specify) h D� (Expiration Date) Estimated Value of Elec rical Work S /v/�o Work to Start Inspection Date Requested: Rough Final Signed under the Penalties of perjury: FIRM NAME LIC. NO. Al 4492 .Licensee Gl Ynn Electric Tric. Signature %NSAll us.Tel.No. Address PO Box 356 East Bridgewater M 0231Z Alt.Tel No.bOU 3/13-04 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check One) i (`� Telephone No. PERMIT FEE S t �"-' (Signature of Owner or Agent) pd 4 [� ( q q C y ff Is-5 0 1 Go x-6565 a - � s a s -777 � v ,Location Ljj� No. Date M / / �oRTh TOWN OF NORTH ANDOVER ,. 09 Certificate of Occupancy $ i +a ; Building/Frame Permit Fee $ S' s"ACMUSE<� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ iBuilding Inspector 04/08/99 09:28 25.00 PAID Div. Public Works 1'1?RMIT NO. Q i APPLICATION FOR PERMIT TO 13UIL1)********NO 11 ANDOVER, MA Jil1 u'NO. 2. Ittcc31u3 DF D\\'r,utsulP PAGE DATE [30nK 7uhk SIM BIV. LO'I'No . ii,L(ff'.1IllIN C 1/J zm PURPOSE()t=Ulm DIN(; Y '"+,y�� IE1l I l/bVj Eft \ 1 !J✓E1 [Pir a► <rJ rn��- �V�1 �'✓1 C 11\\NE{t SNAf.IE NO. ('X Sf(Nt1ES SIZE t OWNER'S ADDRESS /�_G� �1� BASF?i Oft SLAB Alit'l Ill E( 1 S NAME l�f SIZE-OF 1:1 C"11MBERS I 2 3 _ 111111 i)L•k'S N.4nIL' SPAN gi DISTANCE TONEARES I BUILDING DIMENSIONS 01:SILLS DIS I ANCE I ROi STREET DIMENSIONS Of 1110s S DIS I ANCE FROM I.Oi LINES-SIDL•S REAR DIMENSIONS OF GIRDEILS AREA OF LOT FR(M AGE NE1GI fr OF FCAJNDATI(NN T1 I ICK NESS ISBIIILDIW;NEW SIZL'OF)O(jlING - X IS BIJII.DIN(;A)I)I I'I(NN MATERIAL OF CI III.INEY IS BUILDING ALTERATION IS BUILDING ON SOLID 011-Fit LED LAND Will L BUILDING CONFORM TO REQX BREMEN I S OF CODE IS BUILDNJci CONNECT ED'fO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECI ED TO TOWN SEWER IS BIJILDING CONNEM ED TO NA I URAL GAS LINE INS;LII('l IONS 3. PIIOPER'fl'INFOItl\IA'FION LAND COST EST. BLD(;. COST 0 FII L Olff SECfI(>fJS I-3 EST. BI-DG. C(>j'f PER Si). FT. EST. BI DO. COSI PERH(XN.t EI ECTiMc t.IETERS NIHS1'BE ON OOTSIOE OF BUILDING SEPI IC PEItNII f NO. \1-1ACI IED GAHA(iESMUSTC(NNFOItM'fOSfATEFIRE RE(it)LA' IONS A. .A.PI'ltOYka) Bl': t^ PLANS MUST BE 1:11.ED AND APPROVL•D BY BI III-DING INSPECFit* ' BUII.DING INSPECT Olt DAlEF111:D � OWNERS*1 EIA ws {� P� '�7( 'n` CON I R.I 1:1 N 577 1 ' - ` r ( I jl(iN IIH :t `t 'NI:RtNtAtli 11tN1_21;A(il:Nl CONfIt.IJCN :CS (I" � ' �y! G y 111: � ILLC.N � Id � � r + PLHNu�f(iRAtJIfD 1) ( _. Ir 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. *****************************APPLICA-NT FILLS OUT THIS SECTION'***************"'***** APPLICANT VqC �[jY1,y" PHONE LOCATION: Assessor's Map Number 093 PARCEL SUBDIVISION LOT (S) STREET t^i f G i al G- Q-00� ST. NUMBER *****************************************OFFICIAL USE ONLY*******,**'"` *"'"�`� c R £L 11✓ rn�o r m b� pN� o wor K S �--11" RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS O I ECTOR-HEALTH ��DAAPPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT 00l2 Y/ �f'/x, . 3 Z s'=S Z RECEIVED BY BUILDING INSPE-CTOR ATE Revised 9197 jm I i ✓�e (no��a»zaaefuetrlf� o,� DEPARTMENT Of PU81It: SAFETY CONSTRUCTION SUPERVISOR LICENSE Numl'.r: fxpires : 8irlhdafe: CS 060474 08/04/2000 00/04/1961 Restricted To: 00 JEFFRY P GIOROANI 10 HAWTHORNE ST OUINCY, MA 02169 C r-i _ r--1A i r v► I:I II Ii i LL. 11 --�I I mus lr►w� �-- - -� CuT + C*� r-1 _ 1 LLQ .Lgombv_ re i ocats 3/4-stat ton a l l tha-way aga tnet: DR wa l t. Rmove f I at o/c, tof de- pane i to cover ho l oris agatnet noI1 new duct- work � 1 r9-� lL FF--1 F IL_J Liu r L J10I ■9-1S L J FF r---1 ---- Ia! �ILJLJ''j' L_ I�L SS om U C � •,� III � - 6j ri _ I ILJI � S 9+u IZI� r 7 m L� LJLJj II r > — — II. IF_ aiv p LL L- - - —— a-toH MOH _ Irk--�----L.L J _LLI I I 11 it The Commonwealth of Massachusetts ( Department of Industrial Accidents - -- Mics at/nyest/gat/ons - 600 Washington Street A Boston, Mass. 02111 Workers' Compensation Insurance Affidavit name• location: ciN phone# C] I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity airs r p�roovvidingg workers' compensation for my employees working on this job. comvary ramie• � al ��l'�l/{���k7dr22�TiLt.�� �jiy� addrss :A-0 / 1� i /1 If7 i city. Ulfa6yx phone ins rAnce Co. 69X - C] I am a sole proprieto rgener3i contractor, or omeowner(circle one) and have hired the contractors listed below who have the following worke ompe es: company name: addren: city: phone#• insurance co. policy tk. company,name address. city phone#r insurance co. paNcr Failure to secure coverage as required under Section 25A of i'Y1G L 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the psi an p a/ties of perjury that the information provided above is true and correct Signature Date 7 Print name 7TiFP Phone�16 9 official use only do not write in this area to be completed by city or town official city or town: permit/license q f•18uilding Department C]Licensing Board 0 check if on response is required C]Selectmen's Office C]Health Department contact person: phone d; r—(Other (rwud 3195 P1A)