HomeMy WebLinkAboutMiscellaneous - 75 GRANVILLE LANE 4/30/2018 (2)Date........ .. ... .... ..... ....:/.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
e7 -
Thiscertifies that ........................... .....//....ff....,,.................................................................................
has permission to perform ............'7�/..r-... 7 .......................................
wiring in the building of ..................................... .. .` .. . ..........................
at .......... ,, 5`.(9�%2�'?.?.C..l................... -, ,North Andover, M ss.
Fee.... .............. Lic. No...C�.1�
ACTRICAL INSPECT R
{ Check #
e? �f 7
Q Official Use Only
c Commonwealth of Massachusetts
Permit No. 12-9-9-7
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (INEF), 537 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL MFORMATI0A9 Date: lzlyll
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his r her intentiopitoperform the electrical work described below.
Location (Street & Number) -7 U G fl
Owner or Tenant A(om,) i1 Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Ys ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
CoinDletion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ce% Susp. (Paddle) Fans
TransTotal
Trsformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No, of Waste Dis posers
p
Heat Pump
Totals:
Number
-"'
Tons
KW _
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
SecuriNoto Devic : 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 E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: -_ 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
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such overage ism force, and has exhibited proof o ame tq�he permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify/r/`�
Y certify, under tlzepains a d nalt'e ofp rjury, th tl ormatronlllllon ```tlzrs application is true and complete zz
FIRM NAME:. ✓ I LIC, NO. • J ✓3
Licensee: Si nat a LTC. NO.:
(Ifapplicable, enter `exe pt' in the i ense numb umb 1' e.) Bus. Tel. No.:
Address: Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security Work requires DepaMent 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
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of 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 concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass n
Failed IN
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSP CTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:—/4/11
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
ii
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
Name (Business/Organization/Individual): J -v,
Address: 5-8- C, (j,,4/t _-
City/State/Zip:
Phone #: C't 7 0 6 f3—ff3�
A e ou an employer? Check the appropriate box:
Type o/ewconstruction t (required):
1.�J, am a em to er with _
P Y
4. ❑ I am a general contractor and I
have hired the sub -contractors
6. � `
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
�• E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
workingfor me in an capacity.
y p ty
workers' comp. insurance.
9 E] Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
1111 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'
13. [i Other
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 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 their workers' comp. policy information.
lam an employer that is providing orkers' compensation insurance for my employees. Below is the policy and job site
information. 7„ 1,' "
Insurance Company
Policy # or Self -ins. Lie. #: t U Q ' Expiration Date:
Job Site Address: �e1�� 4 4� /�/ 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 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.
r Y do hereby cert uj.*A tlzg p,&fn� ani penalties of perjury that the information provided above is trice and correct.
Sip -nature: /(__/' Date:
Phone #: �,9 a,3— MJ
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 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 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 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
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 of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0211 t
Tel, # 617-727_4900 ext 406 or 1-577rMASSA.FE
Revised 5-26-05 Fax ## 617-727-7749
vvwwanass,govldia
Date.....................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that....................................................`.L,..........:..........
has permission to perform ..... !, ............,+P..,. .....
° `�..-c
..................
wiring in the building of.!......./, Q--
at ................................�icvv � �...C........�G/
,North Andover, Mass.
Fee......0�.....".....r....... Lic. No. !..ci %....................................................................................
ELECTRICAL INSPECTOR
Check #
3 1,3
I-Ild----
we
i
4
Commonwealth o/
eLlePartmeni o��ire �ervice�
BOARD OF FIRE PREVENTION REGULATIONS
Print Form
Official Use Only
/3 Permit No. d &
Occupancy and Fee Checked
[Rev. 1/07] 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 W INK OR TYPE ALL WFORMATION) Date: �! 1 ��/ Iv
City or Town of: �T ' 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)
Owner or Tenant Qf},e/,y /� p¢�j,�� Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes : No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
r Location and Nature of Proposed Electrical Work:,
Completion of thefollowing table may be waived by the Inspector of Wires.
No. of Recessed Luminaires / 2
No. of Ceil: (Paddle) Fans
of Total
TransSusp.
Trsformers KVA
No. of Luminaire Outlets 3
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ElIn- ❑
rnd. rnd.
o. o mergency ig ng
Battery Units
No. of Receptacle Outlets Q
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches Q
!J
No. of Gas Burners
No. of Detection and
Initiatin Devices
No. of Ranges
No. of Air Cond. Total Tons
No. Alerting Devices
g o. o
No. of Waste Disposers
Heat Pump
Number
Tons
KW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers j
Space/Area Heating KW
Local ❑ Municipal ❑Other
Connection
No. of Dryers
Heating Appliances KWSecurity
Systems:*
No. of Devices or Equivalent
No. of Water Imo'No.
of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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
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 ❑✓ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that the information on thi ap lica o true and complete.
FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC. NO.:
Licensee: DAVID HAGGAR Signature LIC. NO.: 14963
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-682-6262
Address: 87 BELMONT ST, NORTH ANDOVER, MA. 01845 Alt. Tel. No.: 978-375-5734
*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
Signature Telephone No.
PERMIT FEE. S
4►
A
h
v
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
,a- Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC
Address. s 87 BELMONT ST - - -
___-
11 City/State/Zip: NORTH ANDOVER,A. M 01845_ -, phone #: 978-682-6262-
Are you an employer? Check the appropriate bog:
1. M I am a employer with 4
4.E] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 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.
workers' comp. insurance.
[No workers' comp. insurance
5. L We are a corporation and its
required.]
officers have exercised their
3. El I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. L Remodeling
8. Demolition
9. L Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12. [ l Roof repairs
13. El Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. -- - - --
Insurance Company Name: FEDERATED INSURANCE
Policy # or Self -ins. Lic. # 9353694-- _ - _- _. Expiration Date: 11 3-1-17
Job Site Address: -- City/State/Zip: �✓ -- �t
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�di! / p/f of perjury that the information provided above is true and correct
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 #:
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DE»MyO�yLISH A ONE TWO FAMILY DWELLING
#OR
FW:
BUILDING PERMIT NUMBER: 5a� DATE ISSUED:
SIGNATURE:
Building CoimissionerflRuEstor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
-T 5 &M\a-iVe- �-,AN t
1.2 Assessors Map and Parcel Number:
10 �
Map Number Parcel Number
1 2 N- y� `
t 1 du
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 R redProvided
RecjWred Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
'C=,0 -2,W P�uv k 1 s G- -e L
Name (Print) Address for Service
Signature Telephone
2a wner of Record:
i
Name Print Address for Service:
Signature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
A-
Addn
«oon i O 3
Signal u e Telephone
1
Not Applicable ❑
License Number
00
Expiration Date
3.2 Registered Home Improvement Contractor
-Fr 4 CL
Not Applicable ❑
Company Name
5 , N S4-
Registration Number
t', I I I 10 4j
Address
Gt/� r
Expiration Date
Si nature Telephone
SECTION 4 - WORKERS COMPENSATION (1VLG.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 ....... V No ....... ❑
SECTION 5 Descri tion of Proposed Work check all
applicable)
New Construction ❑
Existing Building
Repair(s) ❑
TAlterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
�'� � •J � � � Gamic St s }'�'�� S G 2'e-`� -�✓
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE (;1Nh.3t
1. Building
Ga -7
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X bbl
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
a- i `'1
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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, ir•R—Q 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
•e S �'� S �✓i
Print Nam ) j /
Signature of wner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST2ND 3RU
SPAN
DIIV ENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvMY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
r--
NOV-09-00 TUE 01:2"s PM HAMILL TAW -4
TUE 13:02 F_iX 978 470 8MR1 DEPWOLFE AWDUVEX
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers` Compensation Insurance Affidavit
Name Please Print
Name:
Location:fi-
City / " A vJ Phone #
I am a homeowner performing all work myself.
E21 -
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this joix
Company name:
Address
QW. Ptti�r►e#. ,
Insurance Co. POOH
Company name:
Addrfts: .
t �rCir:'
Fa kwe to some coverage as required under Seebon25A or tI X 152 carr lead ta#w kripwbm otab.* perrallim cf"
andlor one WOW
imprisorxr�t_vieelLassa47 pmattFes�ul6eiamn�ta ;fios�€iAA�eriay
understand that a copy of this statemerd may be t anded to the office of kn estigabons of the DIA for coverage veracauch.
/ do hereby car* user fhe pam and penaAties cf perjury fhst the Mamffw pov**d above as true and cmal
0
Print name ?ham # G '6a
�
Official use only do not write in this area b be completed by city or town drziar
City or Town
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 a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
n, -\-e I % b 6 e 0lz,5 -e + C)
(Location of Facility)
Signature of Permit Applicant
3Z, �o y
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
0.
0
Building and Remodeling
5 Appleton Street
North Andover, MA 01845
(978) 682 2023
Proposal Submitted To:
Darrin and Elaine Manke
75 Granville lane
North Andover, MA 01845
Job: Re -build Screen porch
Proposal
January 14, 2004
Home Phone: (978)687-5333
Cell Phone: ( 978)
Obtain building permit
Complete removal of all demolition and construction materials
generated by Testa Building and Remodeling and its subcontractors.
CONSTRUCTION:
Remove all rotted wood around screen porch. Check footings and if not big enough
Re pour new footings.. Plywood over the deck boards. Insulate the floor with r-19 fiberglass
insulation and plywood the underneath of the floor with'/ cdx fir plywood to prevent the insulation
from falling and from getting moist. Install 2 VS306 Velux skylights in the roof. Make the ceiling
cathedral. All new Anderson casement windows. The windows will be white and come with grills and
screens). The room will be wired to code and have 6 recessed lights and one ceiling fan ( supplied by
owners). The walls will be plastered .
A finance charge of V/2% per month (18% per year) will apply to all accounts over 30 days past due. In the event collection activity
is required the customer shall be responsible for all costs associated with collection, including reasonable attorney's fees.
I propose hereby to furnish material and labor complete in accordance with above
specifications, for the sum of:
$ 26,724 Twenty Six thousand seven hundred twenty four Dollars
One third to start One third after plaster and final third when completed.
Authorized signature
I reserve the right to cancel this contract if not accepted in_30_ days
Signature
Signature
' Proposal 2
List of work to be done.
Repair any rot
Insulate the floor
Plywood both top and bottom of the floor
Frame new walls to accept the new windows
Install new Anderson casement windows
Re side the porch with new siding to match the house as close as possible
Install two new Velux sky lights
Wire room to code
Six recessed lights
One ceiling fan
Insulate walls and ceiling
Interior trim to match the trim in the house
Case the opening
Note: There is no allowance for painting or staining interior or exterior other than the pre
primed siding. No electrical fixtures other than the recessed (lights.
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FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
INNER ............a•.....■.........■........................................
\-�PPLICANT ® ci (e\ a4 N V.,c t Z"f PHONE 5�'zs 3
ASSESSORS MAP NUMBER f LOT NUMBER
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SUBDIVISION LOT NUMBER
STREET L c STREET NUMBER
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OFFICIAL USE ONLY
........................Bases .... Eno .mammon .......r...■.....................NONE ....a
RECQMMENDATIONS OF TOWN AGENTS
�...■ ■.............■ .■.la..r...a�..............'...1......ar.........■
G - DATE APPROVED ! (�
CORSERVATIONADMINISTr
DATE REJECTED
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COXQv1EN'1S
DATE APPROVED
FOOD INSPECTOR - HEALTH DATE REJECTED
DATE APPROVED
SEPTIC INSPECTOR - HEALTH
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .. f�� !?r./?. 5......A..7` ............ .
has permission to perform ... ...........
plumbing in the buildings of . lam ....................
at. ?.� ..�,!'!� .�-'..�. �............,..,North Andover, Mass.
Fee. ?>-. .. Lic. No.. --Y. 3 ?. 1.
Check # S
5553
/PLUMBING INSPECTOR
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO-DO PLUMBING
(Print or Type)
n lo^,,l Mass. Date Permit #� 5 Vy J
a .Building Location (-Oe) V I� / /(� vvner's Name
Type of Occupancy Residential
New ❑ Renovation ❑ Replacement LN Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name Heritage Htg . &Plg . CO. Inc. Check one: Certificate
Address 35 plea ---4— t_r_eet LX Corporation 714
Stoneham, Ma 02180 [] Partnership
Business Telephone 781 —438:7=— [1 Firm/Co. _
Name of Licensed Plumber Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes N No IJ
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy M 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 appCrheek one: waives this requirement.
Owner ❑ Agent ❑
Signature of Owner or V,mner s ngem _
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 permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 42 of thG
e eneral Laws.
By _— --- Sig'rfal�fe of icN, d 'I m e
—
Type of Liconse: Master [X Journeyman Q
City/Town License Number__8322
APPROVED OFFICE USE ONLY)—
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BASEMENT
IST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6Tr1 FLOOR
7TH FLOOR
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STH FLOOR
Installing Company Name Heritage Htg . &Plg . CO. Inc. Check one: Certificate
Address 35 plea ---4— t_r_eet LX Corporation 714
Stoneham, Ma 02180 [] Partnership
Business Telephone 781 —438:7=— [1 Firm/Co. _
Name of Licensed Plumber Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes N No IJ
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy M 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 appCrheek one: waives this requirement.
Owner ❑ Agent ❑
Signature of Owner or V,mner s ngem _
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 permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 42 of thG
e eneral Laws.
By _— --- Sig'rfal�fe of icN, d 'I m e
—
Type of Liconse: Master [X Journeyman Q
City/Town License Number__8322
APPROVED OFFICE USE ONLY)—
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ ....lam!- ff.......,�C#it�....................................
has permission to perform ..........
....! ..:................................
wiring in the building f ...
................................................................................
-
at ....%'5...... ..................................... `. ......... , North Andover, Mass.
Fee .. ...... LIc. No �6�Q ......... ?! .... ......... f .."`................
~'ELECTRICALINSPECTOR
Check #
5155
UJJ LV/ LVVJ 1L• LL JIV`l. TLVJI i�.�� L.v� ivi .�V vV..�.1v1-. 1 1"I �.II� vL/ VL
Cornmonurpa�Ih o�%/%ae�acfcfr�sl� Ofii(',i;tl USC Only
ryc�,, �c7•� (� Permit No.
.LJelrarEn►arrE o�}ifs Jarvice�
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fe-! Checked
[Rev. 1 t 199 ----
� � ftrnvo (,1..,,1.\
APPLICATION FOR PEP.MIT �O
All work to be perrormcd in nccordanee with the M
(ISL-r-1SC PRINTININK OR 7 -Y1 -)L -.ILL
City - Of.
By this application tlhe undersigned gives u
Location (Street & Number)
Owner or Tennant
Owner's Address
or
ERFORM ELECTRICAL Wo
chusctts Ciccuical Code (`IEC), 527 CRIR 12.00 RK
Date: _ 3t
To the Insi)eClor of 1-; fVes:
�t to perform the electrical Ivork described below.
Telephone i1'o. �~
Is this permit in conjujtion`uiidin,, permit? yesll" i`lo
(Check Appropriate Box)
l'urltose of I3ullding L Utility Authori7ltion No.
Existing Service Amps 1 Volts Overhead 0 Undgrtf � `
No. of bitters .
Nehti• Service Amps / _Volts Overhead ❑ Undgrd_~
Na. ofltiIeters:
Number of Feeders and Ampacity
Location in Nature bf Proposed Electrical Work:
COBrn12ltQn
No. of Recessed Fixtures ��
- --- - ---- L!!;, ••• �
No. of Ceii.-Susp. (Paddle) Fans
•• — ••+«r as ►ra,%W b • file h•is¢Cron• 0 MI -ex.
t o. of Tota
T ansforncrs KVO.
'V
No, of Lighting Outlets
No. of Lim Tubs
Generators I V AA
o ger`Z
ittitg t
No. of Lighting FL-ttures
Swimming Pool ov
rut.
BattUnits
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARtbI;;
No. of Zones
No- of S»ifches
No. of Gas Burners
No. of Detection and
1111 tinting E-evices )
No. of Ranges
Na of Air Cond. Total
Tons
No. of AIerting Devices
No. of Waste Disposers
glean mp ,i um er 'ons
Totals:
t o. 01 elf ontanttcd
DetectiotUAlerb Devices
No, of Dlshtis•ashers
S, CdArea Henting Klv
Local ❑ 1"Iuni;cfpa
Cona,ection ❑ Other
No. of Dryers
Heating Appliances I{�V
Security ystenis:
No. o. of ater
KWNo.
t o. o t o. of
of Deviees or E rtivalent
Data tiViritta•
Fleatern
Sig -lis Ballasts
No. of Devir:tts or Equivalent
No. Hydronnassagc Bathtubs No. of Motors Total 11? i'efecontmutacations Wiring:
No. of Devir•es or E uivalent
oTxER: .
Attach additional d¢mil if desired, or as raruirad by the Inspeefor o/ Wires.
INSMR NCE COVER-kGE: Unless waived by the owner, no permit for the performance of clecrrical work nhay issue unless
the licensee provides proof of liability insurance including "completed operation' covet'agc or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has e:chibited proof of some to the permit issuing oflice.
CHECK ONE: WSUR kNCE Q' BOND ❑ OTHER. ❑ (Snecify:)
Estiimted Value of Eleclrical Worn:' (When required by municipal policy,) (Expiration Datc)
Work to Start: y- 2-3 -d1 Inspections to be requested in accordance with MEC Rule 10, acid u•aon completion.
I car•rif •, wider [he pains acrd penalties of frerjuq, flint the iafonnariorr on riris applicat olr is jrtle all"
MUM
evurple�rc�
UM NAN1E:t'-WAX-b %- r j f 9
Licensee: rj AM r Signature LIC• i\0.: 1 36
LIC. NO.
/�
(Yf "
applicab/r, enter e • -nip " irr the i • nse umber lire.
Address / d d Bus- Tel. No.. -a
Alt. Tel. No.:
OWNER'S INSURAN CE W.AJVER: I ant dware that the Licensee dors not /rave the iability insurance coy erase normally
required by law. Sy my Signature below, I hereby waive this requirement. 12121 fire (cliccl• one) 0 owner ❑ owner's a,_ent.
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gcnt
Signature 'relephoneNo. PLRIVIT FSE: S,