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Miscellaneous - 69 HIGHLAND VIEW AVENUE 4/30/2018
69 HIGHLAND VIEW AVENUE �U�G � 210/066.0-0052-0000.0 f '�� �� } - Date /�jj ! 107 4 00RT/f o�� .,,•` .' 009 TOWN OF NORTH ANDOVER „ PERMIT FOR PLUMBING Thil certifies that haspermission to perform..... .t .,.../..1..- ... . ...... plumbing i the buildings of...,....r........ a�--'c�� T ................... ire at....................................::...1!........... .�fL�................. North Andover, Mass. . Fee........ ........Lic. No. ..� �? ...........................................................................:..... PLUMBING INSPECTOR Check# 1�_ ✓ kl 4� _4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i, CITY I W JMA DATE6 /f ( PERMIT# JOBSITE ADDRESS OWNER'S NAME S�Qfi�f OWNER ADDRESS or 1711, ✓ TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:U101, REPLACEMENT:Q PLANS SUBMITTED: YES EO NODI FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB I ....._.IV___1 ( ( _._�_� __( __� 1 1, _ __. _._...j I 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ T _..__E —__( 6' ._____ 1 f ?. DEDICATED WATER RECYCLE SYSTEM DEDICATED GRAY WATER.SYSTEM { f DISHWASHER _..l _.- _ f = ___ I DRINKING FOUNTAIN I ...____.1 I ...-----_1 _-I'll FOOD DISPOSER FLOOR/AREA DRAIN i _ a __� .___� INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK __.._ ._.__j TOILET I :. ! _k _ _ _1 ._�1 1 --f. --- _. __ I .__._ �_ _1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING -_j _—A OTHER. _ _ _ _ f 1 1 l i - I I ! ..___1 f f I ---1 __._I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES EA NO �1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY.Q OTHER TYPE OF INDEMNITY D BOND 0 bWNER'S INSURANCE WAIVER:I am aware that the lices not have the insurance coverage required by Chapter 142 of the C Massachusetts I L s,"my signature h' ermit application waives this requirement. CHECK ONE ONLY: OWNER EI AGENT SIG ATURE OF 0 GE T hereby certify that all of the details and information Ive submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed u der the permit issued for this application will be in compliance w all P inent provision of the (Massachusetts State Plumbing Code and Chapter 142 of'the General Laws. PLUMBS S NAME ��6 c d� LICENSE# D (UIP ( JP� CORPORATION M#=PARTNERSHIP®#®LLC IF COMPANY NAME ; ADDRESS 6 11 wt�lh4l CITY _._..__I - ZIP STATE d -- - 3� � EI TEL 0 3- S 36 FAX CELL��EMAIL d �_�s.- TAS._ t+ .i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIOIN&NOTES Yes No 01 / { THIS APPLICATION SERVES 4S THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i r � i The Commonwealth of Massachusetts Department oflndustrialAccidents F 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia r Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organizatioh&dividual): Address: City/State/Zip: Phone#: Are you an employer?Checktlie appropriate box: Type of project(required): L❑I am a'employer with employees(full and/or part-time).* 7. Q New construction 2.E]I am asole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. E!Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my properly. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. - 12.0 Plumbing repairs or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.❑We are acorporati.m and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no..employees.[No workers'comp.insurance required.] .. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who subu if this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the'sub-contractors have;employees,they must provide their workers'comp.policy number. f ain an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: i+ Policy IF or Self,-ins.Lie.#: 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). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fineup 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct., Signature: Date Phone#: I 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 of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or.trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'contractor'(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit 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' compensatioii'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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia I Date....... .�.?�............. OF r►OR7h,� TOWN OF NORTH ANDOVER r- 9 "C._ PERMIT FOR GAS INSTALLATION Thiscertifies that .........................................................:0-.....I................................................ has permission for gas installation .. ................................................. .. .................. in the buildings of............... at.. l ........ . North Andover, Mass. Fee.�3(' ..-... Lic. No. V.D.. ...... .................:.............:..........................:.......... /y GAS INSPECTOR Check# 09924 ��. MASSACHUSETTS UNIHIORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iLt l�fn�ot,Q,� MA DATE ..✓ / PERMIT# CITY Er ---� JOBSITE ADDRESS r' 4h ll�� _ ;��.,. ►IOWNER'SNAME CaT�u _� OWNERADDRESS I " TE`l� FAX TYPE OR Y TYPE COMME IAL 0). EDUCATIONAL ® RESIDENTIAL ill/ PRINT OCCUPANC CLEARLY NEW:� RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES NO® APPLIANCES 7 FLOORS- BOILER BSM 1 2 3 4 5 —6 -7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE I FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - ! OVEN - - ! POOL HEATER ROOM/SPACE HEATER - R _I W NT HEATER I ! U VENTED ROOM HEATER WATER HEATER OTHER — -- - - - -- INSURANCE COVERAGE El have a current liabilityinsurance policy olic or its substantial equivalent which meets the requirements of MGL:Ch.142 — YES 1[]NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER:I am aware tha el ensee does not have the insurance coverage required by Chapter 142 of the Massachusetts eral La nd that my si a on this permit application waives this requirement. CHECK ON ONLY: OWNER E] AGENT SIGNATURE OF OWNER R AGENT 1 hereby certify that all of the details and infoimation I have submitted or entered regarding this application are true a urate to tWbest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com with all P i nt provision of the Massachusetts State Plumbing Code.and Chapter 942 of the General Laws. PLUMB ASFITTER NAME t f G� a-I LICENSE# 0 SI TURE MP MGF 0 JP JGF© LPGI CORPORATION�# PARTNERSHIP #�( LLC�# , __I COMPANY NAME: ADDRESS CITY S�jln STATE MZIP J TEL FAX JI CELL- EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR-INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ' lJ e �L The Commonwealth OfMassa.chusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 •- Boston,MA 02114-2017 www.mass-gov/dia Workers'Compensation Insurance A�T PETTING AUTHOIUTY tricians/Plumbers. TO BE FILED WITH Please Print Le ibl A licant Information . Name(B usiness/Org anization/1 dividud): Address: #: , City/State/Zip: Phone Type of project(required): Are you an employer?Check,lie appropriate box: 7. New construction 1,❑I am.a emp y employees(full and/or part-time).* 8 El Remodeling to erwith�— , 2•❑I am a sole proprietor or`partnership and have no employees working forme in 9 Demolition any capacity.[No workers'comp.insurance required.] all work myself.[No workers'comp.insurance required.]t 10❑Building addition 3•❑I am ahomeowner doing roe Iwill 11.❑Electrical repairs or additions 4 E]I am a homeowner and will be hiring contractors to conduct all work on or r property. repairs or additions ensure that ail contractors either have workers'compensation insurance or are sole 12.d Plumbing p proprietors with no employees. 13; Roof repairs 5❑I am a general contractor and I have hired the sub contractors listed onthe a ached sheet. 14 ❑Other These sub-contractorshave employees and have workers'comp. right of•exero tion per MGL c. 41. _ (•❑We are a corporation and its of6cere have exercise wo kerscomp insurance required.] 152,§1(4),and we have no employ:, •[1?. indicating they are doing all:work and then hire outside cofactors and st to whethereor affidavit indicating s have such' a licant that checks lioir#1 must also fill out the section below showing their workers'compensation pmust su olicy ibmit anon. Y PP affidavit m g l° t Homeowners who suliiriit this, .. the name of the sub con tContractors that check this box mustAtaehed an additional,sheet shQWmg ` employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. el0iv is the policy and job site n etn lo'er tTiat is providing workers'compensation insurance for my employees.' B Lama p Y information. Insurance Company Name' Expiration Date: i Policy#or Self-ins.Lic.#: City/S.tate/Zip: Job Site Address: showing the policy number and expiration date)- Attach atopy of the workers' compensation policy declaration p Cg11T1 nal violation punishable by a fine up to$1,500-00 . Failure to secure coverage as required under MGL c.152,§25A i 1 penalties in the form'of a STOP W ORK ORDER and he DTA up to uran e a 1 as cavi ' tions of -year im ri sonment,as well p d to the Office of Investiga and/or one y p of this statement may be forwarde day against the viol ator.A copy correct. coverage verification. hereby certify under the pains and penalties of perjury that the information provided above is true and I do Y Date: Signature:e: Phone#: Y official.. Official use only.: Do not write in this area,to be completed b city or town off Permit/License# City or Town: Issuing Authority circle one): p Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing p 6..Other Phone,#• Contact Person: I r `4 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 express or implied,oral or written." of Hire, An employer is defined as"an individual,partnership,association,corporation or other legal entity,or Any two or ore of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or he receiver or trustee of an individual,partnership,association or other legal entity, owner of a dwelling house having not more than three apartments and who resides therein,or,the occupant of then he 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 notproduced acceptable evidence of compliance with the insurancecoverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please filf 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'oher 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 far the permit or license is being requested,not he Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a Workers'e number listed below compensation policy,please call the Department at th . Self-insured companies should'enter th self-insurance license number on the appropriate line: eir " 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www mass.gov/dia • I .COMMONWEALTH OF 11A1S5�?CCHISETT.S }• e a • BOARW SF4, PLUMBERS �A'ND: GA � I TTE'RS�� � SSUES T'HE FOLLOWf b": LSI CENSE k GENSEDAS, A �— W>. MA,STER�P�L=UM'BER' � DNAHAN C COYLE { 4 CROWN H1 LL_ RD °x �' r . w ijl� b f Ix Al fItNSO3 x i } { /N{. oe.c` I ' Date...... ............................. CF tAORTp, TOWN OF NORTH ANDOVER 0 va PERMIT FOR WIRING s`SACHU This certifies thatv��, P—, .......................................................................................................................... )R_ L�%- =&............ has permission to perform .................................— q� .. A. 4 6A. .................I................t........ wiring in the building of... N t� ............................................................. at .... ..................`....................................................................1-yorth Andover,Mass. .... .-31,Fee... ...............Lic.No. 1i. 1........ ...H.�.......... .... .... �L 31CAL iNSPEC�OR Check# 1- 3017 1-!s>1 I A - 4X- - Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EQ 527 CMR 12.00 (PLEASE PRINTININKORTYPEALLINFORMATION), xs Date: �� City or Town of: NORTH ANDOVER To:the Inspector of Wires: s By this applicatio ,the undersigned gives not*ce is or i tention t perform the electrical work described below. Location(Street Nu er j je I/ , Owner or Tenant , Q/^ Telephone No. `'$0! —K-I V Owner's Address / r/ Is this permit in conjunction ith a g permit? Yes No E] (Check Appro riate Box) Purpose of Buildingj4 It? Ce,, Utilit' uthorization No. Existing Servicax Amps 12� / }Volts Overhead,gUndgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Natupr�e of P o e E ectrical or�/k: /p n C ��{ G C© GY r D `1 Com letion o the ollowin to a may waived iy the Ins ector of Wires No.of Recessed Luminaires No.of Ce'l:Susp.(Paddle)Fans No.of TO Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above El El o mergency Lighting rnd. rnd. BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.'ofDetection and Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pum Number Tons KW No.of Self-Contained No.of Waste Disposers Totals `�• * .......... _.... ... ."' '' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:*- No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent, No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent ri s OTHER: ,rm� Attach additional detail ifdesired,,or as required by the Inspector of Wires. Estimated Value of Ele t'cal Work: ! (When required by municipal policy.) Work to Start: j' 15 Inspections to be requested-in accordance with MEC Rule 10,and upon completion. �E INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and pen lties ofper•ury,that the information on this application is true and compleie Q FIRM NAME: C/ LIC.NO.: 1-3I A Licensee: Signat LIC.NO.: (ifapplicable,e e ' eftt to t I en u1mb li Bus.Tel.No. -59 0 Address: /(!� �' Alt.Tel.Nod' u *Per M.G.L c. 147,s.57-61,security work equires Department of Public Safety" License: Lie.No. a� 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 aggent. Owner/Agent Signature Telephone No. PERMIT FEE:$ • � 9 • ELECTRICAL ICAL?2'E+ACT XG. ]NSP C'UO RE12Q)RT.- - ELECT3][C.AL INFrRICTOP' , � U . C�•xNSP CTIO�T• f PassecT _ railed--[ j Re-lusgection requi ea($50.OD) Inspector CO)IMwits: OP v 4r -4 ' (Insp ee#o ' i tui e -uoiitaTs) Date 2.PMS,�T .�+CTZON; Passed— Failed-• Re-jmspection required($50.00)-•[ � Inspectors'comments: (Cnspectors'Signature-no initials) Date - 3-(� r ;—[ POUNDTS' GTZON:failed--[ l Re-inspection required($50.00)om.m.ents: (Inspectors'Signature--no initials) Date 4.IOTSPECI m—mWC!co: - A T 1,C.Lr E-0 Mff+ONAI,GDO ; EVAN •. Passed--[ ) I'ailed—[ i Re inspectionxequired Inspectbrs'co3nm.eph: I (fuspectors'Signature-uo initials) Date r ffeaION--OMR:' oanmenfs: (lhsp edors'Signature-no initials) Date ID O OR TAGS.AU TO BE BILLED O'UT.AND LEFT ON f3lTE I`TJIE AREA.TO BE INSPECTED IS.WOT .ACCESSIBLE.AND.ARE 3NSPECTION OF 850.00 INTO BE CHARGED. - The Commonwealth of.N.tassachusetts - Department of lndust lql Accidents Office of Investigations 600 Washington.Street Boston,MA.02111 www massgovldia WOrkersl Compensation bsurance Affidavit: Builders/Cont°actors/BlectiL i.cxans[Pmbers Applicant Information Please Plrint Leibly Name(Business/0rganization&dividuat): Address: City/State/Zip: Phone#: Are ou an employer?Check the appropriate boy: Type ofproject(required): 1. am a employex with 4• ❑ i am a general,contractor and I g, Q N w construction employees full and/or axe time)* have Nixed the sub-contractors ( p ? 7. emodeling 2.❑ I am a sola proprietor oxpar4aer- listed on the attached sheet. ship and'have no employees These sub-contractors have 8. ❑Demolition workerscomp.insurance. g. Buildin working fox me in any capacity. ' ❑ g addition [No workers''comp.zusuranCe 5: ❑We are a corporation and its 10.E]Electrical repairs or additions xequixed.� . officers have exercised their right of exemption per MGL 11•❑Plumbing repairs or additions 3.El am a homeowner doing all work _ c�52,§1(4),and we have no 12.E]Roof repairs myself.[No workers comp. employees. o workers' insurance�regwred.]t13.[]Other comp.insurance xequired.] I Any applicant that checks box*1 must also fill gutthe section below showing their workers'compensatiou policy information. u;Homeowners who submit this affidavit indicatingthey ire doing all work and then hue outside contractors must submit anew affidavit indicating such. 6ontractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. insurance Company Name:. CPi E irationDatc: policy#or Self ins.M.A. _T7S'GI/'Yti7CPi bYf'7"7��i__ Job Site Address: City/State/Zip: Attach a copy of the'workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well-as civil:penahies in the.form of a STOP WORK ORDER and a fine of"up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of insurance Covera e verification- trio 7A for g Investigations of D g • .s - X do rierehy z N trio d al' f pe at tree information provided hov is true and correct. f Date: •IS Si atu Phone 4: Official use only. .Do not write in this area,to he completed by city or town officiar. i City or Town: # Issuing Authority(circle one): . X.board of Health 2.Building Department 3.City/Town Clerk 4.Electrical]Inspector 5.Plumbing Inspector 6.Other - y Contact Person: Phone#: _ 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,co orI tion or other legal enti � g ty,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 dowelling 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 He-ening agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct:buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and Phone number(s)along with their 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 that this affidavit maybe submitted to the Department of Industrial Accidents fo;confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returnedto the city or town that thio application for thepermit 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 u self-insurance,license number on the appropriate line. ' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Departmenthas 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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affxdavitmust be filled out each year.Where ah ome 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 shQ ald you have any quesiions, please do not hesitate to give us a call. The Department's address,telephone and fax number: , The Commonwealth ofMassachurdta . Dapax(=Ut of JhduMal Mcident. QfAco dWestigatioAs. 60 Was ooti Wit Boston,MA 02111 W. 617-7-27-4900 oA 406 ox-1-877 MASS.AFF, Revised 5-26-05 Fax#617-727-7749 Y 1-01 7 OMMONW LTROF.MA SACHUSE � H ECRI9CIANrS . ISSUES THE FLOW ING�LI�C`ENSE d jj R r, ' S AS AEV,JOURNEYKAN ,ELE CTR i N ` `n KEV NS M MEAGLE . ,. fy e 9, SANDY°RON'D�C IR �z E ..:........... ',,� Date ..... ...... `r - °� TOWN OF NORTH ANDOVER * , PERMIT FOR WIRING 'Bs�CHUg� This certifies that_� "tk.... t has permission to erform nfi.? .....,.,..............................a........................................................j......". ,.( .Q. r W vv wiring in the bu' ding of....................::......... N. .................................:.......: at .................................... .. ...`! - ........,North Andover,Mass. "Fee Lic.No ZO n........ .. ^� ELECTRICALINSPEcroR Check# 12054 1 Official Use Only Commonwealth of Massachusetts a ,Department of Fire Services Permit No. 2 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),5 7 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: \� City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of Ns or her intention to perform the electrical work described below. Location(Street&Number) Gc� Owner or Tenant P—�� A! Telephone No. (aO3-Sp2-`6�T53 Owner's Address v Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 3 Existing Service Amps 1N1 Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity a Location and Nature of Proposed Electrical Work- 01\11 N Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans 3 No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o mergency Lighting rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets U No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burgers 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 TonsKW No.of Self-Contained cX3 Totals: Detection/Alerting Devices ^I No.of Dishwashers Space/Area Heating KW Local ElMunicipalConnection Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: �J r Heaters signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP W No.of Devices or E uivalent OTHER: Attach additional detail f desired,or as required by the Inspector of Wires. Estimated Value of Elec ical Work: 3S�jU , (When required by municipal policy.) Work to Start: `�-Ag I 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 i the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covpfage is in force,and has exhibited proof of same to the permit issuing office. CBECK ONE: INSURANCE OZ BOND ❑ OTHER ❑ (Specify:) rz- Icertify, under tltepainand enalties ofperjury,that the information on this application is txue-and complete. FIRM NAME: . ,� L (�SS (\ �Q LIC.NO.: �U Iy Licensee: ���G (���� _ Signature ,. LTC.N6.: �'-- (If applicable,enter "exempt"in the license num er line.) Bus.Tel.No.: Address: 1, fS S Mir\ j �wt� 1 M A G\-)"1-4- Alt.Tel.No.: 6\ *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. ❑ 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 t 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. y 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 conceming 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 R—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: / ,y PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspecto s Signature: Date: •, y ROUGH SPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Sig tures Date: FINAL INSPEVi��: Pass M Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: 7. 7—p—/' Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com IV) ;, The Commonwealth of Massachusetts - j*� Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lesibly Name(Business/Organization/Individual): Address:_ \\O City/State/Zip: Phone#: (g\�1—��� — Vs K Aree ou an employer?Check the appropriate box: Type of project(required): 1,l tL1 I am a employer with 4. ❑ I am a general contractor and I 6 El 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.1 7• ❑Remodeling ap ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition 15 '[No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised they 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance required.]t. employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box91 must also fill out the section below showing their workers'compensation policy information. I-Homeowners who submit this affidavit indicating they a're 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. Iain an employer thaiss providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. (� C Policy#or Self-ins.Lic.#: Expiration Date: L\ lob Site Address: ��\� V\ \ Z� City/State/Zip: U Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA r inurance overage verification. Ido hereby ce i un ' s andpenalties ofperjury that the information provided above is true and correct. Signature: Date: �. _ Pho ne#: 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#: i - Ice 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 adeceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." t 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,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 v applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth ofMossachutsetts Department ofJ dustdal.Accidents Office of Investigations 600 Washington Street Boston,lA 02111 TeX,#617-7274900 ext 406 or 1-877,TMASSAFE Revised 5-26-05 Fax#617-727-7749 - -www-Mass,gov/dia i . 1 rOMMONWpLTH wA':r lu la 1010o r r BoA OF' ELECTft 'C'l A(�S ISSUES THE .F'OLIOW tl"CENSE. .OURNEYN: I`LECTR I CL.AFI.:. A[ R GLEASON 31:.E MAIC ST `. ART::I#fl' 1:3 -A 9 1 �t. tLEgap MA 02346 2492 a80�+ > o 16 99848 . . i C?MMaNW TH O'F S • r • jdLqjklrAji t c.E>�Ti T C I A.S. LES `jpiE fOLLOWI N� L''#LI` 151= AS ti # Elt bi MASTEI;! E E CTR I C I Afl ` ' E :. ASSQCIATES UNC, pBA :J` LEE;;:E �A'k-.GtEk- 753 "f pRSI' ST' I�tgaQA. oi752 3;07 20687 : 07/x / 94:776 1: *- .. E� rA�'��A"CIiF SENT' # C =USA.. asIt T / r a6.96i1�' . � 8.39 /.. CARVER,MA`023301510 ip5 DD 00.0162011Rev 07.15-2000 O Location No. r Date s tJ- Dl Na^T� TOWN OF NORTH ANDOVER �C F - 9 • 1 * i ; ; Certificate of Occupancy $ �ss�cHusEt� Building/Frame Permit Fee $ J Foundation Permit Fee $ ,-.5� Other Permit Fee $ TOTAL Check # yj ) 14913 Building Inspector • TOWN OF NORTH ANDOVER BUILDING DEPARTMENT .i APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLIN BUILDING PERMIT NUMBER: / DATE ISSUED: _ M SIGNATURE: Buildin Commissio a ildin Date SECTION 1-SITE INFORMATION 1.1 Property: ess: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: l Zoning District Proposed Use Lot Area Frontage f1 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G L C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name rint) Address for Service: , Sig ature Telephone ) 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Lirrmed Construction Supervisor: Not Applicable ❑ Licenser Construction Supervisor: License Number i Address Mn Expiration Date ic Signature Telephone rlis 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number ('Address Expiration Date 'ii4nature Telephone ` I l S 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 all applicable) New Construction ❑ Existing Building Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify } Brief Description of Proposed Work: —1\ \ + C>?_ SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be �� Completed by pennit applicant 1. Building (a) Building Permit Fee Q.d Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing , Building Permit fee(a)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 AGEN R C NTRACTOR APPLIES FOR BUII..DING PERMIT I, as Owner/Authorized Agent of subject property T¢ 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 h ,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 A� _4-/ Orin eM/ Si ature of Owner/ e Date IMME1001ma mail 7DMfENSIONS RIES SIZE OR SLAB i OOR TINMERS 1 2 3 } I NS OF SILLS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTIy And .. E" +r T0VM of over No. o�A CoCHO� W� , dover, Mass., IMI '-w DRATED AP�y 5 BOARD OF HEALTH PERM� I�T T D _ Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... ............. .. ' . ............. .. .................. .................... ''" "►" "'!�/ Foundation has permission to erect, �R+a�.......... buildings on . ... ........... ............... .............. Rough to be occupied as Chimney provided that the person accepting this permit shall in every respect conform the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North.Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids,-this Permit. Rough PERMIT EXP�� S it`�l .,MONTHS THS Final ELECTRICAL INSPECTOR UNLESS CONSTW C nON A T Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy.Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location No. Date 40w TOWN OF NORTH ANDOVER a p > Certificate of Occupancy $ Building/Frame Permit Fee s�c.us Foundation Permit Fee $ Other Permit Fee $ J TOTAL $ S Check # z-13 o,-- 14207 dwiding I pector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .rasf$ '�s_2 BUILDING PERMIT NUMBER DATE ISSUED: I c � S GNATURE. Building Commissioner/Ingwor of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Addr 1.2 Assessors Map and Parcel Number: O (0q t ��e ��� 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 Required Provide R red Provided Required Provided 1.5. Flood Zone Information: Disposal System:1.7 Water Supply M.G.L.C.40. 54) 1.8 Sewerage 1 S tem: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record E� Name( nt) Address for Service Xj,1;�Z,-A 1,4 7; Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ joL.icensed Construction Supervisor: License Number mn t�Address Signature Telephone Expiration Date —M 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M Address r— Expiration Date z Si nature Tele hone 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.......❑ SECTION 5 Description of Proposed Work check su a ucable New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be �'Y �OI?F`tC FUSE ONI.1 �� Completed by 2ennit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated.Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) _ 4 Mechanical HVAC asp 5 Fire Protection 6 Total 1+2+3+4+5 0 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, d- SC 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 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 N e gigKfure-of wner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE N°RT11 i Town of North Andover "° '•�" Building Department p 27 Charles Street ° North Andover, MA. 01.845 �;'°•...°.�`{g. D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print G� DATE ! e JOB LOCATION �" G( L e cl/ N tuber Street Address Map/lot "HOMEOWNER S� L6r/u/t, Name Home Phone Work Phone PRESENT MAILING ADDRESS 1. J /Z( 0 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedurgs and r uireme is and th she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Town of North Andovera¢ p►ORTH �z4eo ti t f M y O Building Department o 27 Charles Street h North Andover, Massachusetts 01845 C. m '' (978) 688-9545 Fax (978) 688-9542 9 ..C."Z.K. p�A4TE0 Pf'p (GJ 9SSAcHUS�� DEBRIS DISPOSAL FORM In.accordance with the provisions of MGL c 40 s 54, and a condition of Building permit# the debris resulting from the 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/at: Facility location Signature of Applicant Date i I NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. i I I NORTH Town of over M .. ........... � o z=_ LAdower, Mass., 9'•a •o If, COCy1CMEWICK ADRATED PPS\ 5 '9S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System THIS CERTIFIES THAT /1 SIV BUILDING INSPECTOR ',�I. .......... ...... .......................... ... ......... .......... .. .. ...... ...... ..... """ Foundation has permission to erect..... A��...... uildings on ....'!.�...��.�.... .��..V�.....�..... � Rough i � 11#0• � Chimney to be occupied as.. Q .. ...... ' .......................... .......................�A......0� provided that the person accepting this ermit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. M (0 ; 0)3 Z �. PLUMBING INSPECTOR OMM VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPOS IN 6 MONTHS Final - LESS C ONS` U ON ST' ELECTRICAL INSPECTOR CRough .... ,,�,,, i�,....... ................... ....................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place .on the Premises — Do Not Remove Final No lathing-or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.