HomeMy WebLinkAboutMiscellaneous - 75 MEADOWOOD ROAD 4/30/2018--i � r
7 I�
Date...........................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that..........H.......I..o....-..4e-i
.. H 1c�4,�,
....................................
1C,
has permission to perform .....1 ... .......
....... k`.E%1.4....1............x...........
wiring in the building of,,,,., ..! � �--
G� Y
at ..................1,,............ G U..t Z. ...T.V.................. . North Andover, Mass.
Fee... 17S ............. Lic. No..��.:.,... ....
....................................................................................
ELECTRICALINSPECTOR
Check it —f116
26.99
t�o►ntnonwoailk o� as ac�•tcs¢ Official Use Only
2aparlowni of ire Sarvico9 Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance %villi the Massachusetts Electrical Code (MEC), 527 CMR 12;00
(PLEASE PRIATTIN INK OR TYPE ALL IA'FORAMTION) Date: q - v ..t ,"
City or Town of ,t) aL�b anoff' 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) mtaacl i?oocl Pd
Owner or Tenant j c�r[^[1Q U ire- Telephone No. V - 2(PS_972_
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Cheek Appropriate Box)
Purpose of Building Utility Authorization No. 6 -
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Q�
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system
panels rated [2,SW kW 0- STC Grid Tied. In conjunction with a Building Permit
Completion of thefollotirine table ural, be waived by the hisnector• of II'ires.—l-
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
Na. of Luminaires
Above n-
Swimming Pool rud. ❑ rnd ❑
o. o Emergency Lighting
Bette Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Tons Tl
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Number
'Pons
No. of elf ontained
Detection/Alerting Devices
No. of Dishwashers
Space/Arca Heating K -W
Local ❑ Nl uncal l El Other
No. of Dryers
Heating Appliances KW
ecurSystems:*
No. of Devices or Eguivalent
No. of Water KW
o. o I o. o
Data Wiring:
Heaters
Signs Ballasts
No, of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
TelecommunicationsWiring:
No. of Devices or Eiguivilent
OTHER:
Attach additional derail if desived, or as required by the Inspector of tFires.
Estimated Value of Electrical Fork: o00 (When required by municipal policy.)
Work to Start; ASAP Inspections to be requested in accordance with MBC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
Ole 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 N BOND ❑ OTHER ❑ (Specify:)
I certrii,, under the pants and penalties ofperjury, that the htfornmdon on this application is true and complete.
FIRM NAME: SOl_ARCITY CORPORATION LIC. NO.:1136MR
Licensee: MATTHEW T. MARKHAM Signature LIC. NO.:1136MR
(!f applicable, enter "exempt" in tire license nimiber line) Bus. Tel. No.:774-258-8180
Address- 24 ST MARTIN DRIVE (SUIDING 2- UNIT 11) MARLBOROUGH, MA 01752 Alt. Tel. No.: 774-m-8505
*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 a enL
Onmer/Agent
Signature Telephone Na. PERMIT FEE. $
R
1�
10
0/4. AA JJ ZC,111M%IeA
Office of Consunier At°taiK, and Business Regulation
10 Park. Plaza - Suite 5.170
• Boston, Massachusetts 021 i 6
f lome Improvement Contractor Registration
Registration: 168572
Type: Supplement Card
SOLAR CITY CORPORATION Expiration: 3/8121117
MATT MARKHAM
3055 CL.EARVIEW WAY
SAN MATEO, CA 94402
pl
Aj
'
Office ort'onsutnera4rlids-4 A IiusinessRtgulation
L
HOME IMPROVEMENT CONTRACTOR
Roglstration: 16,8672 Typo:
ExPirxt"snn: 31`2017 Supplement Caad
SOUAR C+1 r t.
MATT Mi RF1 to A
24 ST MARTIN S1 RLL i BLD ZUNI
WI-130ROUG11, MA 01752
U. dercecrets$r�
Update :Address and return card. 9 /ark reason for change.
Address Renewal Employment Lost 0ird
I •icense or registration r:olid for indiriduI use rattly
before the expiration daft% if found return to:
(Nice of Consumer Affairs and Business Regulation
10 Park Playa - Suite 5170
Boston.11A 02116
Not valid without sigrinture
s —• s • r o I
0# '
ELECTRICIANS
ISSUES THE OLLtWING LICENSE AS A �
RE 01ST"ERE,f1 MASTER ELECTR I (' I Alt
SOLARC I TY CORPORA1 ION
MATTHEW T MARKHAM
14 SAW MARTIN Eliz
i1LOG 2 UNIT 11
hARI ROROUGII ►1A 01752-3060
k
dkk
T'he Commonwealth ofMassachr,tsevs
Deparinwnt of Indris&WAccittents
OfIce of Amdgations
I Congress &we4 Srdte 100
.11oston, MA 0211"917
ruruw.rnass.gov/dtFu
Workers' Compensation Insaranue Affidavit: Baildora/ContracterslElectricisntsiPtumbers
Avp_Hgnt I>aformation Please Print Le ibi
Nww(tausinworganizadoa/individuai). SolarCit Corp.
Acitfress: 3055 Clearview Way
City/State/Zi : San Mateo CA. 94402 phone #: 888-765-2489
Are you an employer? Check the appropriate box. _
Type of project (required):
I.0 am a employer with 5.000
4. C3 I wn a general contractor and I
El New con�ttuctlan
emplayses (full and/or part-time).*
2. D I am a sole proprietor or paErMer.
have hired the sub -contractors
listed on the attached sheet,
7. 0 Remodeling
ship and have no employees
Tltese sub-conh%crtors have
S. C] Demolition
working for me in any capacity,
employees and have workers'
D Building
9. addition
[No workers' comp. insurance
required.]
camp. insurance?
5. We are a corporation and its
10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work
of iters have exercised their
11.0 Plumbing tcpairs or additions
myself. [No workers° comp.
per 1`+�GL
12.[] Roof repairs
insurance fe`I°'�') t
c. 152, 1(4), and we have no
§
et Joyees. [No workers'
13 that Solar/PV
comm. insurance mauired.l
*Any applicant that checks boa f1 I most else iUl ow the section below showing their wosttcrs' compensation pofloy intarmation.
t i•tomeowmxs who submit this affidevit indicating they are dofica all work and the► him ootsitk cotur don; mast submit anew attidavit fttdicatiagsaeh.
tCorttractors that duck this box must attached art additkmW sheet showing the tut w of the sub-conttactors and state whether or not those enifties have
anployees. If the sub•cptttmion have employees, they must provide drir workers' comp policy n mtber.
rani art MPloyer that iapropwing workers, campemdon insuravrce for my employees. Below is the polity anti job site
ir{Jormatioit.
InsuranceCompanyNam. Zurich American Insurance Company
Policy 4 or Self -ins. Liter. #: WC0182d
015-00 J Expiration Date: 9/1/2016
7,.)
Job Site Address: Mleodow_Dd City/State/zip: C3L4') ffiA L-�ff
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure in secure coverage as required under Section 25A of MGL c. I32 can lead to the imposWon of critttinat penalties of a
fine up to $1,500.00 andlor 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 maybe forwarded to the Office, of
Investigations of the DIA for insurance coverage verification.
I do hereby eedify under the palis and penalties of perfu?y that floe information provirted above is true and corrmt
Official wa ohlA Do riot write in t'ltis area, to be completed by city or town olTiciat.
City or Town:
Permit/Lle4aise #
9- V 1
Issuing Authority (circle one):
L Board of Hcalth 2. $ultdbtg Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
�®
A «s...... CERTIFICATE OF LIABILITY INSURANCE
DATE{MMrDarYY1rY)
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
08117015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
MARSH RISK& INSURANCE SERVICES
RHONE _ ................. ....... FAX .... ... _ ._....._.__..._..
PHON_,,,,,,-....,-......._. ,. _. _..._...
345 CALIFORNIA STREET. SUITE 1300
till=.... _........_ ._ ..... _. tA?F. Nott...... _ ..............
CALIFORNIA LICENSE NO. 0437153
ApofcE:........ _. _.........._.T........... _...... -
SAN FRANCISCO: CA 94104
...................................._._.........
AiII1: Shannon Scott 415-743-9334
INSURERS] AFFORDING COVERAGE..... .. . _ ......_:._ j ... MAIC #._.
998301_STND-GAWUE-15.16
INSURER A; Zurich American Insurance Company i 6535
_ ..-....-...- - -.. _.......
INSUREDNIA
.. tl`uA _....... _.. _....
INSURER a
SoWity Corporation
INSURER C.:.NIA • NIA
3055 Clearnew Way
_.. ....... .............. ...._ _...._.. _........... _ ._ ......_... _.......:+_ ._.. ......_ .... _.
San Mateo, CA 94402
INSURER D: American Zurich Insurance Company 40142
_ ................_ ...._ _............
PERSONAL & ADV INJURY S
INSURER F:
CnVFRAC,ES CERTIFICATE NUMBER- SEA -002713836.08 REVISION NUMBER:4
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE; LISTED BELOW HAVE SEEN 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
San Mateo, CA 99402
ACCORDANCE WITH THE POLICY PROVISIONS.
Ii151t.. _ .. - '-..... ... _... .......... . _....... D�L.S(II3-r-.—..._... _... __ ........- _ .......... ... T POLICY FFF POLICY EkR'
.._. .....--........__........._.. _.._...........
....... _..
LTR T TYPE OF INSURANCE POLICY NUMBER I M! MMIDiIIYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILmr iGL00182016-M
0910112015 00112016
EACH OCCURRENCE S"-_..._3,01)0,D0I}
i
f X l
I
OA�1hAGE TQ .... ...... +
CLAIMS -MADE OCCURi
j
PRF�iISFS;Ea oarrenrgi ....rg..... __..........3,000,001)
X SIR $25000 I
,...........
MED EXP (Any one person) S
5,000
_.._
_ ................_ ...._ _............
PERSONAL & ADV INJURY S
3000000
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE S
6.000,000
X I POLICYJ I.... !AC
..
PRODUCTS - COMPIOP AGG : $
r -. _._... .__ .._... _ .... _ _... ...._... ....
6.00 ,000
...
i OTHER
s
A ; AUTOMOBUUABILITY
BAP0182017-00 :0910112015 0910112016 %. COMBINED SINGLE LIMIT g
,1fa acP�dQnf1.......... .
5.00;000
t
X ANY AUTO
.....�
:
BODILY INJURY (Per perwn) $
�..... ..
.......... ....._
ALL OWNEDSCHEDULED
r X
BODILY INJURY (Peraecident); S
x..; AUTOS AUTOS
MON-OWNED
X -O
HIRED AUTOS x.
AROPERTY DAMAGE
I P ac $
F AUTOS
F e►...cldeM) . ..... _......... }.. .. ...........
_ ..--..........
COMPICOLL DED: :$
55.000
UMBRELLA LUU3 'OCCUR
EACH OCCURRENCE 'S
S EXCESS LIAR : CLAIMS -MADE
AGGREGATE
DED RETENTIONS
$
D :;WORKERS COMPENSATION *C0182014-00 (AOS) ::09191015 :0910112016
X 'PER OTH. ;
STATUTE SER f...
ANDEMPLOYEIMLIABILnYF_......
A YIN:: WC0182015.00 MA 0910112015 :0910112016
ANY PROPRtETORfPARTNMIEXECUTIVE • }
.................. ..... _. ......
FEL EACH ACCIDENT + $
....._..__ ..
1.000,000
N :NIA {
OPFICElary In ER EXCLUDEO� ;WC DEDUCTIBLE: $500,OD0
{Mandatory in tills) ;
E.L DISEASE - EA EMPLOYE S
- -- - ---._....... .........
1,000.000
H yes. desonbe ender
DESCRIPTION OF OPERATIONS belowi
E L DISEASE -POLICY LIMIT I $
1,000,0w
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (AGO".. 104. Additional Remarks Schedule, may be altachad If more space Is requrred)
Evidence of Insurance.
f'r-RTIFICATF Hs7t DFR CANCELLATION
SolarClty Corporation
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
3055 Clealview Way
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
San Mateo, CA 99402
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh Risk & Insurance Services
Charles Marmoleio-
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
TOWN OF
" )I.
PERMIT FOR
Date. . � vrA � .....
NORTH ANDOVER(
GAS INSTALLATION
This certifies that .............
has permission for gas installation 4"1:7`.... .
in the buildings of -e ........................
at .4 ........ , North Andover, Mass.
.� .... ..
Fee... LI C. N 0
GAS INSPECTOR
Check *1
7066
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS A
Building Locations
C
Permit #
w Amount $
�
Owner's Name X j (r e�j�,,��
NEW ❑ Renovation Replacement Plans Submitted ❑
or type) r j ' / �� Check one: Certificate Installing Company
Name
�( bio%ii/u P E] Corp.
Address Q
It/
0X-2-0
V
Name of Licensed Plumber or Gas Fitter jy c.)�-
11 Partner
l'Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes Er No 13
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑j ` Other type of indemnity 0 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 a
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 instal tions performed under Permit ssued for this application will be in
compliance with all pertinent provisions of the Massac aV State as Code Chapte 42 o_ff thea neral Laws.
By:
Title
City/Town
Signature of Liceld Plumber Or Gas Fitter
Plumber
Gas Fitter License uTm err
(OFFICE USE ONLY) I n Journeyman
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
or type) r j ' / �� Check one: Certificate Installing Company
Name
�( bio%ii/u P E] Corp.
Address Q
It/
0X-2-0
V
Name of Licensed Plumber or Gas Fitter jy c.)�-
11 Partner
l'Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes Er No 13
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑j ` Other type of indemnity 0 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 a
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 instal tions performed under Permit ssued for this application will be in
compliance with all pertinent provisions of the Massac aV State as Code Chapte 42 o_ff thea neral Laws.
By:
Title
City/Town
Signature of Liceld Plumber Or Gas Fitter
Plumber
Gas Fitter License uTm err
(OFFICE USE ONLY) I n Journeyman
y The Commonwealth of Massachusetts ;-
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, A" 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Cont
ractors/Electricans/Plumbers
Applicant Information Please Print Ledbly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for in any capacity.
[No workers' comp. insurance 5.
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. I
These sub -contractors have
workers' comp. insurance.
❑ 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
11. F-1 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
`iii�y appiiCo^ Ii i s� wieci:s
box;; i ml= also tall Out the section below showing their workers' compensation nolicy 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 workerscompensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
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
Signature: 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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions , .
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged. in a joint enterprise, and including the legal representatives of a. deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartrnents 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 Liabihty.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 Iicense 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.
6.00 Washington, Street
Boston? MA 0.2111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5-26-05 NAr"-w.mass.gov/dia
-location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $ --
43Water Connection Fee $
V�. �. r TOTAL $ 0
Building Inspector
6050 Div. Public Works
'Location
No. Date
,T 6109
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ e,,A"11
Building/Frame Permit Fee $ U U
Foundation Permit Fee $I//'%3
Other Permit Fee $ -------
Sewer
____
Sewer Connection Fee $
Water Connection Fee $%�
TOTAL $ d•0 U
Building Inspector '
Div. Public Works
Location lA9 4AE
No. 3 Date
F
7" TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
Building/Frame Permit Fee $
C, <�� (?Foundation Permit Fee $
'' Other Permit Fee $
56 Sewer Connection Fee $
!`
q�,er Connection Fee $%
TOTAL f$all
Buil 1 lnspe t'r
6396 Div. Public orks
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. 3 �� �j PAGE 1
MAP KVO.
I LOT NO.2
RECORD OF OWNERSHIP �DAYE
BOOK PAGE
ZONE
SUB DIV. LOT NO.
Qfd T
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LOCATION
Zak
PURPOSE OF BUILDING
4 It
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OWNER'S NAMENO.
OF STORIES
SIZE
r
OWNER'S ADDRESS Lr
-BASEMENT OR SLAB
ARCHITECT'S NAME'
f
G C.�J
yG
SIZE OF FLOOR TIMBERS
IST �X j® 2ND �x )D 3RD
G.
BUILDER'S NAME O
n
GL
SPAN
DISTANCE TO NEAREST BUILDING
/o !
DIMENSIONS OF SILLS
J—(�
-
DISTANCE FROM STREET
_ '1 /i %
POSTS�`�
DISTANCE FROM LOT LINES - SIDES
FROM LOT LINES - SIDES
'DISTANCE
REAR /4
`�`ss
GIRDERS
[^
12
AREA OF LOT (/ n/�
CJI�iJ f�-7
+Z
FRONTAGEC�
✓
HEIGHT OF FOUNDATION
(� % -THICKNESS I%
Q
IS BUILDING NEW
SIZE OF FOOTING
/l X
2211
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
/IJ
IS BUILDING ALTERATIONu
IS BUILDING N SOLID
FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
O 4
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LIN
INSTRUCTIONS
SEE BOTH SIDES BIDS FCRMN
PAGE 1 FILL OUT SECTIONS 1 - 3 ?;• 'IM
C� r
V 0
LES.... f a�; FEEo 0
PAGE 2 FILL OUT SECTIONS 1 - 12 DUE PERMIT
$
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATION
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED 15- ! 2�
SIGNA
11wWOP/Anwromy
PERMIT GRANTED
I�
DING DEPARTMENT,
IZED AGENT
60/r Z Af DV&Z c'
6 1a S
3 PROPERTY INFORMATION
LAND COST J1 �Ln
EST. BLDG. COST !/ ((/EST. BLDG. COST /�L� ..
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO. C.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
"& d",
BUILDING IWGPECTOR
-BUILDING RECORD
1 OCCUPANCY 12 \ ,
SINGLE FAMILY._ , _
STORIES
MULTI. FAMILY '
FFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION I 8 INTERIOR FINISH
CONCRETE ✓ 3 1 2 13
CONCRETE BL'K. PINE 1
BRICK OR STONE HARDW'D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT 1
AREA FULL
FIN. B'M'T"AREA _
'/, 1/2 1/1
FIN. ATTIC AREA
NO B-M'T
FIRE PLACES .. �•.'\
_
_
HEAD ROOM
MODERN KITCHEN
4 WALLS �_,
1 , FLOORS
CLAPBOARDS VInVi
B
1
2
�_
3
_
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
HARD\!✓'D
COMMCN
VERT. SIDING
_
ASPH. TILE
STUCCO ON MASONRY
_
STUCCO ON FRAME . ._
BRICK ON MASONRY
BRICK ON FRAME C
ATTIC STRS. & FLOOR I_
CONC. OR CINDER BLK.
WIRING
STONE ON MA$ONRY.,
STONE ON -FRAME,
SUPERIORPOOR _
ADEQUATE I^I NONE
5 ROOF
10 PLUMBING
GABLE
HIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING I
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
_
B'M'T2nd �'
3rd I
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF •BU'ILDINGS. WITH PORCHES, GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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A.t/ODYE� /yl.4S.S.4G�//SETTS O/8/O
FORM U - LOT RELEASE -FOR)(
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section******(*�**********
APPLICANT: McGQOW6Qe-1 2fd2.L GL2 _ Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street I�IP����D�D�7 St. Number /
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
- --g <'D Qi&L
Conservation Administrator
Comments
9.1mi'mor') =I,
Comments
Health Agent
Comments
Public Works - sewer/water connections
- driveway.permit
Fire Department
Received by Hu
MAY t i
t
Date Approved
Date Rejected
Date Approved„
Date Rejected
Date Approved
Date Rejected
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art -6b1,0— hl��/'Co/9J
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