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HomeMy WebLinkAboutMiscellaneous - 75 EQUESTRIAN DRIVE 4/30/2018 (2)N J Date t � /- .. J ate .................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................:.. c ......... ......: r.. � .' ......: `''u`'�" '...... has permission to perform : .............................................................................. wiring in the building of ........... �-� :G.- ..��.: - ................................................. jj c- at ...f..✓ .......... r'�.z::.': r �,% . : !..-rte` `�.. , North Andover, Mass. / 1 \J �V / t ::.:.: Fee ..................... Lic. No............. ....................._................................... ELECTRICAL INSPECTOR n Check # �- Y Y WHITE: Applicant CANARY: Building Dept. PINK: Treasurer office use o y The Commonwealth of Massachusetts Permit No..�� Occupancy & Fee Checked Department of Public Safety 3/90 (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMH 12:00 RULE 8 Effective 1/1/78 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date /// C)/ O / City or Town of NV 1-� -e$q ��V�� To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) _ %'S Owner or Tenant 31 ^-N -v- C A 2.t P \e. c-k:.te.l ( _ Owner's Address Is this permit in conjuneti(T with.a building permit: Yes El No ® (Check Appropriate Box) Purpose of Building I St Utility Authorisation No. O 3 ,;� °1 r>.,? Existing Service a rJ Amps 00/ r 44C) Volts Overhead ❑ Undgrd. a No. of Meters l New Service Amps _ Volts Overhead ❑ Undgrd. ❑ No. of Meters— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work g ;.2 .z t f C -C No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above md. ❑ In- md. ❑ Generators KVA 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 Detection'artd V "• Initiating Devices No. of Sounding Devices g No. of Self Contained Detection/ Sounding Devices Locat❑ Municipal ❑ Other Connection No. of Ran Ranges Total No. of Air Cond. tons No. of Disposals No. of Heat Pumps Total Total Tons KW No. of Dishwashers Space/ Area Heating Key No. of Dryers Heating Devices KW No. of Water Heaters KW No. of Si ns No. of Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP Other: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insuran Policy including Completed Operations Coverage or its substantial equivalent. YES J@ NO ❑ I have submitted valid pro of same to this office. YES 44 NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 91 BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Wbrk $_ /9d0,00 (Expiration Date Work to Start l r 19/0 / Inspection Date Requested: Rough Final Signed under the penalties of perjury: _ FIRM NAME t MWv-� c4it, C, - L �AL. t4 t cc LIC. NO. 15--71( 9 e3 Licensee e ✓ t� L M ✓t^— Signature - LIC. NO. 15 -7/ g 14 Address ` 0. 13©A 7Q Lf 174 t o r g Y9 Bus. Tel. No. -9-21? ` 7- 9 7'7U- - G Alt. Tel. No. i�fiGeL_ c/757 �! %.i OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivale• as required. by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner ❑ Agent ❑ (please check one) —[!` Telephone No. PERMIT FEE $1" (Signature of Owner or Agent) Location i No. c-: / �' Date NaRT� TOWN OF NORTH ANDOVER .�?Ott `•O ,•,h� F 41 R Certificate Occupancy of $ s�►cNust Building/Frame /Frame Permit Fee $ 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f/ Check # T 1674 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING v t:�� t1 m Use Q,sl BUILDING PERMIT NUMBER:l DATE ISSUED: �`—o� 6 r SIGNATURE: C�Sz. Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 9 -/Pt y'LA:�i�2z 1.2 Assessors Map and Parcel Number: :). r® o t z� 3 Map Num Parcel Number 75 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 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: Public 0 Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 7"r^ ezA-clk Name (Print) Address for Serviccee Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: / , Licensed Construction Supervisor: 3 r, Add ess Signatu& Telephone Not Applicable ❑ 009;2 License Number Expiration Date 3.2 �cgistered Home Improvement Contractor Not Applicable ❑ Company Name �L!/[ Registration Number �Q Add ss ,,,,., 7 9(� " a � Si nature Telephone Expiration Date Nn Ou rn M Z O CN 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 Descri tion of Proposed Work check q lapplicable) New Construction ❑ Existing Building V Repair(s) Alterations(s) M'_ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief f,Description of Proposed Work: y� CA Al 6A lr X1_ J 7_h 5— 94y e l i w W,' A- Ntig:ii CrvVr— SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (t,) Q -� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 a 7 i Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf. in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as O Authorized ge 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 V 2�'t Print Na Signature Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEvMERS 1 ST 2 3RD 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: 71 A !J/i x�72ary VIL City12e./xGi Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity LD 1 am an employer providing workers' compensation for my employees working on this job. Company name: ZZ22,- Address Cihr If< G'Lt Phone # 7a - G TS - G'��( Companv name: /T!;1 City Phone Insurance Co. Policy Failure to secure coverage as required: under Section 25A or MGL 152 can lead to the k position of airrinat penallies of alfrne up to $1', and/or one yearsimprisonment-s weU-asimalpenalbesjn-tbolixm-da.STQPJ&VRKDRDEP-arAafme-ctISI-OD-OD)-ajdWmgaim.tmm understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for average verificafion. / do hereby cerfy unqpr the pans and pennies ofpe,7my /hat the information provider/ above a hue and correct. Signature Print name —Phone # 5V, - R/ S-k11 Official use only do not write in this area to be completed by city or town official' City or Town Pernill icensing. 0 Building Del (]Check d immediate response is required L kensinQ Bc Q seglectn?an's Contact person: Phone ik E Health Depai F] Other NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this' work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) J JPO / Signa e of Pe Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector J Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 102467 Board of Building Regulations and Standards Expiration: 7/2/2004 One Ashburton Place Rm 1301 Type: Private Corporation Boston, Ma. 02108 NEW ENGLAND CUSTOM DESIG fiat '(_anza 226 LOWELL ST- WILMINGTON, MA 01887C1�' Administrator Not valid ithout s___ re — ✓%e iDominzarN�ueccll� a� �aclucael7a BOARD OF BUILDING REGULATIONS License. CONSTRUCTION SUPERVISOR ' Number: CS 008828 ? Birth date: .04/20/1951 y�. Expires: 04/20/2004 Tr. no: 20132 Restricted: 00 VAL J LANZA 34 BIXBY ST REVERE, MA 02151 Administrator ACORD. CERTIFICATE OF LIABILITY INSURANC ID KC17DATE(MMIDD11EWEN-3/27/03 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DATE (MMIDDNY) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kilgore Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 33 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody MA 01960 03/14/04 Phone: 978-531-6550 Fax:978-531-9442 INSURERS AFFORDING COVERAGE INSURED PERSONAL ADV INJURY $ 1000000 INSURER A: One Beacon Insurance New England Custom Design INSURER B: Safety Insurance Company INSURER C: Travelers Prperty & Casualt Ron Weinberg 226 Lowell Street INSURER D: Wilmington MA 01887 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC INSURER E: rOVFRAnPq LIABILITY THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDNY) DATE MMIDDNY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR _ 03/14/03 03/14/04 EACH OCCURRENCE $ 1000000 FIRE DAMAGE(Anyonefire) $ 100000 MED EXP (Any one person) $ 5000 PERSONAL ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2 0 0 0 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS - COMPIOP AGG $2000000 AUTOMOBILE LIABILITY B ANY AUTO 62853 04/05/03 04/05/04 COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY (Per 250000 (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per 500000 (Per accident) PROPERTY DAMAGE $ 100000 (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY OCCUR F1 CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 7PNB503X108703 03/14/03 03/14/04 X TORY LIMITS ER E.L. EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYEE $100000 E.L. DISEASE -POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Office /Carpentry 1CDTICIr1ATC Ur\1 M1 M .. ._......... ..._..___ —• • • •• •--• • — • •�� av C ANL;tLL.A I ION XXDDESS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR ,kIPBILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR kCORD 25-S (7/97) ©ACORD CORPORATION 1988 C y 0GO 0 d 2 m C/) O m 0 O C7 C yc�dc m v Z m ="o H y � �: m Lo'O. -r = maim y C d �° -4 o m y o -� rte-► �. o imm m a z O n CO) Cl) CD H.. 014 °D �0 CD CD C N n Z y Crj a n c C �. co =r CL CDCIO CDc Cn ccc CL COO n �y co � c H d tom+. 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