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Miscellaneous - 674 SALEM STREET 4/30/2018
674 SALEM STREET 210/065.0-0047-0000.0 Date... 10831 taORTs, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING g$�cHuse V e //C. Thiscertifies that....................................................................................................................... 'bas permission to perform....42../eg........... .................. plumbing in the buildings of at...... ......S........d..................... ........................................ North Andover, Mass. Fee.3?7 ......Lic. No.3413...... .............. ................... PLUMBING INSPECTOR Check.# 2 kqK f/ I' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �1 CITY r _11 MA DATE 10" aq"J`lr (,PERMIT# M�7) JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL[ IFAX , TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: UE( PLANS SUBMITTED: YES® NODI FIXTURES-1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB =1==1==== __.J f ____! ! _.___. ! -J=-[ CROSS CONNECTION DEVICE ! ► ,,•_._! _ .. ._�. _ _._ � _. _,—.-.! DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER I _-----I FLOOR/AREA DRAIN ! I .__ _._._.J � ! __..._-•� � - ._.__I –._t .._ -.J ___.__! — ► _-_! INTERCEPTOR(INTERIOR) ! KITCHEN SINK I _1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET ! ___..--_I __-- _ ! —_. .� __! .____► ._ _1 _ -- _! _.___ ! __..__ -_! .___. f URINAL li WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ! _ ! _ [ t ) I ____-J WATER PIPING li OTHER ! _. -J _______I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES -I NO IF Y6 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY©i OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the ij Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT J® SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr 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 co li ce with all inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# 113 I / IGNA URE MP© JP CORPORATION n#PARTNERSHIP Q# i LLC COMPANY NAMEqit/�' ; ; ADDRESS �^hvna o�a) Vs'a CITY L,eil 1^v�« _ J STATE ® ZIP TEL -a7-7) FAX E CELL EMAIL 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 r n The Commonwealth of Massachusetts •f` Department of IndustrialAccidints Office of Investigations IV 600 Washington Street Boston,MA. 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Hc1\1nqT of I Address: City/State/Zip: 0)99 Phone#: I 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. ❑New 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. 9. E]Building addition [No workers'comp.insurance 5. F1 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.[1Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i"Homeowners who submit this affidavit indicating they tie 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:. j Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). po 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 �r 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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 CoUuAonwealthofMassachusetts - Department of Industrial Accidents Office of Investigatlons 600 Washinigton.Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877-MASSAM Revised 5-26-05 Fax#617-727-7749 www mass,goVfdia } e! ' I f; COMMONWEALTH OF MASSACHUSETTS : e - • • PLUMBERS AND GASFITTERS< sSSUES THE FOLLOWING' LICCENSE, L I G.ENSEO AS A, JOUR ..-. Na.P,LUME�ER` ' a -.ft LAS T DOUCETTE 77 SMITH 'CORNER RU �.ff�,j4 . ���.f {w +m✓ J say.. o Ni 0858 4002 . �0 13 nS'/0161 7125 Date......1. J 3.........1.. .. OF p►OR7F�q� - � mom TOWN OF NORTH ANDOVER o ' PERMIT FOR WIRING ,sS-CHUs�S lG C�- This certifies that ........... ..��..�fGl./ ...............,............G' has permission to perform ........ .. .Pt?...1... wiring in the building of..... � �.. t... ......... ins o of ......6:?.�.... 1C Al................................. ........................,Nprth Andover,Mass. Fee. ./.0..-- Lic.No. .. ............ ..... ..6�� ........... 4!. . ...... ELECTRICAL INSPECTOR Check# 3/5'� 12862 —/ �1 The Coil!/rrolc.Ihealth..of.Alassachltsetts Depal1 1e11t°Of 112dilStl'ld f4`CCZCIe11tS J - Office oflllvestlgQtions . �. .•. s = 600 Wash rzgiori Street Boston,IVA 0.2111 - " 3utum inass.gov/dia Workers' Compensation Insurance Affdavit.BuiIders/Contractors•/Elect��i`cYans/1'Ium�:e;i=s` ' An Print.gebly ' NaMC (Business/Organization/Individual): De-5(a (�b C_ Address: l Su n s.--e'L R�K R City/State/Zip: r b l uec- k 0&0 Phone#: 97? 'F-0 7 ' Are you an employer? Check the appropriate box: Type-of project,(xequited):..... :, 1.❑ Lam a employer with 4• ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.DQ I am a sole proprietor or partner- listed on the attached sheet_ 7. ❑Remodeling " ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' [No-workers' comp. insurance comp- insurancet 9. ❑ Building addit"io'n. ti required.] 5_ ❑ We are a corporation and its 10.0 EIectrical repairs or addibu,::•` 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs.or additioc ' myself. [No workers' comp. right of exemption per MGL 12 0-Roof repairs insurance required-]f c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.) 1 Tony applicant that checks box aI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating[bey ore doing all work and then hire outside contractors must submit a new of iidavit indicating such, tContractors tint check this box must attached.on additional sheet showing the nerve of the sub-contraetars and state whether or not those entities bove employees. If the sub-contractors have employees,they mustprovide their worker,'comp.policy number. I am an einploJ►er that is providing workers'compensation insurance for nip employees. Below is the police and jab site information. Insurance Company Name: I Policy# or Self-ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy dec.laration.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 criminalpenalties of a o 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--fi of up to $250.00 a day against the violator. Be advised that a copy of this statement may b6 forwarded to the.Office.of Investigations of the DIA for insurance coverage verification. I do Iterebp tifp under the pabts and pe ofperjrrrp that the information provided above it titre and correct. ll Signi Date:.. - Phone#: 9-7S- 8.0 7 (0 Official use only. Do not turite in this area,to be completed by city or toren official City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Depnrtment 3. City/Town Clerk. .4.Electrical.Inspector S.Plumbing Inspector d. Other --"'- .. . 4,,,,:. Town of Andover Massachusetts 1'� * 36 Bartlet Street Electrical Inspector 9 "l7y � Andover,MA 01810 Paul Kennedy (978)-623-8306 gC USv ELECTRICAL PERMIT FEES Fax Number: (978)623-8320 (revised September,2012) Office Hours: 8:00 am.- 10:00 am. Commercial Base Fee $50+ $1 each device Residential New Dwelling Up to 200 amp service $225 Each add. 100 amp's $20 Multi-Family New Condo/Multi-Dwelling(per unit) $225 Residential- Service/change/alterations 1 phase-200 am $60 Multi-Family/Single Family 3 phase-200 amp $110 Each add. 100 amp's $20 Additions/Renovations/Replacements (Maximum Fee$225) $50(min.fee) Outlets,switches,plugs, luminaires,etc. $1 each device Residential/ Appliances $50(min.fee) Commercial($50 base $10 each appliance t* Air Conditioning and Heat Pumps $50 Temporary Service $50 Residential Generators/Solar Panels (service additional cost) $100(base fee)+ Additional Equipment $25 each Commercial Generators/Solar Panels (service additional cost) $100(base fee)+ Per KVA $1+ / Additional Equipment $25 each Residential ` Audio/video/data/phone-systems/ $50 Fire.alarm/security systems Commercial Audio/video/data/phone-systems/ $50 base fee+ Fire alarm/security systems $60 Com cial New Construction and Alterations Base fee $50+ Per 1,000 sq.R.of Construction Space $100 Service/Change up to 200 amp $150 See Electrical Ins ecto (or price above 200 am Maintenance Permit/Repair Blanket Permit(up to two electricians) $200 p Over two electricians(per air) $50 Office Furnishings/Partition Relocations $50.00(base fee)+ Per Circuit $10 Transformers(non-utility owned) $50 Miscellaneous Camival rides $50 b Demolition $50 Feeders or sub-feeders and panels $30 (each 100 amp.ca acitor fraction thereof) Motors,per hp or fractional part thereof $4 Siding (re-securin service,lights,plugs) $50 t Signs $50 Meters $20 Swimming Pools In-ground $100 Above-ground $50 Commercial $200 r General Fees Re-ILection Fee $50 Ins er hours(minimum fee) $200 Worout a permit Double Permit fee /,;!�..•:,� `eta 1 - - - - - -__ ._ -- ---- € +1,�,4y t MASSACHUSETTS 1 HU R BELOW FOR OFFICE USE ONLY r PLAN REVIEW NOTES ELECTRICAL INSPECTION NOTES ELECTRICAL INSPECTIDN NOTES FEE: PERMIT# RDUGH FINAL j r, t , lnommorswoaflli a/Mat-Jadqu.alla, (7Cticial Use Only. r� PermitNo. o[JaPardmarcl oIjira Saroi.ced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/07] (leave blank) APPUCATOON FOR PERMIT TO PERFORM ELEOTR6CAL INORM All warlc to be perrormed in accordance with tlieMassachusmsElectrical Code(MEC),327 CMR 12.00 (PLE14sEnRnT__J]Vr�loR TE LLMFORM117l�oi- Date: I�cs. 9 / City or T'bwn of: fl vtdoU,e.r_ To the Inspector-of PTfir-es. By this application the undersigned gives notice ofhisor her intention to perform the electrical work described below. Location(Street&Number) h. t- Owner or Tenant Lcvil4CLY, Q Telephone No. Owner's Address is this permit in.conjunction with a building permit? Yes No —1 (Check AppropriateBo?t) PurposcoCBuilding jtC Ste`-L�� Utility Authorizntion No. Existing Service_tQ0 Amps 1 PU Volts Overhead f'--„-Undgrd❑ No.Of Meters New Service o?.QQ Amps [ O 1 - d Volts Overhend K Undgrd ❑ No,of Meters f Number ofTeeders and Amparity Location a d Nature ofPlroposed Electrical Worla _/=/00 C, J3CeS'(?Jn Com lesion of the follorping table mcnr be tpaboad b Y the Inspector of I No. ofRecessed Luminnires O No.of Ceil.� p'�`us •i )-,(Fiddle)t.�Fn No.Trans 'Total q sformers ICVA No.of LuminnireOutlets No. of Eat-Tubs Generntors ICVA- No.ofLuminaires Swimming Pool Above ❑ In- ❑ t O.o mergencyLrg ting ernd. errid. Bnttery Units No.or Receptacle,outlets �S No.of Oil Burners 1=1 ALARMS No.of Zones No.of& tches (� No:ofG:>_s:Burners o.of Detection and 7nitintinE DCVICCs No. 00Itan es TOL-1I g r No ofAfr-Coad; Tons No.ofAlerting Devices No.of Waste Disposers rf HentPurnp ,rlmxnber Tons I W No.of Sell-Contained • , Totals: Detection/Alerting Devices _ Space/Area Renting JW LOc.Z1❑ Municipal ❑ Other IVa.aCDishtivaslrcrs Connection No.of Dryers heating Appliances ICV Sacurity Sysrerns:- No.ofDCAMS or); uivnlcnt No.of Water ICWNo.of No.of Data Wiring: Beaters Signs Ballasts No,orDcvices or Equivalent No.Hydromassage Bathtubs No.ofMotors To(aI IIP Teiecommunic.itions Wiring: No.of Devices or E quivalent - O VIGIL• �- Attach additional detail ifdesired,or as required by the Inspector ojl Estimated Value ofElectrical Worlc .7�O (When required by municipal policy.) Worlc to Start N&J 2OL5' Inspt iutions to be requested in accordance with N1ECRule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance oFelecHcal work may issue u the licensee provides proof of liability insurance including"completed operation”coverage or its substantial equivalent 1 undersigned certifies that such coverage is in Force,and has exhibited proof ofsame to the permit issuing office. CHECKONE.- INSURANCE CK BOND ❑ OTHER ❑ (Specify:) 1 cert,ttnrder flirt paints and penrritier ofperjurp,!/rot the inrfornttetian on!lits application is trite and coniplete. FIJtM NAIVLG: Dct` L� t`lC LiIC.NO. Licensee: L j9Gy t�ekA- & DAy Signature LIC.NO.: (Ifoppllcoble,enter"esempt"in be Gcerrse umberI- e.),,//tt ff ��J us.Tel.IVa.- �Q �;� Address: � s�hS 12eC.k OA P-it d0Qev 11rX Old/6 l- el.No.. *Per-M.G.L.c. 147,s.57-61,security work requires Department ofPublic Safety"S"License_ Lic.No. OWNER'S INSURANCE WAWER: I am aware that the Licensee does not have the liability insurance coverage norrrr: required by taw: By my signature below,I hereby waive this requiremenL I am dim(check one)❑owner [Iowner's i - «�OtivnerlAgcnt - .,,_, C 19ZA �� ��" ���- m�•kms �y`� -� —46 r. t X8-3" ��'.�� fir`+ .������• �� I as 9lr&�f! ad NUUBER a ` 2301$17 iii ifvs--'f'# p-j m e • » ENGE E e' a Si�NSEfIt(�CIftC (H$f0.4812", • i F 1 Date./b/-" y .......... OF NORT�y,� oma; •. oom TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING S ss�C►Mu5� This certifies that ....1........................... ^��-- . ...................................................................................... has permission to perform ....... ..P................................-.. .. ..............?....... wiring in the building of......_ ( es ............. . ...................................................... at �!..T�... l'"2.................................................... rth Andover,Mas Fee......:..�—�.....4..:.....Lic.No.2��y�....! !/............. ......................... .. . -7 E CTRICAL INSPECTOR Check# '� ! /0 qo 2- 1Pr : -1 .; Commonwealth of Massachusetts official use only Department of Fire Services Permit No. 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(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: QCr 29, —ZD 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. Location(Street&Number) (.Q!Jy SALEM ECERFEZ-1 — Owner or Tenant -TA Y%E S MAN Telephone No.�78 479 5193 Owner's Address 5 -A C 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: �22csw�R� pF CNC t�j 1=yV 02L FT-AV-113 F—U P"AC..E CompWires. No.of Recessed Luminaires No.of Cell.-Susp ,VA No.of Luminaire Outlets No.of Hot Tubs l �►� (!�I� SVA No.of Luminaires Swimming Pool I I No.of Receptacle Outlets No.of Oil Burnbe- No. 1C e� �mes of Switches No.of Gas Burn, , No.of Ranges No.of Air Cond.' No.of Waste Disposers Heat Pump I Nun Totals: I No.of Dishwashers Space/Area Heati ►ther No.of Dryers Heating Applianc lent No.of Water KW No.of Heaters Signs lent No.Hydromassage Bathtubs No.of Motors � _.-.lent OTHER: Attach additional detail if desired,or as required by the Inspector of 07res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:j Q^�9—14 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,ander the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: —r_M, W Y t t AJ F Signature .4" LIC.NO.: (�q 4�� (Ifapplicable,enter "exempt"in the license number line.) �Bus.Tel.No.• 8 Address: t5 GAI-E \/ZLLl4GE RD. NE_WT 71V AIH 03858 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 PERMIT FEE: $ Signature Telephone No. f ❑ 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: ***1oTote:.Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: `" ` Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: .v r Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ ; Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTI Pass LZFailed Re-Inspection Required($.) ❑ lnspectors Comments: ` Inspectors Signature: Date: �o DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com p �= .f Commonwealth of Massachusetts OfficialpU�seOnly Permit No. 7iD Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank 'M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN)NK OR TYPE ALL MFORMATIOA9 Date: C= ? —ZQ 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. Location(Street&Number) WILI SALEM STREIu-T Owner or Tenant TAxc.5 TAN Telephone No.g78 !J'fg 5193 Owner's Address g A INA E 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: ftWZQE OF GNC 1\1 EW cT-L FMAeD F'u RNIPK—E Com letion of thefollowing 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 Above ❑ In- No.of Luminaires Swimming Pool ❑ No.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners �jN� FIRE ALARMS I 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 KWNo.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 if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:10 7Z9—14 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties ofperjury,that the information on Ili is application is true and complete. FIRM NAME: . LIC.NO.: Licensee: --r-Lj-,A WYMI� jF Signature ,r yri 2� �fL• LIC.NO.: AI GI-5 (If applicable,enter "exempt"in the license number line.) V Bus.Tel.No. gP78 9 4`i Address: i5 E A LF- V--LLL-AGF—QD hl IVH 03858 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 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 Jt' permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 00 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: -***N1 fe .Reapply for new permit❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass IN 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 IN Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTI Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: 4 44 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Organizatiordlndividual): "'r=JS 1, WYNNE Address: 15 C=AL.G Vz.1-.1: Coyr ROAD City/State/Zip: bMwmN N14 03856 Phone#: 978 TH &2_Z1 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 workingfor me in an capacity. workers' comp.insurance. Y9. Buildin addition [No workers' comp.insurance 5. El We are a corporation and its ❑ g required.] officers have exercised their 10.❑Electrical repairs or additions A3.ElI am a homeowner doing all work right of exemption per MGL l 1.❑Plumbing repairs or additions c. 152 1(4),and we have no myself. [No workers' comp. �§ 12.F1 Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they 66re 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. 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: (,674 SAL.1=Nt ST. No R?14 AIVDoy E R city/State/Zip: AIA O 1$q 5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Faitire 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 may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby cert&under the pains and penalties ofperjury that the information provided above is true and correct. Signature: .&non `� Date: OCT. 20 1 Phone#: 97B 344 62.21 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions 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 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 notmore 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 liee sing dgency,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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 permit/license number which will be used as a reference number. In addition;an applicant that must submit multiple permit/license application's in any`given year,'need only'subniit 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 F (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 Investigations 600 Washington.Street Boston.,MA,02111 TO,#617-727-4900 ext 406 or 1-8777MASSAFE Revised 5-26-05 Fax##617"727-7749 www.mass.gov/dia r y� fir i i . COMMONWEALTH OF MASSACHUSETT$ _« i BOAtp Of ELECTRI C'I ANS i ISSUES THE FOLLOWING :LICENSE + AS A REG _'JOURNEYMAN; ELECTR I C;I�AN T1MOT:HY G WYNNE 2W 1106 BR20ADWAY AVERHILLMA 01832 1405 31695E OT/3..1/16 ; , 32666 �'a Location &-) K _S A /<e U4 S-� No. C9 L6 3 Date —d�- �ORTh TOWN OF NORTH ANDOVER Oft..•° ,•'�.y� g p ' Certificate of Occupancy $ Building/Frame Permit Fee $ sACHUs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1932 16015 1YM 6 - Building Inspector /0-66,z ' s a � TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMryOLI/SHWA ONE OR TWO FAMILY DWELLING .. ';re-`.� *i"� .}':•. +*�"'°� „ -!V)f:,VT[ BUILDING PERMIT NUMBER: DATE ISSUED: m SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION o 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Re `uired Provide Re4pired Provided ReqWred 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 I N e(Print) Address for Service Signa re 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 ❑ Licensed Constrwtion Supervisor: O License Number mn Address K Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Y Name Company t P rn Registration Number Address r Expiration Date Signature Telephone �1/ 1 SECTION 4-WORKERS COMPENSATION(M-G.L- C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ('c p Ic(ce- ccs G�uwi�ha Gulht^ Jcr- door h w A 0. w e o 0,"cretanti SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be a t�FFICiALUSE 0it714:Y Completed by permit a licant 1. Building 1� (a) Building Permit Fee 'ff �Ov Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee tel X tb> 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my.knowledge and belief Print Name a, Signature of Owner/A ent Date ol NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1 2ND 3 1 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DiMGNSIONS OF GIRDERS 1EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT CCI' �. I 1P Yvi Ci vi ki HONE IM - 6 B>.- 33 y LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET- ST. NUMBERC0 ************************************OFFICIAL USE ONLY*********************************** �REC ENDATIONS OF OWN AGENTS: CO SERVATION ADMINIST TOR DATE APPROVED DATE REJECTED COMMENTS W CJS SIDf ' �' �ea.N► A� ll i TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 Jim r. IZ � li -- � �I� I l , �C�ck dvop • (rc�4 rid, y o,, yx y ti o h cohc./A (LIdeep) drip ¢dyr oi, sidej Town of North Andover • Building Department 27 Charles -Street North Andover, MA. 41.845 D. Robert Nicetta ,.._._ ,• .Building Commissioner . (978) 688-9545 978 688-9542 Fax HOMEOWNER LICENSE EXEMpT►ply Please print DATE /O' 30 02, tOB LOCATION 7 Sct S- ,c e- Number Street Address . Map/lot Ifo MEOWNER 1,10 0 WA 4 Name Home Phone 78•-GJ.?- y 3,,p w Phone ESENT MAILING ADDRESS k-1 1Y Town �J,J^' .T.rp Code The current exemption for"homeowners"yras eittended to i nchjde own of two units or less aW to allow such hem ef�uPied dwellings not possess 3-license.. eneract to engage.an in dividuW..forhire who does. provided that the owner acts as sUpervi5or: (State Bur7dting L=ode mon 108.3.5.?) . DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel o,f land on which helshe resides or intends to there is, or is intended to be, a one or two reside, on which cessory to such_ use. ' fiarrn 'dwelling.ad'ached or dee d sbt.xtures - two-year p'i 6tW shall not be cor►srder A Pin yofip rriioreth+a t 1©ne horfie n.a homecv+ner The undersigned"homeowRer'assumes responsibility for co mPlancAPplicable codes, by-Ian, rules and regulafions, E the State Building Code and other The undersigned "homeowner"certifies that he/she understands the TOS 01 No.An Building Depaftrnent minimum ins aom P on procectures and requirements and that hdover e/she wilt PIY with said procedures and requirements_ OMEOWNER'S SIGNATURE I'PROVAL OF BUILDING OFFICIAL - 4, NORTH Town ofAndover o 0�A-Co��;�� dower, Mass., v� �.9 ORATED PPS ,�5 S w BOARD OF HEALTH Food/Kitchen i- ERMIT T D Septic System r l I POO 1" BUILDING INSPECTOR THIS CERTIFIES THAT......�.......................................................................N(� ........................................................ ..... r ' Foundation has permission to ere t...�5.... 8............ buildings on ...... .. .y.......S ..A.. . �t. ....................... Rough to be occupied as..... ... r 00 IC • go#r' � © � r Chimney .................. .............................................................................................................. y 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, Iteration and Construction of Buildings in the Town of North Andover. &� /C/o? 3 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR CRough ................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. (� � SCJ Location No. ��- Date `f ~ORTOI TOWN OF NORTH ANDOVER f 1 00 C po ,• 4'� - i Certificate of Occupancy $ 9 Buildin /Frame Permit Fee $ '� J�cMuse Foundation Permit Fee $ Other Permit Fee $ s TOTAL $ ' Check # 17116 �C Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATY OR DEMOLISH A ONE OR TWO FAMILY DWELLING *77 BUILDING PERMIT NUMBER: 3 DATE ISSUED: 9 SIGNATURE: Building Commissioner/I ctor of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parol Number: Al- Ayydoe yr Map Number Parcel Number T 7 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Rered 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 2.1 Owner of Record Name(Print) Address for Service: \ N Signature Telephone O 2.2 Owner of Record: iti Narrit Print Address for Service: Signature Tele one SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: . ©b G 00 t •n - � �� � �� License Number Address _ /O �v 7,? ?bv- -63 Expiration Date Signa re t' Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone . r r SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check au a Heabte New Construction ❑ Existing Building ti�- Repair(s) lIL Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: VL SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be �Dollar 4-11" r ( � Mg Completed by permit a licant ,. � I. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee(e)X (b) 4 Mechanical(HVAC) �- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION S f as Owner/Authorized Agent of subject properfy 4' Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief AM V✓' / Pfi9t NAMe Si ature of Owner/A ent Date « NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 15 2ND 3RD SPAN DBAENSIONS OF SILLS DIN ENSIONS OF POSTS -M ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHI VMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE PROPOSAL - ' PRO1'dSA NQS t A,4 $H-,ET��fO DATE. PROPOSAL SUBMITTED TO i fJAME r WORK TO BE PERFORMED AT A13t)RE,SS � �d3 3� m 14 frffi 77 '�Wr ry a 17 E,"OE PL4NS ,? k PHONE 40. ! ^- ARCHITECT =_ We�hereb Yxopose tofCarilsh fhet�la antl¢ e 7777 rorrrt latio 4 • :rte� � �> K ecessa forth t;or p tl�n Of � .':x,"� 5 41 . �` ' s ak a s SA,r 7s� x : a ! XX �( i m � h• Ali material Is guarartteetlibUe as`specified, and, the aboveork t fie- � �� cations.submttted for above work and cornpetetl In.e substentlal woA. rkmanike manner for the stimof ce;with the tlrawtgs:atd spe�Ffi-, Doilars ($ with payments to be made as foliows> s t `O- pectfully "10i L Any alteration or deviation from above specfications mvolvirig extra costs I will be executed only upon written order,-ana will-become , extra,charge Over and above the'estimate.-All agreements contingent upon strikes,"ac- PBC cidents,.or delays,beyond out control. Note, This proposal may be_wlthdrawn 'I! ;. by us if not accepted within, days, I N ACCEPlANCE'E'OF IEOPQSAL The above rices, s eclfl+✓ations anc conditions are satlsfacto and are hereb acre ted,' :You are authorized ;to clo{the voP' p p- rYt as Specified. Paymetits will be made,as outhtied above p Y Signature` Date Signature ami'elms 'NC 3818=50 t MADE IN USA P R®'P"OS /` L z z SOA -D OF BUILDING,,REG(UTIONS' aLicense ;CONStRUCTION SUPERV(SOF2 p Number:tS 0$6230 7 Birthdate x`04117/1967 FBxpires:;04/17/2007 Te.-Ad: 86230 , I Re'stricted00 4R fli R A ALLEN �� 369 WAVERLY i ANO ANDOVER, SMA 0184'5 Administrator Z * The Commonwealth of Massachuwffs �, Department of Industrial Accidence Office of Investigations Boston, Mass. 02111 Workers'Compensation,insurance Affidai& Name - Please Print Name: ALen Vlr' P Y� Location: 369 city 4AI. Ain ✓-e-r" . 0 l Y C Phone # b0"q:S 3 I am a homeowner pe rf rm ng all work myself. I am a sole proprietor and have no one working in any capacity . I am an employer providing workers'compensation for nvy employees Overlong ort this job. Corngga name. /address Insurance Co. `OW# Qoxng rnr name. Adrif�s . _ Insurance Co. Policy.•# Fa&we to some co ummie as required=undw SeCbon 2—A or MGL 1W cartlead b*"nipospion oferierre/p �a�fiatie u fs�o:zy and/or ane years'bnpris _v �a�6eSaem�ta.SJD� fioe�4�OCLi�a��g�;a understand that a copy of this statement may be fawoded to the Offkeof bs cf#w MA for c&Awage vesVh:vfion. J b hereby c&Wy paws and peneA%gs fhe bdo"NWM provA*d above is&W.—iPdec signature Z,10 Print name Patm-� 9 7� 3�•�l6?,3 Offidal use only do not write in this area to be completed by city or town offiCiar or.Tovrn f rxr. DOW 0 ]Check0Onrne4ate respormes isquked U Lbs- /8 0 SaiecbnaW.- Contact person Phone# Health Dep I] Other 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 c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant 3112-/o ff Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector FORTH Town ® o ._ Andover VO N®. S31 3 JO LAK over, Mass. /� O , _ COCHICMEWICK �.�5 RATEDP U BOARD OF HEALTH al Elily IT T D Food/Kitchen Septic System I 40. n BUILDING INSPECTOR THIS CERTIFIES THAT......... ....................4..t............................................................................................ ....... ' """"" Foundation has permission to erect..-WriP................. buildings on ` �......�... � .....,.................... Rough .............. ..... . ...... to be occupied as * ee " ...........1A.-IffY.....A 66Al&".*J.................................................. Chimney p° ................................ ... 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 andiB -Law relating to the Insp ction, Alteration and Construction of Buildings in the Town of North Andover. 0M7 3 O _� PLUMBING INSPECTOR--] VIOLATION of the Zoning or Building Regulations s this Permit. Rough Final PERMIT EXPMS� T�o-�-6� MONTHS c ELECTRICAL INSPECTOR �J 10l LESS CONS 1 R V C 1 O ST TS Rough ........ .... . ....................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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.