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HomeMy WebLinkAboutMiscellaneous - 74 PROSPECT STREET 4/30/2018Town of North Andover Office of the Planning Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 b=://www.townofnorthandover.com Town Planner. iparrino@townofnorthandover.com Julie Parrino June 3, 2004 Anna Daniels 74 Prospect Street North Andover, MA 01845 RE: Site Plan Review Waiver 73 Main Street Dear Mrs. Daniels: P (978)688-9535 F (978) 688-9542 At the regularly scheduled Planning Board meeting on June 1, 2004; the Planning Board voted unanimously to grant a waiver from the requirements of Section 8.3 of the North Andover Zoning Bylaw for your proposed business located at 73 Main Street. The proposed business, Pottery Paint Time, will offer pottery painting for people of all ages. On street parking is available in the surrounding area. The business is a change in use from the previous use as an appliance store. As on street parking is available, the Board voted unanimously to grant a waiver from the Site Plan requirements. If you have any questions, please Si Parrino, free to contact me. cc: Planning Board Heidi Griffin, Community Development Director Robert Nicetta, Building Commissioner Tammy Sullivan-Huapaya RECEIVE[ JUN 0 7 2004 BUILDING DEPT. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 MA 11 Filing Number: 2006401.94660 Date: 03/30/2007 12:58 PM The Commonwealth of Massachusetts Mini William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Telephone: (617) 727-9640 Federal Employer Identification Number: 000869416 (must be 9 digits) 1 Exact name of the corporation' POTTERY PAINT TTKA-P INC 2. Jurisdiction of Incorporation: State: MA Country: 3,4. Street address of the corporation registered office in the commonwealth and the name of the registered agent at that office: Name: ANNA DANIELS No. and Street: 74 PROSPECT ST City or Town: NORTH ANDOVER State: MA zip: 01845 Country: USA 1 5. Street address of the corporation's principal office: No. and Street: 74 PROSPECT ST City or Town: NORTH ANDOVER State: MA Zip: 01845 Country: USA 6. Provide the name and addresses of the corporation's board of directors and its president, treasurer, secretary, and if different, its chief executive officer and chief financial officer. ,.. MINI MAN Title Individual Name Address (no Po Box) First, Middle, Last, Suffix Address, City or Town, State, Zip Code PRESIDENT ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA PRESIDENT ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA TREASURER TAMMY HUAPAYA 63 AMES ST 63 AMES ST, MA 01844 USA SECRETARY ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA PRESIDENT ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA VICE PRESIDENT TAMMY HUAPAYA 63 AMES ST 63 AMES ST, MA 01844 USA DIRECTOR TAMMY HUAPAYA 63 AMES ST 63 AMES ST, MA 01844 USA DIRECTOR ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA 7. Briefly describe the business of the corporation: RWAIL POTTERY STUDIO A 8. Capital stock of each class and series: 9. Check here if the stock of the corporation is publicly traded: _ ,j1 10. Report is filed for fiscal year ending: 12/31/ 2006 IIISigned by ANNA DANIELS , its PRESIDENT on this 30 Day of March, 2007 © 2001 - 2007 Commonwealth of Massachusetts All Rights Reserved Par Value Per Share Total Authorized by Articles Total Issued Class of Stock Enter 0 if no Par of Organization or Amendments and Outstanding Num of Shares Total Par Value Num of Shares CNP �— $0.00000 0 r $0.00 F— 0 $0.01000 2,000 $20.00 12,000 9. Check here if the stock of the corporation is publicly traded: _ ,j1 10. Report is filed for fiscal year ending: 12/31/ 2006 IIISigned by ANNA DANIELS , its PRESIDENT on this 30 Day of March, 2007 © 2001 - 2007 Commonwealth of Massachusetts All Rights Reserved The Commonwealth of Massachusetts William Francis Galvin - Public Browse and Search Page 1 of 2 x The Commonwealth of Massachusetts X41 ' Wil, William Francis Galvin Secretary of the Commonwealth, Corporations Division One Ashburton Place, 17th floor Boston, MA 02108-1512 Telephone: (617) 727-9640 POTTERY PAINT TIME INC. Summary Screen 0 Help with this form Request a Certificate The exact name of the Domestic Profit Corporation: POTTERY PAINT TIME INC. Entity Type: Domestic Profit Corporation Identification Number: 000869416 Date of Organization in Massachusetts: 06/03/2004 Current Fiscal Month / Day: 12 / 31 The location of its principal office: No. and Street: 74 PROSPECT ST City or Town: NORTH ANDOVER State: MA Zip: 01845 Country: USA If the business entity is organized wholly to do business outside Massachusetts, the location of that office: No. and Street: City or Town: State: Zip: Country: Name and address of the Registered Agent: Name: ANNA DANIELS No. and Street: 74 PROSPECT ST City or Town: NORTH ANDOVER State: MA Zip: 01845 Country: USA The officers and all of the directors of the corporation: Title Individual Name Address (no Po Box) First, Middle, Last, Suffix Address, City or Town, State, Zip Code PRESIDENT ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA PRESIDENT ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA TREASURER TAMMY HUAPAYA 63 AMES ST 63 AMES ST, MA 01844 USA SECRETARY ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA PRESIDENT ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA VICE PRESIDENT TAMMY HUAPAYA 63 AMES ST 63 AMES ST, MA 01844 USA DIRECTOR TAMMY HUAPAYA 63 AMES ST 63 AMES ST, MA 01844 USA DIRECTOR ANNA DANIELS 74 PROSPECT ST NORTH ANDOVER, MA 01845 USA http://corp. sec. state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True... 12/10/2010 The Commonwealth of Massachusetts William Francis Galvin - Public Browse and Search Page 2 of 2 0 business entity stock is publicly traded: _ The total number of shares and par value, if any, of each class of stock which the business entity is authorized to issue: Consent _ Manufacturer _ Confidential Data _ Does Not Require Annual Report Partnership X Resident Agent X For Profit _ Merger Allowed Select a type of filing from below to view this business entity fill ALL FILINGS Administrative Dissolution Annual Report Application For Revival Articles of Amendment © 2001 - 2010 Commonwealth of Massachusetts All Rights Reserved A View Filings New Search Comments ID Help http://corp. sec. state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True... 12/10/2010 Par Value Per Share Total Authorized by Articles Total Issued Class of Stock Enter 0 if no Par of Organization or Amendments and Outstanding Num of Shares Total Par Value Num of Shares CNP $0.00000 0 $0.00 0 CwP $0.01000 2,000 $20.00 2,000 Consent _ Manufacturer _ Confidential Data _ Does Not Require Annual Report Partnership X Resident Agent X For Profit _ Merger Allowed Select a type of filing from below to view this business entity fill ALL FILINGS Administrative Dissolution Annual Report Application For Revival Articles of Amendment © 2001 - 2010 Commonwealth of Massachusetts All Rights Reserved A View Filings New Search Comments ID Help http://corp. sec. state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True... 12/10/2010 4 I i J 2 r J This certifies that -J�',-e-A) 7-4,�7 ',I, Date ... kx.�.SVzl....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform .. / .... - ........ plumbing in the buildings of ........ ......a..�.................................................... at ......7y... ........................ North Andover, Mass. Fee.'-'/7 ... Lic. No.%.3Y7!................................................................................... _ PLUMBING INSPECTOR Check # 5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK' CITY ,r,4 C MA DATE JOBSITE ADDRESS �� 7 OWNER'S NAMERy P OWNER ADDRESS _ TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL (- PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ N0E�r— FIXTURES Z FLOOR--• BSM 1 2 3 4 5 6 7 8-T 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM - _. DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ ....... _ ._..... _ .. _ ._... _ .. _. INSURANCE COVERAGE: 1 have a current liabililyinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND . OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best.of my knowledge , and that all plumbing work and installations performed under the permit issued for this application will be in compliar Pe all i nt rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME N LICENSE # © SIGNATURE MPeJP❑ CORPORATION❑#COPARTNERSHIP❑# LLC❑#� COMPANY NAME t ADDRESS 6 1 tq{� �t2t V1A The Commonwealth of Massachusetts z . Department of IndustrialAccidents a. d I Congress Street, Suite 100 '< Boston, MA. 02114-2017 -� . wwW mass gov/dia sy Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/1'lumbers. TO BE FILED WITH THE kERAUTTING AUTHORITY. Name (Business/Organization&dividual): Address: %S' 'u- City/State/Zip: /�.¢/J:�,��� Phone #: %'d' ,s.Td ' J-611 Are you an employer? Check the appropriate box: 1. ❑I am a em Toyer with :..: employees (full and/or part-time).* 2, am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), andwe havenQ.e loyees. [No workers' comp. insurance required.] Type of project ()Vequired): 7. ❑ New construction 8. F1 Remodeling 9. ❑ Demolition 10 [1 Building addition ILL] Electrical repairs or additions 12..0 Plumbing repairs or additions 13.0 Roof repairs 14.E] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. rContractors 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. ' X am an employer that is pYoviding workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: / y �' /' ��'��°/� City/State/Zip: Attach a copy of the workers' compepsation-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 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under thlopiFand genaldes ofperjury that the information provided aboviis truefrnd correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town.: Permit/License # 2,1' A Issuing Authority (circle one): i 1. Board of Health 2. BuildingDepartment 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 they empYoyees. 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 employes' is defined as "an individual, partnersWp, association, corporation or other legal entity, or any two or more of the foregoing engaged in. a joint enferprise, 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 constx act buildings in the commonwealth. for any applicant who has not produced acceptable evidence of compliance with the insurance coverage regmred." 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 0•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 Depah meat of 7Adustd-al 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 yo a'are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter'their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat 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 U-23-15 www.mass.gov/dia , 1,2 Date ... �/�A ... . 4. TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION fr ,SSACMUSEt This certifies that.�.......................!`.'.......�..` . has permission for gas installation ... ............ in the buildings of ...S. `..... :.. ... ...................... . J� at ..�. ........ v �"Pc North Andover, Mass. Fee... .... Lic. No.. FV . t?. ^ ..� � �G,..... . GAS INSPECTOR ' Check # (� c% 7 7260 a MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date / l (� l o NORTH ANDOVER, MASSACHUSETTS Building Locations—2 `ii Pl? U SAe- cT / Permit # Amount $ Owner's Name S, L41,&4 4/ New ❑ Renovation Replacement +� Plans Submitted ❑ SUB-BASEM ENT G7 x F w x Z > o Address 0 a "":ja IZ". w xIX. U < w x z w x w rA x z- W a U o `a o o W z o H o °o a> w z > 7 k Ip H `� o y w✓�✓s� BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR IST H. FLOOR (Print or type) Name, ° `I '/Pitot` 44 4F jO Check one: Certificate Installing Company ❑ Corp. Address 0 a "":ja �� -1� Panner. au-e-� 114 41 / Pv Business Te ep one Cl 7 k Ip 2-0[3Firm/Co. Name of Licensed Plumber or Gas Fitter y w✓�✓s� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0-- No � If you have checked yes, please in ' to the type coverage by checking 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. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and insta ns perfo ed under Permit Issued fo this application will be in compliance with all pertinent provisions of the Massa sett tate G�e and Char 142 of�Ge�, i Laws. City/Town VED (OFFICE USE ONLY) Signature of Licensed P�6ber Or Gas Fitter I [3 --Plumber n) 3Jo Gas Fitter acense Number easter MJourneyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AL4 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�bh Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I employees (fiill and/or part-time).* have hired the sub -contractors 2. E] I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and 'ts required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other t `.Yny applicant that checks bo #1 mils, also fill out the section- below show-;ing + ,,.,rt.=. c _ Homeowners who submit this affidavit indicating they are doing all work and then Hire outside contractors must su moit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensatio information, n insurance for my employees Below is the policy and job site Insurance Company Name: Policy # 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Simature: Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town 6. Other Contact Person: Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information an d 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 pe-rson 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 -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 iequ.-sled, 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 lime. 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 homeowner 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 lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Rsed 5 -26 -OS Fax # 617-72.7-7749 wvvw.mass.. aov/dia )36', S °."`° '• :"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that............................................................ 4........................... haspermission to perform .r--...................................................................... wiring in the building of....e. ............................................................................... at ...7f.......`.. :. .................................... . North Andover, Mass. 0.4' Fee �O,.............. Lic.No`37! A��.:........................:.............................. -ELECTRICAL INSPECTOR Check # THE09MM0NWE4LTH0FMASS4CHUSEM Office Use only Q _ DEPARTMWOFPUBLICS MY Permit No. BOARD OFFIREPROEMONRDGUTATIOAN527C7t1 120 ' Occupancy & Fees Checked APPLICATIONFOR PERMIT TO MWORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat o2 0�� O oZ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street A Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes [D No ® (Check Appropriate Box) Ed Purpose of Building si ►'lql� 7i4r�/>'y �S . Utility Authorization No. Q,� ?4? Existing Service A90 Amps 40 / Volts Overhead [;3 Underground a No. of Meters New Service v20� 6 AmpV90� Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work C X76- 2--7171-P7&- llee cr> r1 c40 a?OD #/s /O No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground oumd No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Nd. of Ranges No. of Air Cond. Total Tons No. of Detection and h! o. of Disposals No. of Heat Total Total f Pumps Tofis KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Connections a Other No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER ;imranoeCovaag� Pusilatbthenagtmarla�ofMaSsadit�Ga�aallaws Iha%eaaxmtliabldyhstrd=PchLyatcludatgCa VI* CograWortsstaf&aiait - YES NO IhawstlbmkbdNandpoafofs&neio#eOlii=YES U NO tfjcutmtcfiteiWYES,Plea9 wdc*ttteWofouwa bychadmgthe NR ANU [D' BOND amm r-1 ftmspeffy) rC4Y2 eecl I'n A W!l� cW/l F�ratirnDaie 7 d,'L FstinaodVakxcfEkctricdWak$ Jap, WoklDsw �`S`ila hlspictiDilleRegt> *d Rough Firtal u/il/ ttl// Signed unda'ie of FIRMNAME D tJ f 10 LioaiseNa 3 7 7396 Lica�see - Obe12l /�i 9/£Q4 377585 - ���� .--- Lioa>SeNo �/`'J &Eir sTei.Na (a/7- 79?— A c3 � T/ 1"h linrJ AUe , Sil 14,9 019040 -.�. AkTaNa /01-3,32-374,40 � OWNER'SMRANCEWAIV ;IammmthattheLioawdoesnotIng$reit,suanoeot orilcs>i tec atastogtaedbyMassadtitse�CanalLNS and#tetmysigtlatiliecnthspetmitaom,dlist (Please check one) Owner Agento CW Telephone No. PERMIT FEE $409 -- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 2f-- Omni fL(rint or Type)�% A I7� ass. Date AVYT 19.�k_ Permit # P.? 2. Building Location :• %�dS e Owner's Nam d" _ ,A c � ,� Type of Occupancy_ IR E51 -1'-) N 71 14 G� New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No ❑ Installing Company Name :2e'AeL2 T A .:�Am mA T rl �0 Check one: Certificate Address OJOA [ H Ih a ry `K1, ❑ Corporation M 7 H U E fJ r11 rl D ❑ Partnership Business Telephone l� •-�2 — 5 9 "7 ( 2--Firm/Co. Name of Licensed Plumber or Gas l=itter "�R f) D E P T A- a A M M II Tri c D INSURANCE COVERAGE: I have a current j bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Les, please Indicate the type coverage by checking the appropriate box A liability insurance. policy 0"" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent Q I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work -and installations performed under the pe ' i ued for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oft].ner Laws. BY T%.i.er f License: C� mber n ure of cen u _ or Gas fitter Title license Number eyman O C NL 0 OBESE IRS IS Installing Company Name :2e'AeL2 T A .:�Am mA T rl �0 Check one: Certificate Address OJOA [ H Ih a ry `K1, ❑ Corporation M 7 H U E fJ r11 rl D ❑ Partnership Business Telephone l� •-�2 — 5 9 "7 ( 2--Firm/Co. Name of Licensed Plumber or Gas l=itter "�R f) D E P T A- a A M M II Tri c D INSURANCE COVERAGE: I have a current j bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Les, please Indicate the type coverage by checking the appropriate box A liability insurance. policy 0"" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent Q I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work -and installations performed under the pe ' i ued for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oft].ner Laws. BY T%.i.er f License: C� mber n ure of cen u _ or Gas fitter Title license Number eyman O C NL z O U W a N 2 J a z F r IL H Q n O G O r _r ¢ o z d 0 W Z o_ r a v J 4 IL W W W z O U W a N 2 J a z tr. 83, Date .. �� �.i .......... TOWWOF NORTH ANDOVER --l-A, PERMIT FOR GAS INSTALLATION A FE This certifies that "M 44-1 • • • • • • • • • • • • • • • S M has permission for gas installation .. ! )f,. V ..................... in the buildings of ........................ . at.. —'i ....... North Andover, Mass. Fee. R .. ... Lic. .. ....................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer a .) I Z� -7 N2 z- 3 0 Date. A. ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ �0. has permission to perform.................................................. wiring in the building of .............. . .............. 1� .................. ....................... .......... at............................................................................... . North Andover, Mass. Feed..... ....... Lic. No . .......... -'s ................ i�...EC . .. TR . ICAL . ..........INsp . ....... EcTOR ................. 11/19/98 10:50 15,00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THE00MM0NWE4LTH0FAftMCHUSEI7S Office Use only DEPARTMFVTOMBLICSAFM Permit No. C -,el BOARD 0FFIREPREVEM70NREG 4TT0NS527CMR12:00 Occupancy & Fees Checked 1 APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00— (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 14MA419 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) -� V fro S 7 Qc Owner or Tenant /'h i ��� C. -o L -(e.1 Owner's Address Is this permit in conjunction with a building permit: Yes 1:3 No (Check Appropriate Box) Purpose of Building 01,01/, Utility Authorization No. Existing Service 0 Amps ca Dl 2.40volts Overhead Underground M No. of Meters t_._� New Service Amps / Volts Overhead Underground No. of meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work rP lece�MPit c5 .Pl No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 1:1round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No of Switch Outlets No. of Gas Burners FIRE ALARMS No. of zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices. Locala Municipal Other No of Dryers Heating Devices KW Connections a No of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP 1t- ranc e Co eaW- Riwam iDthe ragtmanats Laws I hale a arras Liability lrmratrce Pohq utckdutg CarrpklL- CoAzaWcr gs akgarmal e4avaki t YES NO 0 Iharea&imedvaWproofofsa{rr iDdrOffm YES M NO n Ifycm lmedcdwdYES, pleaseedc*theWofwAWbydak:ngthe Workuslat * pI/ 101 .� _ trspeWm *Rgx�d Stgred utxiaTie r a s ofl l FIRM NAME C'l�„ /�_ eine,, FtPe1s cGt Licensee�1 Signmn 4A-6— E�-), n,,—kPk 54. PI` Hn,ISS 7r.c/ OWNER'S INSURANCE WAVER; I amawA=d attheLi==(h and that my sigr iati nar this permit appticMm waises this tti#ume tt (Please check one) Owner M Agent Dai Estrnad VakredEkctrtcal Work $ Rough Final GT/ Lim -&No 3633h� Q Business Tel. Na Of ;29. 7 g$'• Cldg A— 01C,4� Alt Tel% 221-202'22(13 En the cnuranewymiWcrits albsontial eWndaitas tegtmW byM%sadtsem C..,araal Laws Ii Telephone No. PERMIT FEE $ 8 / Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received /0 , /� �6 IMPORTANT: Applicant must complete all items on this page LOCATION 7q I Q a S p,,' � 4 PROPERTY OWNER /1�-,t.. ° MAP NO.: -0 PARCEL: / TYPE AND USE OF BUILDING Print a, x, ,ti I '� Print ZONING DISTRICT: HISTORIC DISTRICT VFfi n ?D�t1l.ED 16'6NO� O q 1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 4Addition ❑ Alteration © One family ®-Two or more family No. of units: ❑ Industrial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only UtNUKIF 11UN UP W URK l U DB FREFURMED /� Identification Please Type or Pant Clearly) OWNER: Name: /c K., /1� e� �Mti Phone: 17f" -6e6 -721y Address: % ` ( 7 ,iso s CONTRACTOR Name: ke- %, &-, n ►-e ) Phone: W-- � 6- 7ZY Address: �/t( J ,..�,, ,•-l• �9- �(„�n �. Supervisor's Construction License: O S -7 1, y'S Exp. Date: (- ( �L - Z n- 7 Home Improvement License: t IT a- '714 O Exp. Date: - 2 6, 2—, ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S. F. Total Project Cost :$ FEE:$ Check No.: Receipt No.: Page I of 4 TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer � Well ❑ Tobacco Sales ❑ Food Packaging/Sales [I ❑ Permanent Dumpster on Site ❑ Private (septic tank, etc. Electric Meter location to prod ect NOTE: Persons contracting with nr iste}ed c t ctors do not have access to the guaran f nd Signature of Agent/Owner Signature of contractor. Plans Submitted /Z Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED 0 DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED 11 0 DATE APPROVED FIRE DEPARTMENT Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 1V V l LN and UAl A — (for department use SERVICES Created JMC. Jan.2006 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. 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