HomeMy WebLinkAboutMiscellaneous - 69 BRIGHTWOOD AVENUE 4/30/2018 (3) - ( 69 BRIGHTWOOD AVENUE
210/066._0-0016'0000.0
1 III
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Date.......:............................:........
NORT�y
TOWN OF NORTH ANDOVER
o
PERMIT FOR WIRING
_ °' `o cog
HU
This certifies that ...!L 7r' � / ' `/ r� a
...................................... .. ...........................................................
has permission to perform ...``... !/! �- !l-
......................... .........................................................
wiring in the building of....- ��i . . ...:/�.. .......................................
.............................................,North Andover,Mass.
Fee ....:............Lic.No.
.............. .. ...... .........................F.....�..................
E��ECTRICAL INSPEC'F�OR
Check# 2,7,v �—
Official Use Only
� -C-\ Commonwealth of Massachusetts OKnomZ
a o Department of Fire Services Permit No.
/ r//
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
t� All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12. 0
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: -- 5=
\ City or Town of: NORTH ANDOVER To the Inspector of Wired.
By this application the undersigned gives notice of his or her intention to erform the electrical work described below.
Location(Street&Number)— 69-71 A�-
Owner or Tenant SI§44
e±!2&e` ' Telephone No.
r Owner's Address I&C 9-7—
Is
-Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building ($Cg Utility Authorization No.
Existing Service Amps l aO/ a-I`O Volts erhead 0--- Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 46_
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires �- No.of Cell:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- o.o Emergency Lighting
No.of Luminaires Swimming Pool rnd. rnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: """"" '' . .....""."'""""' Detection/Alerting_Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
\ Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (}$ (When required by municipal policy.)
Work to Start: (¢-S—(q Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERA` : 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 E4"IBE OND ❑ OTHER ❑ (Specify:)
I certify,ander the pains rend penalties of perjury,that the information on this application is true and complete.
FIRM NAME: . f L� f�� LIC:.NO.: An
Licensee: Signatur LIC.NO.:
(If applicable, nter 'LaxeOpt"in he l' ense n mberlii e. Bus.Tel.No.•
Address: 01? Alt.Tel.No.:
*Per M.G. c. 147,s.57-61,security work requires Deparhne t of Public Safety' '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 EEE.$
Signature Telephone No.
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed e
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 F
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 Chanter 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.
[ORule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
rmit Extension Act—Permit/Date Closed:
Trench Ins ection
Pass 0 Failed'
Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Inspectors Comments: Failed 0
Re-Inspection Required($.)❑
-
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass Failed
Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: �.
Date:
ROUGH INSPECTION:
i
Pass M Failed Q
Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
7NAL INS CTION: j
Pass
ns Failed 0
Re-Inspection p coon Re uired
ectors Co q ($') ❑
p mments:
I
Inspectors Signature:
� Date:
:B WEINHOLD ... TOWN OF MERRIMAC,MA.
......dweinhold@townofinerrimac.com i
ry The Commonwealth oftVlassachusetts -
Department of Industrial AccMiks
Office of Investigations
660 Washington Street
.Boston,MA 02111
-www.mass gov1dia
Workers' Compensation Insurance Affidavit:Builders/Cony°actors/ElectrzeianslPirimbers
Applicant Information Please Print Legibly
'Name(Business/Organization&dividual)
.Address: "Va,4
City/State/Zip: /1 (c Phone#: 6,17—15 — tZ
Are you an employer?Check the appropriate box: Type of project(required):
1.[Al am.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.[] I am a sole proprietor orpartner- listed on the attached sheet. 7• El Remodeling
ship and'have no employees 'These sub-contractors have 8. ❑Demolition
working forme in any capacity. workers'comp,insurance. 9. E]Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.�trical repairs or additions
required.] officers have exercised.their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions
myself.[Eo workers' comp. c.152,§1(4),and we have no 12,0 Roofrepairs
insurance re edemployees.[No workers'
required.] 13.0 Other
comp.insurance required.]
xAny applicant that checks box 41 must also fill out the section bel6w showing their workers'compensation policy information.
f'Horneowners who submit this affidavit indicatingtfiq tie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an emyloyer that isproviding workers'compensation insurance for•my employees Below is thepolley andjob site
information.
Insurance Company Name: Lt 5UA410C Pn
Policy 4 or self,ias.Lic.#: !qzam, ��— ExpirationDate: 1 —1
Job Site Address: 6�— / City%State/Zip: A4/ A4 10119,K_r
Attach a copy ofthe workers''com e satinn
PolleY declaration page(showin the policy number and expiration date)
Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a
tins 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 tine
ofup 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 ver cation.
Mo Hereby cert u de fliepains andpe alties ofperjury that the informationprovided above is true and correct. -
Si ature: Date: — f
Phone#:
Official use on1y. .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 41.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person• Phone M
- _ t
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 trdstee of an individual,partnership,association or other legal entity,employing employees. IY6ever tho
owner of a dwelling house having not more than three apartments anal 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),addresses)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 notrequired to carry workers'compensation insurance. If an LL C or LLP does have
employees,a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial
Accidents for confnmation 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 pen-mit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a*orkers'
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 andprinted legibly. The Department has provided a space at the bottom
of the affidavit for you to fill,out in the event the Office of Investigations has to contact you regarding the applicant.
Please be-sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/Iicense 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 to city or town may be provided to time
applicant as proof that a valid affidavit is on file for future Hermits or licenses. .A,new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e.a dog license orliermit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
Tho CQ O-Umalth ofMQ8s iarhv&ofts -
Depaxtieut ofTudu&ial Accidonta
Office OURVIONUg t iom
6.9G Wa. biagtoj.j Strut:
Boston,;tom,02111
TQ1,#61M-217,4.900 ext 406 or-1-877-:MASS��
Revised 5-26-05 `ay,0 617-727-7749
WWWMass,goVjclia
VkOKIH
Town of
Andover
No. 377 _
I � ^ _ ' ay
* - o dover, Mass., •
LAKE A,
�� COCKICHEWICK\y
'9S RATED PP 'C� BOARD OF HEALTH
Food/Kitchen
PERMI D Septic System
fBUILDING INSP C OR
THIS CERTIFIES THAT ��•��. .....W....
T�Q�?'�...- .. �... Foun&t n Uf~i 7J cn
• .... buildings on �r '.?�.•..• • ! A a
.................... / oug
has permission to erect........... . � �• � � � '
to be occupied asa)..A44 W.,44pow ........�...., , ��:...... .... �!.�..................
4 �. ON ney
.. ..
provided that the person accepting this permit shall in every respect conform to the terms of a 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 7.z .
Jr I
G INSPE o c
Buildings in the Town of North Andover. ( ___,01 i
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Qfin
PERMIT EXPIRES IN C MONTHS ELECTRICAL SPECTOR
UNLESS CONSTRUCYnp S TS Rough =`s
Service
BUILDING INSPECTOR
tnal
-A5",�`�
GAS INSP(C YOR
Occupancy Permit Required to Occw y Building /
F&J �
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
X7
Until Inspected and Approved by the Building Inspector. Burner G�
p a
Street No.
Smoke Det.
SEE REVERSE SIDE
Date..../�... .c> ...
� � gORTN
TOWN OF NORTH ANDOVER
y # _ PERMIT FOR WIRING
i c� Qom,
'�S7S-SACNU
This certifies that ..... ........-....... .. ......:......:./ :....:2.... r�.....
` has permission to
wiring in the building of/:.1 . �..... !.V�-mac/. --....r.!.. ......
� rr�-•-T -•-^Y-� ,North Andover,Mass.
at
...............
` Fee.9�.:l......... Lic.No.l
ELECTRICAL SPE Rte••
Check #
r
8560
�. .
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. .9�G�ct
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 (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 WINK OR TYPE ALL INFORMATION) Date:
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) (0?-?/ !Y
Owner or Tenant 2 Telephone No.
Owner's Address
,n/,, /� —
Is this permit in conjunction with.a building permit? Yes No
❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service ;2-00 Amps 00J Volts Overhead 0—Und rd
g ❑ No.of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: i ) �i
I� ,q,
Completion o the ollowin table may be waived by the Inspector o Wires.
No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans NO•°f Total
Transformers KVA
No.of Luminaire Outlets No.of
'Ell
Generators KVA
No.of Luminaires l Swimming Pool Above ❑ In- o.o Emergency ig g
d• d. � Butte Units
No.of Receptacle Outlets �� No.of Oil Burners FIRE ALARMS1`do, of Zones
No.of Switches /D No.of Gas Burners No.of Detection and
� InitiatinTotal Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers .Heat ump umberTons KW No.of Sf-Contai
elned
......__._.
Detection/AleDevices
No.of DishwashersSpace/Area Heating KW Local❑ Municipal
Connection 0 O��
No.of Dryers Heating Appliances KW Security S stems:*
No.of Water No.of lvo.of Devices or Equivalent
{ Heaters KW 'i s Ballasts. Data Wiring:
No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications iring:
OTHER: p
No.of Devices or E uivalent
• l C
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 1Q� (When required by municipal policy.)
Work to Start: /(_dl_pQ Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: P
Unless waived by the owner,no permit for the performance
. P of electrical work
the licensee provides .� rk may issue unless
p ides proof of liability insurance including"completed "
g p operation"coverage P g or its substantial equivalent. The
undersigned certifies that such covers is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE �BOND ❑ OTHER ❑under the p (Spec
I certify '')
aims and penalties of perjury,that the information on this application is true and complete
FIRM NAME:
LIC.NO.: JLZ
Licensee: m Signature 7
'�Ll� r
(If applicable, enter"exempt"in t e is nse number lin )
LIC.NO.: (,�'3
Address: L e sus.TeL No.: ;i?
*Per M.G.L c. 147,s.57-6 ,security work requires Department o Public Safety"S"License: Alt L cl.No. lof 7- 93-& 7
tmC
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) ❑o
Owner/Agent wner ❑owner's agent.
Signature Tele '
phone No. PERMIT
FEE:$
1 � '
.z
1 s'�
6
t
1
The Commonwealth of Massachusetts
' ! Department of Industrial Accidents
Office of Investigations
°'• '� 600 Washington Street
tils� /
x, a i Boston, MA 02111
{j www.nzass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers
Applicant Information Please Print Legibly
N8Trie(Business/Orgataizatiott/Individuaf)
Address:_ l�3
City/<State/Zip:—!�;,r�c7�,•e� yam,alqV57 Phone #: 78—
Are you an employer?Check the appropriate box:
r�,�
1.l� t am a employer with�_ 4. ❑ I am a general contractor and t Type of project(required):
employees(full and/or part-time).*. have hired the sub-contractors 6. ❑New construction
2.❑ I am.esole proprietor or partner- listed on the.attached sheet 2 7. Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for mein any capacity, workers' comp. insurance. g. Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10- cal repairs or additions
3.[} I am s homeowner doing all work right of exem 'on r M
ungpti Per GL 11.� Plumbing repairs or additions
myself.y f.[No workers'comp, c. 152, §I(4),'and we have no 12.[] Roof repairs
insurance required.3 employees,ees, (N workerst em to o '. comp. insurancerequired.) 13.[]Other
`Any applicant that checks bo>l#l must also fill out the section below showing their worker;'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 sheetshowing the name of the subcontractors and their workers'comp.policy information.
I ant an employer thot.is provrding workers'compensation insurance for my employees: Below isthe policy and job site
information.
Insurance Company Name: ' 41
��
Policy#or Self-ins.Lie.#: ��Q 7 3 Expiration Date: —Z�c
Job Site Address: i-71 f&,Nd�,l -, ,,� � City/State/zip: MaLo lnql
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
fine up to$1,500.00 and/or one-year im p fres of a
y prisonment,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 certjy under the p 'ns an penalties of perjury that the information provided above is true and correct
Si titre: Date: a Q
Phone �,7g Z , —
LOt
se only. Do not write in this area,to be completed by city or town ofcial
A
own: PermWLicense#
uthori
r ty(eirde one):
of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
erson: 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 of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,assodiation,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 apaa-tments 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."
MOL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of 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 shalt
enter into any contract for the performance of public work rurtil acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage.. Also'be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,notthe 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"lieense number on the'appropriate line.
City or Town Officiais
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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for our cooperation and should you have
P Y p�� an questions,
y Y
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
Tel. # 6I7-7274900 ext 406 or 1-877-MASSAFE
Fax 4 617-727-7744
Revised 5-26-QS www.ntass.gov/dia
Date/z/l:C?X
"" TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
;,SSACMUSf
This certifies that . . ��f�.�a«'.S. . . c .V l./1i s . . . . . . . . . . . . .
has permission to perform . . . . :. . ... . . . . . . . . . . . . . .
plumbing in the buildings of . . .
at . . . /.�.'.5.�. . ` . �. . . . . . . . . . ., North Andover, Mass.
Fee.& . .. Lic. No.P ?'f.3. . . . . . . . .
1 PLUMBING INSPECTOR
Check #
7952
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) 6��2j
NORTH ANDOVER,MASSACHUSETTS ! Q
Building Lo 7/ Date
t-ft*'/d f-kowners Name Permit#
IL��anc - Amount 'Go
New Renovation Replacement '13 Plans Submitted Yes. E] No ❑
FIXTURES
Qr �
U
U
O
)3�ig11+ �+ril'
l5'lr II+IJQ2
3MFLOCILZ
41H FLOCILZ
6M� t
_71HR-om i
SIIi bIf)at
(Print or type) Check one:
Installing Company Name CSG t?-U fills Certificate
Corp.
Address L.�
Partner.
BusinessTelephone
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverag by checkm the appropriate box
Liability insurance policy F1 Other type of indemnity aBond
Insurance Waiver. I, the undersigned,have been made aware that the licensee f
three ' ur Of application does not have any one of the above
ip Owner ❑
Agent
I hereby certify that all of the details and information I have sub ' ted (o en d)in above application are true and accurate to the
best of my knowledge and that all plumbing work and ' tallation pe under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massae �te p
0 ode and Chapter 142 of the General Laws.
By. ign jure of cons um er
Trype o lumbinj icense
Title e1ZS3
City/Town ,,Cense um er
APPROVED(OFFICE U5E ONLY Master Journeyman ❑
i I`
/ R
Date. /,`� . ... ..
Of NO DTM 11,
TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
" th
�,SSACNUSEt
This certifies that . .�l. . . . . ? .f . . . . . . . !` '. . . . . . . . . . . . . . .
has permission for gas installation . . . . .R.e�
in the buildings of . . . . . . . . . . . . L. ?
at , . . . , . . . . ., North.-Andover, Mass.
Fee. �. .. . . . . Lic. No.. . . . . . . .
GA INSPECTOR
Check# ) 102L-
6663
1U2L--
6663
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FMING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations a CG6
Permit# _
—71. Amount$$
/ n e
New Renovation �/ Replacement Re
p � Plans Submitted ❑
U
E4
° m F
c F d a• � � �
W � v] z U W � � Z F C C � � W
z F Z F z x W V > F F
0;
W O Z EL z Q } Z O z W O O
SU B -.BASEM ENT
3 c > a a N p
BASEM ENT.
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
.5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
STH . FLOOR
(Print or type)
Name Check one: Certificate Installing Company
Corp.
Address
Partner.
usmess a ep one
Firm/Co.
Name of Licensed Plumber'or Gas Fitter -J wee,
INSURANCE COVERAGE
I have a current liabilityInsurance Check one:
policy or it's substantial equivalent q valent Yes No
If you have checked vees,please indicate the type coverage b checki O
g Y ng the appropriate box.
Liability insurance policy Other type of indemnity
13 Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass I L s a at my signature on this permit application waives this requirement.
4 nt.
S ture
Check one:
of Own O er s Agent Owner Agent 13
ereby certify that all the details and information I have submitted(o ent ed)in above application are true and accurate to the
best of my knowledge and that all plumbing work and insta tions , rf m under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuse i Sta G
j e and Chapter 142 of the General Laws.
By: ign , re of icensed Plumber Or Gas Fitter
Title Pl ber _4�Z—5-13
City/Town; G FitterNumber
Master License
APPROVED(OFFICE USE ONLY) 0 Journeyman
i
h y-7l ,f'� �` O
Ldcation
No. s 7 Date /-2
N •
f AORTII TOWN OF NORTH ANDOVER
,3?o•�t..° 0
p Certificate of Occupancy $
Building/Frame Permit Fee $
s Foundation Permit Fee $
w IT CHust
Other Per mlt Fee $
Sewer Connection Fee $
tj Water Connection Fee
TOTAL
1 Building Inspector
r
- 6749
6749 Div. Public Works
I �•
1 `PERAft No. `� APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. /PAGE 1
MAP d40. LOT NO. 12 RECORD OF OWNERSHIP PATE BOOK 'PAGE
ZONE I SUB DIV. LOT NO.
1 OCER'S N o,� i�J �� ,s PURPOS Ao o/�
j t/OWNER'S NC,
��lb 7i,S �j 'C� .•�� // C �, �p NO. OF STORIES SIZE t
.DOWNER'S ADDRESS D � BASEMENT OR SLAB _
ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD
ILDER'S NAME �/� w.q/ i'J J n� U10 SPAN ---
DISTANCE TO NEAREST BUILDING C� Y7 �L� ) 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
BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
I
ILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
j IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES BLDG. COST
"d PAGE 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
1 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 FILED ZZ
BOARD OF HEALTH
GNATURE OF OWNER �AUTI�I.IEI�AGNT
FEE ��
PERMIT GRANTED
DOWNER TEL.#-66:25V PLANNING BOARD
� -
�CONTR.TEL.#
/! Y c2 G t9 I c..--CONTR.LIC.# 3
BOARD OF BELECTM[N
td' Z—L
/„ �� BUILDING INSPECTOR
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY s�oRIES 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 3 1 2 13
CONCRETE BL K. PINE _
BRICK OR STONE PLA TER
PIERS PLASTER
_ DRY WALL _
UNFIN.
3 BASEMENT 1
AREA FULL FIN. B'M'TAREA _
'/. '/t '/. FIN. ATTIC AREA _
NO BMT FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �—
WOOD SHINGLES EARTH __
ASPHALT SIDING HARD���'D
ASBESTOS SIDING _ COMMON
VERT. SIDING ASPH.TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. 8 FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME 1
SUPERIOR II POOR r
ADEQUATE NONE r
5 ROOF 10 PLUMBING
i
GABLE HIP BATH 13 FIX.) _
GAMBRELMANSARD TOILET RM. FIX.)
FLAT 11 SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR 8 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. 6 COLS. STEAM
STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G I
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
B'M'T 2nd ECTRIC
1st 13,d I_ ELNO HEATING
i
Page No. of Pages
�P�OOA�Q w d,
G. CHOUINARD CONSTRUCTION
General Contractor
152 WATER STREET Tel. (508) 687-3554
LAWRENCE,-MA 01841
PROPOSAL SUBMITTED TO PHONE DATE
STREET JOB NAME
R l a S S /4- ,-;f
CITY,STATE and ZIP CODE JOB LOCATION
ARCHITECT / DATE OF PLANS JOB PHONE
W8 PUP069 hereby to furnish material and labor — complete in accordance with specifications below, for the sum of:
Payment to be made as follows: dollars $
J a
IS-0 o r vv
Two-thirds of proposed estimate at the time of delivery of material and balance within 10 days
following completion of work. If not paid at that time 15% interest will be added to the total amount.
O's f'/ iv r s/- -X/ b�
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner
according to standard practices.Any alteration or deviation from specifications below involving Authorized
extra costs will be executed only upon written orders,and will become an extra charge over Signature
and above the estimate. All agreements contingent upon strikes, accidents or delays beyond
our control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully Note:This proposal may be
covered by workmen's Compensation Insurance. withdrawn by us if not accepted within days.
We hereby submit specifications and estimates for:
.c............... /6- ...........1...�.Q44 .R4:6..s....................................................................................................................................................
............ .-4.,t.P.........S../...�t!r„y ...5...................................................................................................
....................................,e.4�.....:0..1.1[..............1e...... ', . r..l-u .o.1�.. .....S.A.-.Ag� ......x:.1..111."q .. t-S......
...................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................
..........................................................................................................................................................................................................................
..............................................................................................................................................................................................................................
..............................................................................................................................................................................................................
..........................................................................................................................................................................................................
. ....................................................................................................................................................................................................
......................................................................................................................................................................................................
.............................................................................................................................................................................................................
A"flt m eb Pup"of — The above prices, specifications and
conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above. /
Date of Acceptance Signature
i
i
a NORTH ANDOVER Norah Andover.
APPEALS U-sr
MassaChuselts O 1845
BUILDING DIVISION OF' (617)685-4775
CONSERVATION
HEALTH
PUNNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON,DIRECTOR
.ir+ •
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit
Number C� is that the debris resulting from this work shall be
disposed of in a preperiv licensed solid waste disposal facility as defined by MGL c 111, S
150A.
The debris will be disposed of in:
(Location of Facility)
` I
Sicnature of Permit Applicant
Date
NOTE-: Demolition permit from the Town of North Andover must be obtained for
3uilding Inspector.
this project through the Office of the
NpRTM
Town of �rAndover
o
No. 559
19
1! O
�
:_ A Edover, Mass.,
T COC MI C ME WICK �•
V
AERATED P'P�\
'9S BOARD OF HEALTH
i.
i.
PERMIT T D
Food/Kitchen
Septic System
• BUILDING INSPECTOR
THIS CERTIFIES THAT......to...tirw.-Nn Mt.,S..ro.ao.�X...............................
Foundation "
A1C .... g (r..l....- ���il�If �.Q..f '
{ . has permission to Met.. . ...�.�.� buildin son.. ... .... .... . . .. ... . . ....... .• Rough
to be occupied . or .�. Chimney
provided that the person accepting this permit shall in every respect conform to the terms ofthe 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
I,
PERMIT EXPIRES IN 6 MONTHS Final
3 UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
5
........ . ...... .................. Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display a Conspicuous Place on the Premises — Do Not Remove Rough
� p y �in p
No Lathing or Dry Wall To Be Done Final
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
{ Burner
PLANNING FINAL CONSERVATION FINAL Street No.
k"
iSmoke Det.
SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT