Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 67 LONGWOOD AVENUE 4/30/2018
67 LONGWOOD AVENUE I �� 210 060.C-0050-0000.0 i V' 9264 NORTq 3j��,��•';. �oo� TOWN OF NORTH ANDOVER OA 9 PERMIT FOR PLUMBING CHUS / ,S'r?1 va C'yrra o This certifies that . . . . . . . . . . . . . . . . . . y . . . . has permission to perform �? ?�9? .I.f'!!t T s . . . . . . . . . . plumbing in the buildin/%s of . . . �'!!�. . �!1.� -��. . . . .. . . . . . . . . ,aeat . . 4o. 7. .. . . . ..... . . .e. . . �, o.rt,, Adov r, Mass. /J!cl�r✓ �"�. . . . . . . PLUMBING INSPECTOR Check # rroa� 4.,.—j MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or Print) NORTH ANDOVER,MASSACHUSETTS Building Location / L,.A,1 >WOOd A-UC Date Permit# Owner. —701-17V 6 tZ Amount New ❑ Renovation ❑ Replacement EN Plans Submitted Yes ❑ No FIXTURES w S[SffiV� &4S7RMM MELOCR f r 2�1Qoa� � �ELOCR 41H>L Sm rlowl 6 1 H>� (Print or type) � / / Check one: Certificate Installing Company Name Ste/ ( r A,&� Pl( y � ❑ Corp. Address Y C� X Doo G v ❑ Partner. Business Telephone � Firm/Co. Name of Licensed Phunber: SA / e A Insurance Coverage- Indicate the type of Insurance coverage by cher the a Liabilityinsurance Policy 0 PP1OP box: P CY � Other type of indemnity Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner, ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massaehus Sta Pl ing Co and Chapter 142 of the General Laws. r tore ILLOU1 Title Type of Plumbing License City/Town r duse�-9 APPROVED(OFFICE USE ONLY Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Lnvestigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information � N -� Please Pr><nt Legibly Name (Business/Organization/Individual): �� (—�u(��/al-0 G/ Address: 2n-?C CPO 0 City/State/Zip: ( ©lf VV Phone#:_ 2_� $G,_�, 5 g Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or art-time) p .*' have hired the sub-contractors 6. New construction 2 I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers comp. insurance 5. 9• Building addition ' p ❑ 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 11.9 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no insurance required.] t 12.❑Roof repairs q ] employees. [No workers' comp.insurance required.] 13.0 Other '.finy applicant that cheeks box r1 must also fr1:out the setion belowsho•�n„4u— comym�sation Policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below,is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: / Expiration Date: Job Site Address:_ Z-0 fl-)it: �,�rJ� �ZJF City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t e pains and penalties of perjury that the information provided above is true and correct Si ature: Date: —zQ.— � Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Sr 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 or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,.are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents 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 ori license is being request--d,not the Depa_ri ent.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 permittlieense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business,or commercial venture (i.e.a dog license or permit to bum 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-8 77-MAS SAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass..gov/dia y. R uXylbj 18^Hgt x,64 I ft : 1000S.fi331`l m :3 { 3-DOB 10/31/19638Eye BRO I rt 79 Htir BRO: 4.6Expb��0/3�J2014��- - sF 1sSex M 2ALV4TORE'CURRAO4 '.„ 3! NO IAIN3ST., x EWTON NH 038583304 ; F LICENSED AS A MASTEr".:t- )ER 1 . ISSUES THIS LICEI SE TO ' ;r SAL:VATORE,` CURRAO \\� 8 N" MATN. ST NEWTON E NH 03858-.3.3 13G.9.4 05/01/12 9293 Date. h ?�. X41 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �,sSACMUS + .Gr. .� ' This certifies that � .C/./`',l'"ftf.�. . . . . . . . . . . . . : . . . . . ,- has.permission to perform . . G/.f/Zt� �,�.�`✓�+7. . . . . . . . . . . . . . plumbing in the buildingsof . . G .S4'o. . . . . . . . . . . . . . . . . . . . . . . at. . xa% ... . . . . . . . ., North Andover, Mass. Fee. ??P.Lic. BING�IPECk Y. Check # ?(2�i fYr ' r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �' MA DATE [PERMIT 11 JOBSITEADDRESS�(� L otJ9 Woo A At/C I OWNER`S NAME] J-d f-,l1v G✓2���, i tJ 1 OWNERADDRESS TEL . ,- __. __ . FAX(. TYPE OR OCCUPANCY TYPE COMMERCIAL( - EDUCATIONAL . RESIDENTIAL PRINT CLEARLY NEW.1-�.J RENOVATION: _ REPLACEMENT:[' PLANS SUBMITTED: YES 1-1 NO[-'I FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB GROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM ! s # S I t I ! DEDICATED GRAY WATER SYSTEM 1 # DEDICATED WATER RECYCLE SYSTEhI I j. _ ! - # y I i I „ DISHWASHER - _ 1 -1 j 31 DRINKING FOUNTAIN ) FOOD DISPOSER FLOOR/AREA DRAIN I INTERCEPTOR INTERIOR KITCHEN SINK I LAVATORY ROOF DRAW SHOWER STALL 1' / I SERVICE/MOP SINK TOILETi l URINAL — —_ - - 1 WASHING MACHINE CONNECTION i I I WATER HEATER ALL TYPES. WATER PIPING OTHER I 1 1 l i 1 I . l INSURANCE COVERAGE: I have a current liabilit insilrance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY�PT OTHER TYPE OF INDEMNITY BOND ,._I 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 I SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding jhis 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 incon i r ith all,Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE#i / °1' SIGNATURE MP 10. 1 JP 1 CORPORATION( ]ff PARTNERSHIP.] .# J LLC 'Ilf1 _ COMPANY NAME�SAI "It i4t) Pt— � ADDRESS CITY �"T' v7ir✓ __ STATE yylJJ 21P TEL FAX i CELL �JeYf '73 €MAII _ I i ! I I j ROUGH PLUMBING INSPECTION NOTE S BELOW rOR®� + CE USE ONLY T MAL INSPECTION NOTES Yes No THIS APPLICATIOW SERVES AS THE PERNdIT ❑ ❑ FEE: ,$ PERMrr 9 PLAN UVEMNOTIES r:.� r 3 E I 4�Cnitttrto.'ifittreerftfi o,�'li�tissfrcfitrselFs .� De_��r37ncerrtgf�'�rrfirs(�irl�Siccideirfs 8g0 jYrrstifrfglocF�SYrect 33 s".lotr;MAQ��IX '' avitli��.tarrssgot/dirt � rf'at�Ttct.s'Ca»zliciisEitknl�T�ttst.CEn�Ctficlztrit:BEttlesfL�or�Ft�nt fo's�i�`leetC�cint#sf' ttieei�� •'i�»IieattElEStfot�iutetC6if. ./ .. .. ' ..P�e1s�:t?�•iitFX.�' iCi:, . i�"Eitite;�I3tfulcszi0i�tuiiittoa7ltifisidual};` ��'L. �c��.-,.Q�/� .��uv��� �C� 4�t}�ISt�iCel�i�w/?'�T`�,•✓�l3-D i�`1_ ltltott�#fit .�jl � �/�' � � f AygvirttttemiftivaCltccirthenpp(oprimekox: 7�n�brl,tojcct�tctttrLtedj; I:Q tap it entplo cruitit rt-Q 18111 n general cou(rdctormttl! icnitloccs�ftdlaucttort� G• Q,I`rGt@loiisEaiGtioa 1 Inti-tiittc};� htiee•It(rcdlitcsI&cotilmclors 2.OXantnsoieproprietorw•parCncr- listedtjntfioaUaClfecls�►eoi._ 7. tjlietnotte(iag sitip•arcd[ta��cuoclnplo}ccs Zlics`gsub cai(ractot�him 8 De»tolfiion 1 aiorkatg forincfit any copadly. uorker,.'cotttp.lasi(rattce. h ❑'[in�(ttinggdditiom. i [l OI%VoiL*i:FeCQlitp:Pnsumuco $•❑Nvo* gcacoipagatigaandIts - nitlt>dF.J QfPtcersLa��ccccrcfsect{hear LO Q.Isteclricrtlieitatrsot trttdiciotis 3.QI;nm.alionieotrltertioii>sall jyotl: ofctertpt(onpofm& Y'Itumblug.npatrsoradditiont ua self.[No workcr,'comp. V.1152,,11�gj,titulwo vive'to _ I2.Q Roofrepatrs. fusurmice rcqui(ecl jt tNotti ortceis' comp.lnsurimcc re-'ired j OD Omer ESugxulm•s'trEiafilttaSliaiccEicatclRtsstlattE,t�ttninter$iFi 10117}ilLlttOtlraliyfnCuimatia `t;isoSliquo��lrafetmutthi,enrsu�i 111dimliuslbwc da?rrrdltrurhrrdMen ttfn otrtsideEclma,(7sntn,lsu;+:nitnHhtcffedtvetinJnatn>esuttr. ' _ tt�:trr 6t,tliutEft;cLli,'sh»rttr,[.7.Ia.fxdifnL�t1�UR�rllSfaitSlfllltt7�{rt:Rn3ritC�rt�]eSlilPthnlf1titdiSRfii/ti(Y[LStti�YfS�dL'Url•ttdrpGdanuu'muW.�Wu lrrurrrrt•err�rlvfc�rttrrrLlslrot�trlirr��u�nrl+c°rs'cnirlrertstrllnrtlrrsrrrarrceforrt{(,eruplvpees 1lplo)*lr•NieErolfcf�mrtlJgl►slte � E ii�(orirrrrrlorr. - lgst(rauccCongtan}tnit(ire-_� Policy.fF of Se{l ins.Iic.lf:. );1ii3titti�it,llatG•- s Sob She A&tres " Ctt}fStaEcIZ1�1 .. -:.. . : fi t Jlttncltncolt�brtltctc�ni;ttet5'contyie:Isiti(ottZtDtify diccllraftaupage[sJtttt�tngtlltitoltc5 i{tttitlrgrdtttt'Cclllr�tasttTnCe�. t�ifttrr iaaeGurac6�cttgensres)ultedunderSect(otil3/tofMC3i.c.Ls2tanlead:talite iiliposit(ottQ€criiitiliat cttatticsnCa W10 lip incl(as c(c i('pettattics trtibe fornt otit STOIr ti ORK ogoj3RY—d itl'at1fr1L ti€upfo SZ50.t10a•Ctty+.a�1(ItSE((1Gt'(olREof'. Utz adxisciUttatncopy°aF4lusstatentelf-tfuz}�fte€onvar<tecltothGOfficeoC tuvesligei(ons.oLlfte T3t/Lfor(nsuratice aorcroge tcriGcation. Itlo[rer`efiveerlw,raffle•N pulusoitilperrnfliesojpciftr r,rlinrrlrc=/rifarttrn17b1ttrsDttcicrfabovelslirle pill ireff cG Sieti�tirre� I'tioileP /vj 8_. c' _ J j 67+ -- [4810D.1uttlor s;ami o rrpf n�r1rG Frr this area,to Fie carrUMe?erf O ctO vrlatvtr gtffefaf.• yY aiYiCr MOM 2.Building Dep.,iKi hent 3.Cif.06%%it doik1'IntnUingirsCot'ci�soir 1'tiottC%l: 1 Massadhu&ett§,,GeuertdLtavschapter 152regtthesalremployers•ioyiravidc.tvarfcCv. in)iptisVjWrforIhehstntpTo}ees. rutsuanttotitisstatute,aneri J'o��ki ;Tefiileclas"..,giei gersottinfltesenicaofan.oflicitinderyconCractol'Lite,. o�pi��sorbitltlied,.pmiollti?itteiL" _ - 41rpl03er'ist�eirietl as"titi inilividttaT,patiltersliip;,as�ooiatioh;cxp�rlion Qi other legoleiitiCyt oiranp[ti'b 5>•iiiore oEijte foregoingeitggecl'na;joinFetttpr?se,aiicl fu�litclinthe teg1r�prasentatitIs sofa Qeceaseclemploy.et;or#Ie iecen:es-clrfil�stee:o£acEincli�.id�tal,l�ae[ttership,.association:orotlterlegal'elttity;,ettlJi�o}�ing;e�ployees, 1fo.�ve1erthe olvner ofA tl�velliiigliousehaving uaE�iiDrz iliaii tliiee:apartutents:aud�ivho resides lfierein;or tiie occupant of'fite tutuelluig itonseofnnoflternilto eniploys:petsous to do-inaPiitenance•,construction orx,&b5irivorl;on Sack ci4}z liingltoiis iblpu:thhgrolntclsoxbullcliitg8ppttrlenatltthereto, Fall ttotbecause.ofsncll.etnployutentb deentett"tbb�ouen�plo}YeO* WL'CYmptet 152;• iO 6.also•statesthat'`•`eyel3 srri[e:othe#stiaueeor• y atel>i t.Din 1tecl�sC b}perniitto operate a busittessoi=to:eottstritcf blilldiugs in the connrtoltt eRill,i'oi-atty np�Iicaiif�vL lies.IiotprgdueeilaccepfstbletticiettceoTcotnliliame�vt_thei�ustirsiuceedverage"quire8" t1ciditioually;lViGL:ell@pt0r15225C(7)states" teithertnecotnmonivtaltititoranyofifspalitical.subdivisionI slidl oilt9rintoany contractfortlieperfontla[ic0ofpltiilicivork-untilacceplabTaevicidi eoftotupliaucertiiltfifeinsttrance rztyitit>;mentsofibiscltapterl►avebeen reseutedtoth0eo 1111 ' ��� p h cttngau(liority, I A.ltpltcattts rleaseftltouttlu itiothers' onlpetisatiouhTflkAHi:6niplq 16pyTieclvttgilielitotesihatapplyf4yolirsitttatipiltnld,if MbM'sflrj;supply stib-contractoi(s)itatue(s),adcli•e.ss(cs)'Atictplloitenuthbal;(s)along xvtth their ceitificale(s)of N-filraiim LimitedVability=Compaiues(LtQ or-UnitedLitabililyPaw iietships(LLP)1011 naetnptoye sotller'th8ti:tile tii6ibersoi•parttletsioreitotreouiredtoigAteivorkers'cotppensatioiiinsutance, IfanLLCorLLPcloeshavo e�iploy ees,apolicy is regttired.$si tldvised that'fhis tiifTdavittnay 6e sitbmittetl to theDep,°trtntent of Industrial Eicoideiitsforconft-mationofiuslnancocoverage. A)sbbestirefoSig"nitciclntethettftiAnvit< The rifticlavitshonld ba returned to the.city or tolvn that 1110 application for the permit or license is being requested,not MaDepaitnient of Fnd(LAd l Accidetifs. shoidd 3,01111ato ally fiuest�gns rcganiing.tl►e Ittty 8c ifyoi►are rcgaired ta'obtaiit a ivorkcrs' 0atiipettsation policy;please call the'D;.jiatfinent tit the number-fisted below.'$Ojf insttieil.cottipat4ies_sltoulcT enter their �eMbisucatiee license numberon,V104ppropriate,line. + GitF or Tgjv i Oificlals Plcasebv.uref}tatfhe afGilavitis cottl)rlete9lictprintetT.legibly. 7luebepatititenthas ptouideti R.515;[rortfhebottotut oftfie,atiiciavifcur foryoiadfill'oliE'inth0evettftTieOflicetifinvestigatianshasfocoittnc€} 8garclu;giheapplicant. Please be sur@lofllin thep0nnifllicensettuntbecix]iichtwill_betisedasa:referenceaiimiTief; lnadcTition,anapplic�tat tftat tmust:subibit multiple peruilthicense.applicatioi s�in anygiveii year,iieed oniy sabtnif one affidavit indicating cement iiolicyInformation{ifnecessary)and,tuidei"Job SitaWdrese'the applicatitshoulclwhe"alfloca[ioitsin . (cq-or 1 to tiii)."A cppy afthe atfidatilt(fiat has been official[ystamped or marked by tile city or toil,n may be-provided to the i tiliplicantesproofthat-attalidaffidttvitisotifi[eforf'u[ureperuiitsorliceuses.X,tieivri6idavitnmstEiefillectoute<•tcli l ve�ir.Zt'llere a Monte d►sner 0r citizen is obfaiit"tug a jMense of pernuft xtot related la anj�btts,fess ore i' vejttltie F (i.e.a dog.license or'permit to burn l;at es etc)said person is NOrrecluired to colnple€e thls•effidatizt l 'the t5)I.`ice o€IritfeA'�a(ions llould like f6'tliatit-j'o[tin advance for yotu copjipr�tioi>.ititd WPM�c�ott lta�l��ttiu}gtiestiotls, ptas0 do not lecsifalc to giva its#i ce1C �'ttc bepiit#itl�ut'sactdsess,telepltoneauti fi;fnintl'izY: .. �— s The ConimonvyColtl>'4__!\�t1s�21ti�setts - �. t Beliadilleat of kdu$futll.Aacidants Office o£Itn'esiigW'OW 600AVash'►,ngtbli Stfeet Bostoli,AIA.021 H t TVA.0 617-727-4poo 01406 ur 1-$77 MASSAPP Itei+is ii 5 2G-t)S P419W 6I7-727=1749 ���ti�4,iilassgoelciia Date..f/ � Z-.. . . . . .. OF NO oTM 1'4 o= �` TOWN OF NORTH ANDOVER • 'PERMIT FORS GAS INSTALLATION h .. �,SSACMUSEtl C.UrO This certifies that . . .. . . . . . . . . . . . . . . . p . . . . . .�, has permission for gas installation in the building of . . r�/'�rio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . 4.. 7 os. . . . . . . . j"�h� ver, S. Fee. . . . . . . . ..�S( Lic. No.�3C f �� t GASINSPECTOR Check# WX 8036 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - ' CITY No.A/d A_: 0✓��' MA DATE�� 3 f`� - 1 PERMIT# JOBSITE ADDRESSOWNER'SNAME �.�l�N OWNER ADDRESS S'Yl'?r-a_ TEL TYPE OR OCCUPANCY TYPE COMMERCIAL F] EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION-. REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - CONVERSION BURNER COOK STOVEDIRECT VENT HEATER i`=—� DRYER _- l _ FIREPLACE - - .: FRYOLATOR FURNACE GENERATOR GRILLE - I INFRARED HEATER _-- ` I _ .._::I _._.-.__'.. • - LABORATORY COCKS 1^ -- - - - _ MAKEUP AIR UNIT - ._:_ ._ ___ - _ '• OVEN , - - --- - --- - - - - --- �,__ '� I POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER - UNVENTED ROOM HEATER !' 1 WATER HEATER OTHER _... - - - - • r i INSURANCE COVERAGE _ I have a current liabili ��insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ) OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [7 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j PLUMBER-GASFITTEP,NAME j�� ��ZlL6� �� LICENSE f szi SIGNATURE MP jd%� MGF ,,. JP .a. JGF . : LPGI _ CORPORATION E,,-]# w_ T PARTNERSHIP # _ LLC COMPANY NAME:.�(:�q � ADDRESS CITY STATE TEL sr� _ a. FAX CELL 19-7 MAIL . ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY'', -FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES kl. it The COM11ROOlveault 0fM'"Sacklaeth Deparlrraertf afhrdrrs1 alAc&ei, Ox/r ajlrrf�gariat�s 60Ffl W"lrirhglarr street Roslarr,AM 02111 alwt.uram orldhe 'Worrkew Ca RPCM VWR lustrrfame Atrubvift.OttRd'entt riufiractori etule nT �4,lalnnf M=fo>iumt►fii�att @iet�s��tritnt L 6(21\ a00 A�tt�Q��si> tuz�atirictb�at�i: �,1�-e, � t CcfOW�ip� /!rc ttnE etmpttuyer2 MeeTr ehc npproprlttfe box: 'f5 ofI 1:0 I ane,a e*mpteyer with. 4-D f am a gene►al cautractoramt! 6. 13 Nets coustrtWan emprloyms, Enlf andeor pat-t-timar have Wed the sk—contmciers 2.El L am,a sole proprietor or Itattncr- fisted'.on ilio attached sheet.f 7. �IdctnotTding stt'gr and Crave no,entl>foyees lime stilt-c iratractors have 8. DentuUtton Wotkfng r'arme ftmuycapaaifty. workers'conip.insurance, 9 B iitdittgt thorn P�"*%wrkers"cmtrp, nstMIee S. ❑We are a corporation and its ra uit+cd.j' officers haVOexercised them~ f(.Q IFi'ectrtarC oradctfefatns 3.E3 f atn ahomeownerdohig aff-work rkht of exemption perMGL 1)10 PtumbiDg irepabs or,additious utyst:Tf[No,vorkue comp. c.M,a lQQ.gild vve have no02. Roof trs. alsuraure regp�fred:]'t employees-[No workers" � n conte fnsutmtce regttired.] 13,Q Otttcr "`14ny cppliSr 1 flSatch.-dS bax Er neuslefso fi#out Mc sectionfbdoirsllowiag Mdr wolkas'coiiwitsatton polky infowidlion. !Hat .�tLuexstcimsufinittlikaffibvtfindi titin;theylicedoing-all%corkgildthenhkew4sidecontracthisilius!Submitdeceeatr&%-ll Wicalingsurk Iflultr-weirsdim error u1 t"ovnm;tonachcdMaddition.-dAeaswlwing(LTHautebrOr'!Sull-coutgaccon;and Oicir vwlkas!.COW FORC&R-numfintc lain an entirAwertha is proeldirg nmrkas`cumpenscrd rr!'irrsuraarce for rgtr erqplerjrrec fidonn is firepolw mtdf b'stte lflfar11149611. I numanceCompartyl trc. i Porky a at Wf rtes�/8+-/'� racjitvittiaaro Date;. Job Site Acfike i Attach a cGpl of(he vrartc "Compensation polfcy deelaratfatr imp(showing the poney atrm!berand,erptntfan date l iei ter see r.w age as rt timired�ttttt{er ectimt 25th of MGL c.f 52 cF►n lead to di--rn�lsositicut orf�riat'trirr6lts�rafti�ora !'rite tip t af.SOOL(Yo andlor ent-year inTr,t'somitentp as well as civil penalties flu tho fo nt of'a BTOf"WORK ORDT' °and a fns: df up to 0Mi a day agahtst the vfofator. Bo ad,rised that a col)y ofi thts statetuent ntaay lie fomrardeaf to the Offtce of tnvestigat:iittts of the DTA for ntsttrance coverage tTFfftcagou. # I de lrePcfmcert rf Q' irttiGrs ar rlprurcC es o�lrer rcr l[tat,the lrrforuraf oapm-M,abwe&aue arrrl+ way Skmafare. �f�`fel�rcasT orrlf.Da rrat tcsalC���ctt area;fo 8ecrfrrrlrfetetlli�a dt},k orlutvrr uf�IelrEt Cifpor`T'oWhz-x t'erinfULteetnseiP i IIss.tttttg;,�Mhorfty(cfrdeaite� � f.Mard of l'emfUt 2.Building;Department 3.Cftyfrotvtt Ciera 4.ClMrlcat inspector S.-phuttUng rupteter° Ca.Other Cottt�c�f'^ers4tr� Pliotte!&; Information asi� M"W%ximseft General Laws chapter 152 requires all eraployers,to,_piro�•ido wouke&co pa rmamt to ws statutes an eWlopee is&frred asn"",.eves rnpensatione for their employees, person in the service of araof}tef a nderany contract oft, or implied;oral or ivritten,.m An erarploj ^r is defined as"an inci of ivicttlal ,p inrershop.as tiorr,eorPO'ation ai other legal entky,or any two,or more tine foregoing,engaged im an joint enterpriise,and incFi'tcl+Fmg the: i�e�ceiver ar trsrstee oaf an indivirinal, aitiiersl' , ''representatives:of,a decease cF eLtnploj�r,or the P enp,asmeiatfun oretlrer leges entity,employffigemployam However the Owner Of R fteltiing house having,not more thah three aparifnzents and who resides therein„or the occupant of the dst effirm home of another who enrlrlaYs persons to do maintenance,consfnuction or repair work on such dwelling house ar on.the groamds or building appurtenant thereto shalt not because of such employment be deemed to be an employer!' MGL:chapter 152,V5C(6,)also states that`"every state or local liming agency,shall withhold the is anance or aeneu;al'of is license or permit to operate a business or to coustrtnet buildings in the commonwealth for any applicant who hm.not produced accept,#ble evidence of camplfancenifth the insurance coverage required." Additiona ly.M.GM chapter I5§25C(7)states"Neither the camnmconwealth nor any of its political subdivisions shall enter into any contract for the performance of publiic Uor1 until.acceptable evidence of caornoiance�vr"th the insurancae requirements of this chapter have been.presented to the contracting authority:' �glrIi�irts Please fill out the lvoike e compensation affidavit completely,by checking the bones that a to raecessar}c,sugply sails-conirador s �nlme s adc ply` Y�situation and,if () (�, Fress(es)and phone nuitnbe )along Nvith their certifcate(s)of insurance, Limited Liability Cormparnies(1I;�or Limaited Liability Partineiships(LLP)wifIi.nay er aployees other thain the riiemnbers or partners,are not required to carry workers'comgensatiom idsurance. If ars LLC or LLP does have ernlnloyees,a policy is required.Be advised that thisaffidaint maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also he 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(p regarding tinelaw iii ify^oie at-e requitred tar.obtains a workers' cotrtpensation policy,please call theDepartmepntlit the number.listed,below._Self-insured coia4mvies should enter their self=ursurance Iicense number on tinepro to tine. CTY or Town 0fticiats Please be sure that the affidavit is complete and printed lea Glir. The Department has provided a spare at the bottom, of the.afl&vit for you to fill out in the evenf the Cff'ce of i nvegigations has to contact`.you regarding the applicant. Please be sure to fir I in the permitlliicense nurrib=r which will be:used as a referencenumber. in adclitiion an applicant that must submit nuiltiple permit/license applications;in any givers year,need onto,subunit one affidavit indicating current policy information(ifrnecessary)antiunder'Fait Site Address"the Wficant should write"rill locations.in (city or towh)-7�' copy of the ofCrdax it that has been officlalfly stannped or marked by the city or to`vn may be provided to the 3 applicant as proof that a valid affidavit is.on file for facture permits or Ficenses. A newaffidavit must be filledout each year-Where a home owner or citizen is obtaining a license orpermif not related to any business or commercial venture � (i e.a dog license or pierrait to bursa Ieaves etc.)said person is NOT r 'ed to complete this affidavit. � Investigations would Reto thane,oat tri eganr p The Of"fee of igations y advance for ^our coop,-ration and should You have any alEiestFon please'tea not hesitate to give us a ca�if_ - "a Deparhneint s address,telephone and fax raanrnlier: The(:OMMOANVealth of-Mmachusetts Department ofIndtistAal Acendents Mice offnvest gaiffuns 600 Washington Street Bostorip MA 02111 Tel.#617-727-4900 ext 406 or. 1-87 MASSAFE I Revised 5-26-05 F.aX 617"721-7749 WVt°tV MASS-9Gx,1Q a t Date....!Z.'... .--. ... �aORTN i : �.`` ,��"�, TOWN OF NORTH ANDOVER F ` P PERMIT FOR WLRJNG �,SSACHU`+� This certifies that ........... b............. . 7 &a ..................... has permission to perform ..s�?,�?c�k .......................... wiring in the building ofS S,D, 5 ,,'....................................... ................ at 67 r. t North Andover,Mass. ...... ................ ........ ................. ©6 Fee.. .......... Lic.No.. h- ................. . . ELE CAL l IECCOG R r/ Check # " 055 _n , i �mmoitweafZh o`///a�eachu�e Official Use Only l c� c7 Permit No. BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy and Fee Checked ev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: !a /Q/ /` p City or Town of: Not^ *4 cendyy- n To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (0 7 Lon!) WDocj aV flop y h on o✓ e`` Owner or Tenant C (`aS.jo C 6nd-4 Telephone No.cl 7X �V-0 a ��® Owner's Address v t-' V t` Is this permit in conjunction with a building permit? Yes Y No ❑ (Check Appropriate Bo xJ Purpose of Building Utility Authorization No. 80 Existing Service ( 0 0 Amps 120/ a4C>Volts Overhead Eg' Undgrd❑ No.of Meters 1— New Service 7Z00_ Amps 1'Lc, /-,*�Sf v Volts Overhead GJ- Undgrd ❑ No.of Meters Number of Feeders and Ampacity 5 Location and Nature of Proposed Electrical Work: - Completion o the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. gryd. Battery Units No.of Receptacle Outlets �- No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 7 No.of Gas Burners No.of Detection and 2. PW-tU Initiating Devices 9 Comao No.of Ranges i GNo.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/AlertinLy Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection �. No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of Waters KW No.of No.of Data Wiring: HeaterSigns 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: 1;t./a t/t/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: 1VICck yet LIC.NO.: 0 Licensee: Signature ,pc CLIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No. ct7d' Gt^ ��37 Address: � f,.3 i�vodc( bcJtn Drive- r1e'fh��h Mot C>ly Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ v /10 - o - 17 - 12 C The Commonwealth of Massachusetts Department of Industrial Accidents -- - - - —- - -- -Office of Investigations - - 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): M t Ch c1 Address C-3 Wood bo(l) p rl✓e City/State/Zip: m e~f h v e h M R_ 0 W01 Phone #: 2-6 S- X 03 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑mew construction ,mployees(full and/or part-time).* have hired the sub-contractors 2.2 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. 9. ❑Building addition [No workers' comp. insurance 5• ❑ 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.❑Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.F]Roof repairs insurance required.]t employees. [No workers' 13. Ro r comp. insurance required.] ❑ e *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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#or Self-ins.Lic.#: Expiration Date: k Job Site Address: City/State/Zip: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification., I do hereby certify under the pains and penalties ofperjury that the * .ormation provided above is true and correct. Signature: 6 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: w fp �i Date.....r .-5..-.1.42.... Of 40RT" TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING s Et s ACMUs This certifies that ........J�S,T hi....�/,Au-77-.............................. has permission to perform ...S'Ftua<..F..l(.��!C7.(..Sr/I�..L�!�/.�:���. wiring in the building of 7—� �................ ................................................ l--al'{!.9..w ll ............... .North Andover,Mass. .+ Fee.../ >.. ......... Lic.No.J.7, 7'.K'9'9 ... !ls��o,,....... LECTRICALINSPECTOR ` Check # S%O/I,17 9278 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit N°. 92. 7 8 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] peave blank ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) 6 City or Town of: NORTH ANDOVER ) Date:—,5-- S- 1 By this application the undersigned To.the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) o,1100 Owner or Tenant " Owner's Address Telephone No. �,Q ��, � -Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building (Check Appropriate Boa) Utility Authorization No. Existing Service—[D Amps / 2'L(�Volts Overhead EY Und d 1'R' ❑ 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�- Com letion o the ollowin table m be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Sus f T . p.(Paddle)Fans o.ootal No.of Luminaire Outlets KVA No.of Hot Tubs Transformers Generators KVA No.of Luminaires Swimming Pool Above ❑ )n_ o,o mergency lg g � ' --, No.of Receptacle Outlets No.of oil Burners d• d. Batte Units FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o,of Detection and No.of No.of Air Cond. Ranges InitiatingDevices Totem Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons _ KW_ _ o.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal i Connection ❑ other i No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of No.of Devices or E uivalent C Heaters ' No.Si s Ballaat Data Wiring: sts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications icing: OTHER: No.of Devices or E wvalent Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires. Work to Start (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE:---Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Zd� BOND ❑ OTHER under the pains I certify, p p ❑ (Specify:) . and enaldes of perjury, that the information on this application is true and complete FIRM NAME: Licensee: n LIC.NO.: 112 Sign LIC.NO.:applicable, enter "exempt"in the license number line) ' ( If l� Address: Bus.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety" Li c.License: Alt L l.No.. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabili ty insurance normly required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner co❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. S The Canmonweaith of Massachusetts Department of.industrial Accidents Ogee of Investigations 600 Washington Street Ua j.' Boston, MA 0211 . www-mass gov/dia . Workers' Compensation I iItrance Affidavit: Builders/Contractors/Electriciara/plambers A licant Infornl:atiion Please Print Leeib Name l . Nae(Business/oTpniratiorLnndividual): Address: City/State/Zip: Phone#: . Are you an employer?Cheek.the appropriate box: I.❑ I am a employer with Tof project(required): 4. ❑ I am a general contractor and I ' employees(full and/or pari-time).* have lured the sub-contractors 6.7[[3Naw construction 2.Q i am.a:sole proprietor or partner. Iisted on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in an ty. g' Q Demolition Y�paci workers'.comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9• Q Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing WI work right of exemption per MGL 11.[] Plumbing repairs or additions rgyself. [No-workers'comp. C. 152, §I{4};and we have no insurance requrred j t employees. [No workers' 12 Q Roof repairs comp. insurance:required_] 1317 Other Any eppliaem that checks bot#I must also flit f out the section below showing their worken;'compensation oil t Homeowners who submit this affidavit indicating they are doing all work and then him outside con policy information 4contractors that check this box must am an additional shear show'. . cam must submit a new affidavit indicating such mg the name of the sub.conttact e a Ft c. I am an employer that is ro ' ::� .,.ssp.policy inibtmaiiou. P ,ndurg workers compensation insurance for my e I iafornration. �P o3'ees: below it the policy andjob site Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration Date: a Job Site Address: 1 Attach a copy of the workersCity/Stste/Zip. ' compensation policy declaration page(showing the policy number and expiration date y Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminalfine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up to$250.00 s day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certajy under thepains andpenalties ofperjury that the information provided about is an and coma Si Date: Phone#: Of}Icia1 use only, Do not write in this area,to be completed by city or town oaiaL City or Town: Permit/License# Issuing Authority(circle one}: I. Board of Health 2 Sodding Department 3.City/Town Clerk A.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person Phone#: Location No. Date 4 NORTH TOWN OF NORTH ANDOVER . 9 Certificate of Occupancy $ + x Building/Frame Permit Fee $ �'�s'•^°t��' Foufl YerFee rmit Fee $ wcHus $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector n 1� � 1 V 1 "'0 Div. Public Works � °8 PERMIT NO. 3 e,6 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP Kdp. LOT NO. 12 RECORD OF OWNERSHIP (DATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. F- i LOCATION PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES Llslzk OWNER'S ADDRESS -- BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAMEj> ao � , SPAN -- DISTANCE TO NEAR ST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS ♦ IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM �► SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILEDN �YILDINO INSP[CTOR S TORE OF QWN R AUT2,0 IZEQ AGENT F E E OWNER TEL.# PERMIT GRANT D CONTR.TEL.# 19 - CONTR.LIC.# H.I.C.# 16 .3 L /. BUILDING RECORD ` 1 OCCUPANCY 12 SINGLE FAMILY STORIES I THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL K. BRICK OR STONE HA". —R PIERS PLASTER _ DRY VJALL _ s UNPIN. 3 BASEMENT AREA FULL FIN. B M AREA 1/1 1/2 1/1 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARD1q'D _ ASBESTOS SIDING COM/+ICN VERT, SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME I BRICK N MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I—] POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHING -KITCHEN SINK - SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. &COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC lsf 13rd NO HEATING NORTIy g _ - Town of -. 0 over No. 3156 0 dover, Mass., K 19FC CO -C.E-C. "ATED P-' BOARD OF HEALTH Food/Kitchen PERMIT T D Septic Syfitern O THISCERTIFIES THAT...........................................7 ........... .. .. . .. ....... .. ................................................. BUILDING INSPECTOR has permission to erect........... . . ..... .. .... ...W.0- Foundation buildings on.................. ...10-4)................ Rough 1��.'Oi� Chimney to be occupied as................................................... . .4 ..... .........7.......................................................I......... provided that the person accepting this permit shall In every respect conform to the terms of the application on file In Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S DING INSPECTOR TWL6i Rough ....................................... Service Final Occupancy Permit Required to Occupy, Building GAS INSPECTOR Display in a bonspicuous 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. Smoke Det.