HomeMy WebLinkAboutMiscellaneous - 743 JOHNSON STREET 4/30/2018 (2)O A
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Date ....
...................................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
70 ...........................................
has permission for gas in tallation ........ I�v ..........................................................
in the buildings of ............... ...................................
........... ...........................................
.
///,3 E�- Morth Andover, Mass.
at................................................................................................. .
........
Fe ...........
Fee -S'0:. Lic. No. j
US INSAECTOR
Check #.
9827
`
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING
WORK
CITY
MA DATE PERMIT #
JOBSITE ADDRESS OWNER'S NAME
`lJ
OWNER ADDRESS TEL FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALY
CLEARLY
NEW:' RENOVATION: REPLACEMENT:PLANS SUBMITTED: YES NOk
APPLIANCES I FLOORS- 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
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES )(NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY k/ OTHER TYPE INDEMNITY i 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.
C
SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true accurate to the b of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in
comp an with all Pe nent p o sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 IGNATU
MP )( MGF JP JGF LPGI CORPORATION# 3631 C PARTNERSHIP #: LLC:: #:
COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224
FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com
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The Commonwealth of Massachaasetts
r
Department of Industrial Accidents
IOffice of Investigations
l' 600 Washington Street
Boston, AM 02111
www.mass.gov/dia
Workers' Compe>insation, Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Name (Business/Organization/Individual): L j
Address:
.'t'Z-'_Y/
/State/Zi �' ' ` r�
p: ,�/,t'lr,li;� riv. iJ �� c%/��:�� Phone 4:
Are you an employer? Check the appropriate box:
I am a employer with &,1— 4. ❑ I am a general contractor and I
employees (fill] and/or part-time).* have hired the sub -contractors
❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] 1
employees and have workers'
comp. insurance.+
5. ❑ We are a corporation and its
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
10.0 Electrical repairs or additions
l 1.❑ Plumbing repan-s or additions
12.❑ Roof repa'
13.Other
'Any applicant that checks box #11 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. )f the sub -contractors have employees, they must provide their workers' comp. policy number.
P am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
`1 information. 01 1
Insurance Company Name: &
i
Policy # or Self -ins. Lic. #:Expb-ation Date:
Job Site Address: �,��,9 fCity/State/Zip: 11,1 ele' 5'D
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 tip 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�yerifrcation.
I do hereby cerf1fjYunrkr the
tu>y tat the information provider! Bove is true and correct.
Official use only. Do not write in this area, to be completer) by city or town official.
City or Town:
Issuing Authority (circle one):
L Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
City/Torun Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone #:
BMW_
DateloZ�l? ...
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
1/1)
This certifies that ../X,*7F7,e f7 ...
has permission to perform .... (�&y .....................................
plumbing in the buildings of... ......
at ... 74/. 8 .. .. �e:A. P xfo! Q
Fee,4�.,.6'-) .... Lic. No.,
Check #
.................................................................................
.........s-,..........! ,North Andover, Mass.
.
............
.....................................
VUMBING 14PECTOR
Date ...... io�hi&Ll ..............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies 44", 111,14 12 ...................................
haspermissionfor gas installation ... Z)X*... . . . .... .............................
In the buildings of .......................... A .........
at .... Z44
............ W
... .........:.:.5 ............:.
Fee:.1,�.... ..... Lic. NoAk.P...
.......................................................................
............. . . NVolliAnIdlover, Mass.
...... ... .. . ...................
.......... ...........................
GA NSPECTOR
`
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING
WORK
CITY MA DATE/al PERMIT# tt 09 J-L�
JOBSITE ADDRESS'S / �� �� OWNER'S NAME '10!GkeAi
GOWNER
ADDRESS TELPg,W-4-"y FAX,
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARLY
NEW:' RENOVATION: REPLACEMENT PLANS SUBMITTED: YES N0�
APPLIANCES Z FLOORS— 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
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER {
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I�NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYX OTHER TYPE INDEMNITY BOND j
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.
C
SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER AGENT
-hereby
[T certify that all of the details and information I have submitted or entered regarding this application are true an accurate to the best of m nowledge
i
and that all plumbing work and installations performed under the permit issued for this application will be in
comp c with all Pertinent ovisio the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE
MP%/. MGF JP JGF LPGI CORPORATION # 3631 C PARTNERSHIP #. LLC #
COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
CITY Methuen STATE MA ZIP. 01844 TEL 978-689-0224
FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�,
� Lv��,
CITY �,�/� MA DATE /p� /� PERMIT #
4
JOBSITE ADDRESS �i%,�Je"�iJ/111e/ OWNER'S NAME
OWNER ADDRESS TEL; �� �� FAX
_.
f•
TYPE OR
OCCUPANCY TYPE COMMERCIAL' . ' EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION REPLACEMENT: PLANS SUBMITTED: YES
NO
,'
FIXTURES -1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12
13 14
BATHTUB
_.
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM W
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM ;
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I'
DISHWASHER 3 I
I
DRINKING FOUNTAIN f'
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY it 'i i. ,.
.
,
ROOF DRAIN
SHOWER STALL 3
SERVICE I MOP SINK ,
TOILET
URINAL . , t -_:._
_.
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
,
f;
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY t BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER m ' AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are truecurate to the best of m
knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli nc with all Pe inen rovisi
Massachusetts State Plumbing Code Chapter 142 General
of the
and of the Laws.
.. _ __ .._. _.
PLUMBER'S NAME Peter G Vlens LICENSE # ; 12116 SIGNATURE
_.._._ .. , _ ..._.... .___..._.. ,.....__.._......
MP' -` JP,- CORPORATION #` 3631 C 'PARTNERSHIP # LLC ,,,,• #
_ ..... __....._... .. ,. _..._._.__.
..
COMPANY NAME Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
.. -_.,_,..
CITY; Methuen ;STATE MA ZIP 01844 TEL . 978-689-0224
_.
FAX ! 978-689-2206 ' CELL , 978-807-281 9
78 807-2819 EMAIL 'pviens@mvalleycorp.com
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21
^Commonwealth of Massachusetts
Department of Public Safety
Hoisting Engineer
License: HE -110323
PETER G VIENS-
9 BLUEBIRD Ll It
ATKINSON NH- 03 `
J
Expiration: Commissioner ,e tat 11/13/2015
State of
GAS FITTER
NAME: PETER
Hampshire
ENSE
f
I STP
DATE ISSUED: 10/15/2013
DATE EXPIRES: 11/30/2015
LICENSE #:GFE0700587
I certify that I have examined
inaccordance with the FederarMoTor Carrier Safety FVEjulations (49 C.W 391.41.391.49) and with knowledge
of the driving duties, I find this person is qualified; and, if applicable, only when:
❑ wearing corrective lenses ❑ driving within an exempt intracity zone (49 CFR 391.62) -
❑ wearing hearing aid ❑ accompanied by a Skill Performance Evaluation Certificate (SPE)
❑ accompanied by a ❑ qualified by operation of 49 CFR 391.64
waiver/exemption
The information I have provided regarding this physical examination is true and complete. A complete examination
form with anv attachment embodies my findings cmmnletely and cnrrectly- and is nn fila in my nffice.
SIGNATURE OF MEDICAL EXAMINER
0 a
UMMVIVWrAL117; Vt MA.JKtif7V�L
tv•=vmmv��rchi>+ n yr :mcaravnvvc.•. rAM
• • • • 'sr
..
• • • � � •� •
❑ MD ❑ Chiropractor
F BOARD OF
PLUMBE1f5 fldD GIISF I ITERS
;
$I
ARS OF
PLUMBERS A1dD GASi ITT1:R5
} ISSUES THF FOLLOWf=AIG L i'CENSE<
ISSUES THE FOLLOW] NG`
L I LENS
L I GEN D AS A JOURNEYMAN PLUMB
f1 EEUSED ASA
P IfkB.ER.
CDL
.MASTER
FETE IR. G • V I ENS
t
❑YES NO
w,hL cj
i x :
�
PETER :G V i ENS
t,
'r�
8°LUEBIf2D iANE;�
Ems'®p�
9� ' v�
9 BLUESI-RB' LANERi
r
t,
TK:I NSON.„ H 03811-2302
ATr=1 MON NH 0381 1-2302
:>
21
^Commonwealth of Massachusetts
Department of Public Safety
Hoisting Engineer
License: HE -110323
PETER G VIENS-
9 BLUEBIRD Ll It
ATKINSON NH- 03 `
J
Expiration: Commissioner ,e tat 11/13/2015
State of
GAS FITTER
NAME: PETER
Hampshire
ENSE
f
I STP
DATE ISSUED: 10/15/2013
DATE EXPIRES: 11/30/2015
LICENSE #:GFE0700587
I certify that I have examined
inaccordance with the FederarMoTor Carrier Safety FVEjulations (49 C.W 391.41.391.49) and with knowledge
of the driving duties, I find this person is qualified; and, if applicable, only when:
❑ wearing corrective lenses ❑ driving within an exempt intracity zone (49 CFR 391.62) -
❑ wearing hearing aid ❑ accompanied by a Skill Performance Evaluation Certificate (SPE)
❑ accompanied by a ❑ qualified by operation of 49 CFR 391.64
waiver/exemption
The information I have provided regarding this physical examination is true and complete. A complete examination
form with anv attachment embodies my findings cmmnletely and cnrrectly- and is nn fila in my nffice.
SIGNATURE OF MEDICAL EXAMINER
T EPHO E
�c�i84�.✓ �
DATE
l/
ME AL EXAMINER'S NAME (PRINT)
NAME: PETER (&ENSp
❑ MD ❑ Chiropractor
V���'"�c✓ao o'9z�C�
[1130A dvanced
Practice Nurse
MEDICAL EXAMINER'S LICENSE OR CERTIFICATE N0.
ISSUING STATE
❑ Physician ❑ Other
Assistant Practitioner
NATIONAL REGISTRY NO.
SIGNATl1R OF IVER
INTRASTATE
CDL
ONLY
❑YESNO
❑YES NO
DRIVER'S LICENSE NO.
STATE
ADDRESS OF DRIVER .
9 113�kA-�Ze
MEDICAL CERTIFICATION EXPIRATION DATC'
Ems'®p�
FLY 1 ®HIVEH PLY 2 MOTOR CARRIER
26520 (5/13)
121 ib " 05J01/>1:b 213,E
i ,
�.
Commonwealth of Massachusetts
:10
Department of Public Safety
Pipe#itter Journeyman
License: PJ -028388 �lip`Qr
PETER G VIENS
9 BLUEBIRD Lr o ! 1
ATKINSON NH;a3811
`✓.�..� may,► t++`� Expiration:
Commissioner
11/13/2015
STATE OF NEW HAMPSHIRE
BUREAU OF BUILDING SAFETY & CONSTRUCTION
PLUMBING SAFETY SECTION
NAME: PETER (&ENSp
r
LIC #: 3249 M{ r
EXPIRES: 11/30/2014
f'
w -I- ra i s
*y�MEiv,
Peter Viens
Cert #
a_
1023121001-12
Expires: 10/23/2015
Certification
N. F. P.A. 99-2012 ed.
ASSE 6010 Installer & ASME IX Brazier
OSHA 600316337
U.S. Department of Labor
Occupational Safety and Health Administration
Peter Viens
has successfully completed a 30 -hour Occupational Safety and Health
Training Course in
Construction Safety & Health
} R ue /2
The Commonwealth of Massach aasetts
r
Department of Indarstrial Accidents
5 ( Office of Investigations
600 Washington Street
4: BO.stort, AM 02111
www-mass.gov/dia
!Workers' tColnpensaiflu 1D Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/individual):
Address: ,cJ
City/State/Zi Phone #:
Are you an employer? Check the appropriate box:
I am a employer with 4. ❑ I am a general contractor and l
employees (fit]] and/or part-time).'' have hired the sub -contractors
❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.!
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] f
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
C. 152, §l(4), and we have no
employees. [No workers'
comp. insurance reouired.l
M
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof Z"014ee
'13.�.Other63/0-1-1 i
'Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,� _nil f_ Z S j(!qt il:a �., /��.
i
Policy # or Self ins. Lic. Expiration Date:
Job Site Address: 773 City/State/Zip: /(��,y,�p�!//%r� Bj�✓'�
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 i reposition 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 tip 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
pains rd pend es of perjury that the
Aw �rAwv
provided above it true and correct.
Official use only. Do not write in this area, to be completer) by city or town officio!
City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Torun Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Date...J/.-.r .-.e.7
0*
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................ K ....... � . 5,x-/......................................
has permission to perform ......... M.0 a/ en F-
. ......................................................
wiring in the building of ........... ...... ?V. C1.11 --i ..............................
at .................
.V .... North Andover, Mass.
Fee ..35—!!�� . Lic. No. 7 Zj=�- Ole
......... .......... ..... *"****"**, PI/4 '0!0�4
. ........
ELECTRICAL INSPECTOR
Check # /0/"F
7791
N Commonwealth of Massachusetts Officia
l
-U7se Only
Department of l=/ire Services Permit No. 77LZ
_F1_BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/99] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1.1./2/2007
Cit or Town of: North Andover To the Inspector of Wires:
By th s application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 743 Johnson Street
Owner or Tenant Kristina Niccoh Telephone No. 978-685-4536
Owner's Address same
Is this permit in conjunction with a building permit? Yes ❑ No X Servo # 360-1550
Purpose of Building
Utility Authorization No.
Existing Service 100 Amps 110 /220 Volts Overhead X
New Service 100 Amps 110 /220 Volts Overhead X
Number of Feeders and Ampacity
Undgrd ❑
Undgrd ❑
No. of Meters 1
No. of Meters 1
Location and Nature of Proposed Electricals 'Work: Replace current 1.00 amp service with new 100 amp service
Completion ofthefiollowing table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑In- ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
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
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs _
No. of Motors Total HP'
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:.
.Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK_ ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) On File
Estimated Value of Electrical Work: 1600
(When required by municipal policy.)
Feb/2008
(Expiration Date)
Work to Start: 11/2/2007 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
LIC. NO.:
Licensee: Kelly M. Casey Signature LIC. NO.: 37200 L -
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-697-4453
Address: 700 Robbins Ave Unit 3 Dracut, Mass 01826 Alt. Tel. 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 FPERMIT FEE. $ 45
Signature Telephone No.
Date..................................
NORTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................ 4.4r& ....... C'etsy.c...............................
has permission to perform .................. kt.-TZMA.al ...................................
/V [ Z-- 04� 1
wiring in the building of ..... h� ......................... ,:L- ................................................
v- -, $—
at ........... 3 ........ S ................. . North Andover, Mass.
Fee..t-/ Lic. No,3T.....:a ..................!•...............
.. �- --tjI-.......
ELECTRICAL . ..
Check # 10/7-
.7792
.�
Commonwealth of Massachusetts Official Use Only
NO
Department of l=ire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/991 leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11/2/2007
City or Town of. North Andover To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 743 Johnson Street
Owner or Tenant Kristina Niccoli Telephone No. 978-685-4536
Owner's Address same _
Is this permit in conjunction with a building permit? Yes ❑ No X Servo
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts OverheadUndgrd ❑ No. of Meters
New Service Amps / Volts OverheadUndgrd ❑ No. of Meters
Number of Feeders and Ampacity _
Install new wire to dishwasher, microwave, refrigerator and counter outlets. install under cabinet lighting.
Comnletion ofthe %Ilowine table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil.-Sus P (Paddle) Fans
s Total
of
TransKVA
No. of Lighting Outlets 3
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets 5
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection andInitiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
_
No. of Waste Disposers
P osers
Heat Pump
Totals:
Number.
Tons
KW
.....
No. of Self -Contained
Detection/Alerting Devices
_
No. of Dishwashers 1
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Sec No of Devi es or Equivalent
No. of Water
Heaters KW
No. of No. of
Ballasts
Data Wiring:
No. of Devices or Equivalent
No. II -dromassa a Bathtubs - -
3 g
_Signs
No. (if Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) On File
Estimated Value of Electrical Work: 2800 (When required by municipal policy.)
Feb/2008
(Expiration Date)
Work to Start: 10/24/2007 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
Licensee: Kelly M. Casey _ Signatures
(If applicable, enter "exempt" in the license number line)
Address: 700 Robbins Ave Unit 3 Dracut, Mass 01826
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does
required by law. By my signature below, I hereby waive this requirement.
Owner/Agent
Signature Telephone No.
LIC. NO.:
LIC. NO.: 37200 0
Bus. Tel. No.:
Alt. Tel. No.:
not have the-Tiability insurance coverage normally
I am the (check one) ❑ owner ❑ owner's agent.
PERMIT FEE: $ 35
I
`F'• • �••
Date..! G. •••••
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
9 ..y •
This certifies that ......................
has permission for gas installation ^ ...................
in the buildings of ..1, c c d / .............................
at ...7. `.x2.1.6 e !.......... , North Andover, Mass.
s
Fee..?.).'—... Lic. No.. x.33. ?... ... Q-._.( - .. .
GAS INSPECTOR
Check # ! 5
5344
____ a .. - � tib ,. • i
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... ee�eieieieeeeiete==ieum=
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• • • • e��eiee��e�e�ee��eeiieee�e�eie�ee�IN
... �eeeeie�ie�eeie�iee�eieeiei�e�e�eie
... 1e��e�eee�ee�v�ee��enee�eiiee�e�INee
Installing Company Name
4ddress
Check one: Certificate
'M IVA ❑ Corporation
r
lusiness Telephone ,U ❑ Partnership
--U.
lame of licensed Plumber. or Cas Fitter irm�Co.
INSURANCE COVERAGE:
'I have a current 11 blllty Insurance policy or Its substantial equivalent;
Yes No ❑ which meet; the requirements of MCL Ch 742.
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability Insurance policy / Other
type of indemnify ❑ Bond ❑
OWIER'S INSURNAiCE WAIVER: I am aware that the licensee does not have the Insurance coverage required
142 of the Mass. General Laws, and that my signature on s per a
ppllcation valves this requi ement by Chapter
Signature o Owner orOwners Age -n- Check one:
Owner ❑ Agent ❑
,ereby certify that all of the details and Information I have submitted Ior enterecil In above a are true and accurate to the best of
r knowledge and that all plumbing work and Installations performed under the permit Is Le
application
pertinent provisions of the Massachusetts S tate Gas code and Chapter 142 of the Ce
r this application be In compliance with
By Type of License:
Tide ❑ Plumber
Cityrrown ❑Casfitter S gn re ofL tensed Plu ber orCas Fitter
APPROVED (OFFICE USE 0 Y) 10ter License Number e
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Building Inspector
Div..Public Works
Location
-
No. _ .
Date
' NORTh
TOWN OF NORTH ANDOVER
3? : , • c `
tin
. - A
Certificate of Occupancy
$ n'
Building/Frame Permit Fee
$
SACHUSE
Foundation Permit Fee
$ -+
Other Permit Fee
$ t
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL w�
$f -
Building Inspector
Div..Public Works
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Location ` S d til �
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No. ��� Date 17,1`°
„°RTM TOWN OR NORTH ANDOVER
F w
s
• � ; . Certificate of Occupancy $
�' b'•^° Eta Building/Frame Permit Fee $ o
CHus
Foundation Permit Fee $
Other Permit Fee $ /
TOTAL $
Check # 800 Q,
4 16515 t
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building CommissioEEInSR&tor of Buildings Date
SECTION 1- SITE INFORMATION
Ll. Property Address:
1.2 Assessors Map and Parcel Number:
/
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Re red
Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes O
2.1 Owner of Record
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
e
/7 i6mL.7 1-/2 Jo14hrJc&I Sr
'Name Print Address for Service:
1'
4
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
�'Z,q'%va 1 o Pr 7 r/"I vyf nK b Vr1z
Licensed Construction Supervisor:
Q
License Number
�s � �rc/
/� (l � r �'/L r,/ L.. N ��✓1� � -/lv .tn it
Address
C1
Expiration Date
SignattwC Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
` 7 / "' -� L/� c `' / x.27 r K t; is Rr
Registration Number
Address
Expiration ate'Sigi
7 3 'r✓ S
ature Telephone
P
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 A s licable
New Construction ❑ 1 Existing Building ❑ I Repair(s) ❑ IAlterations(s) ❑ Addition ❑
Accessory Bldg. ❑ I Demolition ❑ ( Other ❑ Specify
Brief Description of Proposed Work:
I SECTION 6 - F.STIMATFI) r0NCTU1TVT1nN rnCTC I
Item
Estimated Cost (Dollar) to be
Completed by permit applicantqM��
�, �OCIi`O
(a) Building Permit Fee
Multiplier
y�� ,
., A
1. Building/5
O
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
JLCk,IWf4 isUWAJKKAUIHURIZATIOIN TO BE COMPLETED WIZEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, ��� `f,Mv �• 1 ;�,� ,.h ,': r o �� f�c ,as Owner/ orized Age f 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 me
Si a f Owner/Agent / Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRVIBERS iST 2 ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
t Jize T�arrr�rranurea.�� a�✓�,a<1vaciu�dr�1G
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 046636
I Birthdate: 06/02/1948
Expires: 06/02/2005 Tr. no: 11256
Restricted: 1 G
RAYMOND E DAMPHOUSSE JRA� / �p
75 BUTTERNUT LANE
METHUEN, MA 01844 Administrator
r /
�\ ✓le �arnmz.a9uuea�, o�._ �/(aJaa��r�.de�d
-- lloard of Building Regulations and Standards
r, F HOME IMPROVEMENT CONTRACTOR
y Registration: 101862
Expiration: 6/29/2004
Type: Private Corporation
RAYMOND E. DAMPHOUSSE, JR.
flaymonconicd Damphousse, Jr.
75 Butternut Lane
Methuen, MA 01844 Administrator
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RAYMOND E. DAMPHOOSSE, JR. AND SONS
ROOFING CO., INC.
BOX 431 LAWRENCE P.O.
MA. CONSTRUCTION LAWRENCE, MA 01842
SUPERVISOR LIC. #048636 TEL: ( 978) 683-4588
HOME IMPROVEMENT
REG. #101862 ROOFING — SIDING — INSULATION
Date z
From: ��/�'�( �l%� f:� i'� �.I c*J .i
(Name) (Address)
To: UTNOND L DAIRNOOSSE, 1!. AND SONS ROOM CO., OIC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842
I (we) hereby authorize the Contractor to furnish all materials and labor necessary to Install, construct and place the
improvements described below In -on building located at No. ,/ �.���"�� moi' Street,
City � State ��• X -1 in accordance with the following specifications:
/1 "A r,! tit :, ii l'
ils° i./ � `i �_ ✓.,!��� t f � <•� t;/n..,°`i 1 -ti `rte i �' � �1 �� " i.:�F �'3 (-'L.-;"�- i 1'% � r'7 1'J � r'-(1 (' . rte% !�
°'"� /�./ i; i� �; .tel' j (' /1' ..l�.r--- � -� %� / ' f� ri �� •.�.� ,/� %' /a'' !'1 f1 , (..
rfGIC
All of the above work to be done in a good and workmanlike manner.
All men and equipment Insured. Premises to be left clean upon completion of work.
For the total sum of
dollars. �".
Entire Sum to be paid immediately upon completion in accordance with plan as shown below.
rG"G'Lt
TOTAL CASH SELLING PRICE .......... S l7 "1 rr "
DOWN PAYMENT IN CASH .............
DEFERRED BALANCE
UPON COMPLETION ...... . ...........
The undersigned agrees to keep property mentioned in this agreement properly insured against loss by fire including the
Contractor's interest therein.
This agreement shall become binding only upon the written acceptance hereof by said Contractor, and upon such acceptance
this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promises or agreements,
written or oral except as herein set forth. It is the intention of the parties hereto that this contract shall be binding upon their respective
heirs, executors, administrators, successors and assigns.
Customer agrees to pay a reasonable sum as attorney's fees and Court Costs if placed in hands of attorney for collection.
The owner further agrees that in event of cancellation of This contract after acceptance by the contractor and before the work is
commenced the OWNER agrees to pay 20% of the total consideration herein named as liquidated damages for breach of contract.
Said contractor shall not be responsible for damage or delay due to strikes, fires, accidents, or other causes beyond his
reasonable control.
We, the undersigned, certify that we are the sole owners of the property herein described on which said work or repairs are
to be performed.
IN WITNESS WHEREOF, the undersigned has (have) hereunto set his (their) hand(s) and seal(s) the day and year written above.
Accepted By
RAYMOND E. DAMPHOUSSE, JR. AND SONS
.erfgd'
Mail Address
(If different from above)