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HomeMy WebLinkAboutMiscellaneous - 67 BLUEBERRY HILL LANE 4/30/2018/ 67 BLUEBERRY HILL LANE 210/098.C-0099-0000.0 k k l Cunningham Lindsey U.S.,Inc. AM y� . P.O.Box 703689 CUn�l Ingam Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM March 20, 2015 TOWN OF NORTH ANDOVER BUILDING COMMISSIONER NORTH ANDOVER TOWN HALL. 120 Main Street North Andover, MA 01845 Claim Number: A033556893 Policy Number: 47698400002 Company Name: Arbella Mutual Insurance Company Date of Loss: 03/05/2015 Insured: PAUL SEAMANS Property Location: 67 BLUEBERRY HILL LN, NO ANDOVER, MA 01845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. i Date.......A........................... NOwrN TOWN OF NORTH ANDOVER PERMIT FOR WIRING g8�+cr+us�t This certifies that .,....., a has permission to perform ........ LP'J" in— wiring in the building of............................ •c at ..l(a ... ,1 J � ,North Andover,Mass. Fee......1..�..'.'.'........Lic.Nopaq....... ........................................................... ELECTRICAL INSPECTOR Check# �� 11611 i Commonwealth of Massachusetts Official l�e Only Department of Fire Services Permit No. Occupancy and Fee Checked y BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK M All work to be performed in accordance with the Massachusetts Electrical Code(12,; EC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5 2 31 a J City or Town of. NORTH ANDOVER To the Inspector of Wires: / By this application the undersigned gives notice of his or her intention to perform the electrical work described below. N Location(Street&Number) CQq Owner or Tenant ?QA l,( &MYVAMS Telephone No. Owner's Address _(63 W-00 EXYLk k7hU (_Gy^Lk Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) " Purpose of Building Utility Authorization No. q. L Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters C\\ New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity �1 Location and Nature of Proposed Electrical Work: 7 Q y/W of y wut Completion o the ollowin table ma be waived b the Ins ector 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 G KVA No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones l-► I No.of Switches No.of Gas Burners No.of Detection and TotaInitiatin Devices No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices Heat No.of Waste Disposers 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 Kms, Security Systems: No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: �+ Attach additional detail ifdesired,or as required by the Inspector of Wires. `n Estimated Value of Electrical Work: COSZyn L(Z (When required by municipal policy.) V 1 Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. r INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The �-- undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. N CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: U-c LIC.NO.: >y63 J9 Licensee: Signatur w LIC.NO.: 7y k- (If applicable enter "e empt"in the li ens umber line.) Bus.Tel.No.. &03- a 7(170 Address: 4 i_LRtL S Alt.Tel.No.:��— !a0 `�PDE-1/ *Per M.G.L c. 147,s.57-61,security work requires Department of PP b is 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 Signature Telephone No. PERMIT FEE. $ � 5 r t l ' y� The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations 600 Washington Street .Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): eD(e_ C LCe Address: 0 3v City/State/Zlp: (/l'lCe v�-c��.-C S�-/`- l�� � .� rh�nc�: I e.,you an employer?Check the appropriate box: Type of project(required): 1am a employer with . ❑ I am a general contractor and I _y 4 b. E]Now construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance, g, ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance .re uiredemployees.[No workers' required.] 1311 other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they fie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name:. Policy 0 or Self-ins.Li*c-.#: II � , ��/ Expiration Date: / Job Site Address: (S� ( Ql U �`� z `ll( &U City/State/Zip:/l. Ay- (Q -W I Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby certiounder flze ams anti a of perjury that the information provided above i true and correct. - Signature: Date: PhoneM X920 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 4: i z r Information and Instruction's 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 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 j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)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,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pemut/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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The ComTonw-oalth o£l-a.,ssoohvsetts Depaftent ofladwtxial Accidents Office of Tavestigations 600 Washington Street Boston}MA 02111 TO,#617-727-4900 cit;406-or 1,-877-MASSAk'.h, Revised 5-26-05 Fax#617-727-7749 ttnt-----If,1... t i i �OMMWEALTH OF MASSACNUSET'fS ' � .� � 4 '` p .e•` CENSE t© TV "TE" ELE�TR,SCAL RONALD j14 r ,; DC©'TE m pyAL1� E;E'T " g N {1 705 P YNE�STR < MA�1CfiiESk7tR 1 ' COMMONWEALTH OF MASSAGH_USETTS '...-, I ? r S�SSUE THS BOVE LICENSE TO f F �+ r, f' Date . . Zv .� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION y This certifies that . . . l� �.\. . C �?.wn o '. . . . . . . . . . . . . . . . has permission for gas installation . . P.,.,(�. ,. ..... . . . . . . . . . . . . . . Sin the buildings of. �?,mmA... . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . �� 1j�?. �`}'�,��.L . . ,North Andover, Mass. Fee . . . Lic.No. A\4 .�. . 6 . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# 8699 w c MASSACHUSETTS UNIFORM APPLICATION FOR A.PERMIT TO PERFORM:GAS FITTING WORK CITY MA DATE PERMIT# 1. JOBSITE ADDRESS OWNER'S NAME G OWNER ADDRESS TELA _TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ` PRINT CLEARLY NEW: RENOVATION; REPLACEMENT: PLANS SUBMITTED: YES[j NO[j APPLIANCES Z FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 3 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER Pn 'ROOF TOP UNIT TEST < UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER M INSURANCE COVERAGE � I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I IF YOU.CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY CO--' OTHER TYPE INDEMNITY ( BOND OWNER'S INSURANCE WAIVER,I am aware that the licensee does not have the insurance coverage required by Chapter 14,of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT �! I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with inent provision of the _ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMES LICENSE:# I NATURE MP El MGF[--] JP Ej JGF[j LPGI Ej CORPORATION[J# PARTNERSHIP[J# , LLC[]# COMPANY NAME: A ADDRESS S LSJ. CITY I STATE ZIP v► TEL[ �^��3 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Q , Yes. No THIS.APPLICATION SERVES AS THE PERMIT ❑ FEE: $ PERMIT# PLO. PLAN REVIEW NOTES J r ,12/X`19/2006 .11:29 9787740718 PUBLIC WORKS DEPT The Commonweattit of Massachusetts Deparbnent oflndustrialAccidents Q/,j`''ice of,Investigations 600 Washington Street Boston,MA 0211.7 www.mass gov/dia or ere CoxnpeMatiion Xrh,9u7rance Afi>aldavit:BWlders/Contractors/Electricians/Panmbers A► I' t I:nfolrma 'o Please Print.Le ib ly Dame(13usiness/0r9Wzation(1tdi*iidua1):; Address: city/state/Zip: Phone#:_ Cl C%-) Are yoy.an employer?Check e.appropriate[lox: Type of project(required), 1.�I aim a employer with 4. [11 am a general contractor and I 6. [�New construction employees(full and/or part-time). have hired the sub-contractors 2.❑ l ant a snle propkletor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractorhave 8. ❑.l]emolitioza working for me in any capacity, employees and have workers' Building addition, (No workers'comp. insurance comp.irasurance,t n$ required.) S. E3 We are a corporallon and its 10.C Electrical repairs or additions 3.❑ I&ILl a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions _ igyself,(No workers'comp, right of exemption per MGL 12.0 Roof repairs insurance required.]r c, 152,§1(4),and we have no employees..(Nomorkers' comp,!h!urance re uired. °Aoy applicant that checks box#1 trust also fill out the section below showing their workers'compensation polloy in:f rwwjon. t Hornwwrters who submit this afpidavit indicating thoy am doing all work m4 then WM outside contraaton must submit a AM affidavit Indicating auoh, tcontnwtors that rbagt{this box must attached au additivual sheet showing the name of the sub•cautraators and state whether or not those entities have «nptoyew- if the sub—nu-tors have employdes,they must provide their workers'comp,policy cumber. A am an employer that is ptrovtding work¢rs'.CO"W n 4110n in$uraACe far my e4VIoyeds. Below is the policy acid Job sire � fr�orrratioa Insurance CO my Name., c pn S� Policy 0 or Self-ins.Lio.#;_ �'(��— �p�c�J"l Expiration.bate: �. ��I Job site Address: City/State/Zip: •Ns+ntlr c7 v fir! ��` `� Attach a copy of the workers'.compe tion policy declaratlon page(showhlg the policy number and eapiratiou date). Failure to secure coverage as required.under Section 25A of MOI,c, 152 can leas(to the 6position of criminal penalties of a tine up to S 1,500.00 and/or one:-year imprisonment,as well as civil penalties in the form of a STOP WORK ORM and a fine of up to$250,00 a day against the violator. Be advised that a copy ofthis statemant:may be forwarded to the Office of _Investitrations Of the DIA;for insurance eoveraae verification 142 hereby r bey under the pains and penalties ofpeVury that the ft ormadon provided above is true and correct. Dole: 15;— l � 3 rl,Zbard se oti y, o not wrue in MIS area,to be comp ate y city or town q�flrial own: 1Perr<u1t/License tl uthority'(circle one): t fHealth 2.Building Department 3.City/Towa Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.Other Contact Person: P•bone M. i I I I , I I I , I -Fofd.Then Detach Along All Pedorations - CON-MOL# H35.64.27 .I _ IMPORTANT ' I If this license is lost or destroyed, notify your Board'at the: Division of Professional Licensure,1000 Washington St., I Suite 7.10,Bos ton,_MA.021181-6100. I I If your.riame or address shown is changed;.notify your board i . Of correct name.or address to insure proper mailing`:of:next - i Renewal Application.Always,refer to your license:number. This license is subject to the provisions of the Genefal, t aws s a as amended.It ipersonalpriVilege;and'must-not bedoaned or assigned to any other person. Keep this license on your person or,posted as.required;by law_ i. WARNING.THIS DOCUMENT HAS ENHMCED SECURITY FEATURES Fold;Then Detach Along All Perforations, ' - I ' - ' idrThea QeWcn'AlorJg Atl Padoia4ons Bt3i4JiD NOTICE. _ �E.�• ,.a,�.. G21 1J571t NEA©R'1SEDT s�� ya q -a^ FACIIII] 0: �1UP,A THja. -�-�iQS?: ', SGS OFFYGE T F E BOAR -TY"p'� ro 34821:2 iLICENSE NO. EXPIRATION DATE SERIA, .• � - Fgld;''IIYC?��clt Alpn9`A,`.lj PejforaGoas:-`''...-..-. . - '• .- ,. GENERATOR APPLICATION DATE: ,`1�1� LOCATION: OWNERS NAME: GENERATOR I<w NO I NSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR:T ACTOR: PHONE NUMBER; 7 Z���3 i a ELECTRICAL rGAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: �- 1�4 of TZONING DISTRICT: (Z-3 *CONSERVATION APPROVAL ii b r North Andover MIMAP May 20, 2013 9 qJ 47 0. �'� •;��;� * ,fry { - _ �q, I 4 rr " k i f a N s A. s' Y' U r" i-, w.' L .. ., r W Interstates Interstate Major Roads Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for This map was produced by Merrimack NOR7y Valley Planning Commission(MVPC)using data provided by the Town of r Easements Of s`io �A, North Andover.Atlditional data provided by the Executive Office of r� []MVPC Boundary ? `fit ��OO Environmental Affairs/MassGIS.The information depicted on this map is -I Parcels for planning purposes only.It may not be adequate for legal boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Y ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY •s a OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT oma. _.. M ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF •(� o+�r�o .�� THIS INFORMATION ,SSACHUS�t 1"=73 ft ^'�° North Andover MIMAP May 20, 2013 o9a:c-0o2, o9s:c-0o8�l 098 c=oos; N 444 BLtitp�g 2 M LL 098'.,C-01'61', 098.040 102�HILLSIRD 098 C=0017 098 59 O_VQEBELI2Y�HCLL L'N! ;C01,10 098;0-0089 62 8LUEBERRYAHI,I LN, B11,U�EBEFtRY H..ILLaLN; R� 098C 0099:( 098 C,Q090 4� 74a8LlJEBERRY'HILLaLN 098. -00 ; 9'24 HILL'SIDEIR6€ 0981.0-0,09811 ) 7,9ftjBLUEBERRY1H--11W LN' 098:0--0091 84 BLCIEBERFtHILLLN � 098:C<d1019' 098;0=0097 936aHILLSiDE R_D 89JBLU EBERRYxHILL{LN FQ214--P-WA 9,4�,BLUEBERRY H"L'ALN Rail Line 'W Wetlands Zoning Interstales !^Exempt Lands K Busine s 1 District Horizontal Datum:MA Seaplane Coordinate System,Datum NAD83, Interstate C Busine s 2 District p Ys — Major Roads Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack / IN Busine s 4 District NORTN Valley Planning Commission(MVPC)using data provided by the Town of Roads ®Genera Business District Of «ao '0,�, North Andover.Additional data provided by the Executive Office of O Plann Commercial Dev �< `6r�O Environmental Affairs/MassGIS.The information depicted on this map is L r Easements ? ♦ O Corrido Development Dist L for planning purposes only.It may not be adequate for legal boundary Q MVPC Boundary q Comido Development Dist O — "' A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER ❑Municipal Boundary G Corrido Development Dist �'- p MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Zoning Overlay Induslri I 1 District « THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY C Induslri 12 District +s y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT B Adult Entertainment 10 Induslri 13 District • e P 410ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ©Downtown Overlay District ©Historic District p Ind.Mint S District THIS INFORMATION :e°C"""".� .� �` JOj Water Protection Reside ce 1 District ♦r�o Reside ce 2 District ,SSACMUS�� ❑Parcels Reside ce 3 Dislricl 0 Hydrographic Features de ce 4 District dei ce 5 District Streams 1"=73 ft de e B District wge esidential District 4151 Date...�C� J NORTh °`t"'°;•�"� TOWN OF NORTH ANDOVER t PERMIT FOR WIRING SSACNUSf This certifies that Po� � /n�- . .LT ........ .. has permission to perform ......... .....f............... ........................................ wiring in the building of l P . . " 5 J 1-4 ,, 7 � P �/ . '/.. . North Andover izee..- ................ Lic.NCUO.. ... ........ .:z u...... ...................' ELECTRICAL INSPECTOR ..... Check # THS+'COMMONWEALTHOFMASSACHUSETlS O ce Us only DEPARTMffa0FPUX1CS4FIt'Is'GUTATIONS527CN1RI2ElY :019 �� BOARD OFFIREPREVEMONRWALWONS527 Permit No. Occupancy&Fees Checked APPLICA77ONFOR PERART TO PERFORMELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date '?/��� Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street&Number) 3V e (� Owner or Tenant o,,�\eN 5 t Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building s'k �Nm,k` Utility Authorization No. Existing Service Amp kolts Overhead Underground g No. of Meters New Service � I Amps Volts Overhead � 'round � ---� g No.of Meters Number of Feeders and Ampacity Under ---� Location and Nature of Proposed Electrical Work _ LJ'-,,(2 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total No.of Lig ting Fixtures I O Swimming Pool Above Below KVA Generators KVA round round No.of Recceptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons —� No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices --�� No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained No.of Dryers Detection/Sounding Devices Heating Devices KW Local Municipal Other'��� No.of V,Ater Heaters KW No.ofNo.of Connections Signs Bailasis No.Hydko Massage Tubs No.of Motors Total HP DTHER i W&=Co�,Ptn tgtathezagtm�naltsofMas da> �.,��Laws haveaomet tLmbdityhuwamepbkymdxhngCaTCowraWor&glstfftdecprivala�t YES a NO ha�esubrn dvalidploofofsametotheOffice YES It'youbaWdled�cl haddT the box L.�x�J � YES,Pkeir> ed�etypeofmVrageby vsURANCE BOND EVirdlim 132k ✓otkto Salt _ IO��1(0 h «ID�Re rea Rough �'�<< C0.lE�naW VakledEbMicaI Wak$ iglledtuxlar�iePerlaltiesof Final RMNAME t—`e t'�- Iicen9eNo. : -- owed�O Cj 0 VO-,eSigtrahue 3 / No ,{� v ,A Lioerlse a�J Q��.J tl�c� O l��c��V0 LIQ_ O lC?c( Busmc Tel No. �.. O(c(t dVNE12SINSURANCEWAIVER,IamawacethattheLioel>Ssedoesnothavethen�stnul�co orksstt at�ti� � Ah Tel No. IdlatmysigrkillneonthispUnitapplicationwaivesdristegtutentet>t bYM 1 �Lsws lease check one) Owner M Agent ll Igna ure o Telephone No. PERMIT FEE$ caneror gen ��! V Date. . f Q�/?-O z TOWN OF NORTH ANDOVER 00 PERMIT FOR PLUMBING i o • • ,sSACHUSE� �. C'� . .'�s . . Thisr certifies that . . . . . . has permission to perform . . . '4. 1"+! . , , `� o C�-.. . . . . . . . . . . . . . . . . . . . plumbing in the buildi gs of . . .5'01 a IM A!Aj S at . . .'l. . . .�v."�. . . . . . . . . , North Andover, Mass. /f Som J.�i0 2Z l Fee. . ee. .'7 . . .Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . 00w PLUMBING INSPECTOR Check # 5409 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS U to y� y (e—/A Date U /.,7 '(L u Building Location 9AA Owners Name AN`P Permit# _ Amount Y� Type of Occupancy New 0 Renovation ® Replacement Plans Submitted Yes No FIXTURES Cn a con SLsFL%K RASEV[Nr M FLOCK 2. 1 2Nn RDOR 3 HIM 4M FL" 5M FLOOR _ sly FIOM 7M H-(M gm FLOOR (Print or type) A Check one: Certificate Installing Company Name,� / ❑ Corp. Address 4,pb �' ��y� G x Partner. Business Telephone 07f-- Q2 - —/27,6Firm/Co. Name of Licensed Plumber: Lhela&A/e d' CA 4 lG77 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policyIZI Other type of indemnity Bond ❑ ;J Insurance WAver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insuranu,, Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations p ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett Stat umbinge Cha r 142 of the General Laws. By: igna ure ot I icenseuriumDer Type of Plumbing License Title ) r2q r City/Town 17icense numDer Master F1 Journeyman 0] APPROVED(OFMCE USE ONLY d k,kp 41161 Location No. / Date d �aRT� TOWN OF NORTH ANDOVER 0 - w a + > : ; Certificate of Occupancy $ ; Building/Frame Permit Fee $ a O s�CMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ V Check # 3 l d 15868 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ws a- ga rn BUILDING PERMIT NUMBER. / DATE ISSUED: SIGNATURE: Building Commissioner/lEaWdir of Buildings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number /1.31 Zoning Information: L� 5G 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Pri Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Y Licensed Construction Supervisor: 059 G 33 `` 5A f Y cT 'Seve)- '�e MCI Dl9)s License Number mn AcSdress 9�p— 92 75 2 2 Expiration Date §igirature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ R. K . �Aelson Cons\roc- lox" Company Name > 95 8 S )-1 0kl �r C CA 13 1 9 5 Registration Number r Address Ir 749- ,9,9'7—t j b-212 Expiration Dat ^ Signature Telephone YI SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result g in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) J Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 11 f Renoya�c two aal-600rns aha In 4J snt sAs 0� e p)otemrn4 Scg,s c SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed bypermit applicant 1. Building f y/,5oO,C)U (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of ��•�d Construction 3 Plumbing Up Q Building Permit fee(e)X (b) 4 Mechanical HVAC p2 czf(/ 5 Fire Protection 6 Total 1+2+3+4+5 00 .00 1 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> as Owner/Authorized Agent of subject property Hereby author' to act on My belialf, n ers r o work au rized by this building permit application. A' D Signaturl of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, Robe r' K N e-lSD n as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief RobeA K Prim` t�� 8/2 6 &Z / Signa ure of O er/A ent Date 4 NO. OF STORIES SIZE J BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IsT2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE - i II i y ✓he LJo»zmana�Ar�(/i a�✓4lirs,�at�u0ejld I ` i = BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 059633 I { Birthdate: 11/10/1969 i Expires: 11/10/2002 Tr.no: 4078 Restricted To: 00 ROBERT K NELSON i 85 HULL ST#3 - ! BEVERLY, MA 01915 v- Administrator 07 (- ql Boa rd of B-ildi-9 Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: R 112958 Expiration: 05/06/2003 + Type: MA R.K.NELSON CONSTRUCTION ROBERT NELSON 85 HULL ST#3 BEVERLY,MA 01915 - tid�ninisfrator North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11-, .S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant G/-2 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts ,� 7r Department of Indust�al Accidents: ,R ^ f t �,, Office.of Investigations,:,_su ;`" t��N:ri;) .`t ;�F"mat i�� 600 Washington Street aA Boston,MA 02111 a o, Worker's Compensatjon Insurance Affidavit Applicant Information Please PRINT Legibly . .. - ... •.i�tyik;i' r;:.�" i�' fir:`aiaJ u , ... - ::vJJN.rJ.,{.. /yr rr'.::• ,:}{, rn -.ri ff- f. i'."'Y "3 �'ALtl�il {iR: !rJ 1r. ;{... ::r{ :{.�::,Y{{.y.::•YyYr.:}:+..i F:?•.:.Jf :c}Y'.; !r'//•%?'.{'l.,J.:r J J' ii+, :Lalyy. •;:•::: ';•. : .:. '{.:,., ':.. ;:� .%:%/...,r :•:{,.i::{•.:%.. ?;•:•>:;{.:i,.::{�,lJ.:. .././..F//!/.,//!�}yJJ1{! .'/.: ?�l;i�ylr9v/. 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I understand that a copy of this statement may be forwarded to the Office of Investigation of the DIA for coverage verification.*eWint I do hereby certify under the pains and penalties of perjury that the informal on provided above truce and correct T Signature: Date: Print Name:_Robc��F- 1< tif�1 a� Phone#:_927-'S 622 Official use only Do not write in this area-to be completed by City or Town official City or Town: Permit/License#: Building Department Check if immediate response required Licensing Board Selectmen's Office Contact Person: Phone#: Health Department Other 011�Q UC��'tr' ln�a o r No K ►-M 0 of E .: ower No. /G z MC, l - - '� M �� COCHLA IC � dover, Mass., '� a �d ADRATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �� I' C N BUILDING INSPECTOR THIS CERTIFIES THAT.... ...................S ................................................... . ............................................... ' Foundation .. .fit M• a // //y� has permission to e+�ett. ............. buildings on ..4P "I.......jl�44 .. .rl!r! ../ t.../ Rough to be occupied as �f rm O 1 N tit�•!N �.y.. 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 Inspectio , Alteration and Construction of Buildings in the Town of North Andover. a 8 C/9r9r 67 V0 o. 0., PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR C Rough ............. ............................................................................................... Service BUILDING 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.