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Miscellaneous - 75 WINDKIST FARM ROAD 4/30/2018 (2)
PERMIT FOR PLUMBING This certifies that. ( m x� ....���.� has permission to erform .46&/A— . A' -'. f ........ . :� plumbing in the buildings of .... .................... at ... 5T...? �`? . �; North Andover, Mass. Fee ,36-� . Lic. No. 130 ................ ... PLUMBING INSPECTOR Check # 3 9 5 /�� 0- 13 o,j ����3 • Ih9�IIIIAIIIIIII®111IfI, • F. r, M.I.M. F�FM- FM FM- fMFM-I WMFM- FMFM M(�I� DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHR _ _ INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Z NO IF YOU CHECKED YES, PLEASE INDICAT�tYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND �Q 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 [Q AGENT J0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE S NAME _ _,__ GtCd _ 4 . _.F�e/s w i LICENSE # 3 32.SIGNATURE IMP _ _, JP Q CORPORATION # P PARTNERSHI#=LLC COMPANY NAME �!ADDRESS ;ITY � ori i1!✓ __.._............iISTATE_ ZIP Lsa-- ,5 TEL X CELL _ 6 EMAIL MASSAC iUSE 1i"iS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY D _ _ ckP,✓ _ MA DATE _ Z� 13 PERMIT # _ 1 JOBSITE ADDRESS`7%r� cU�Pn OWNER'S NAME POWNER ADDRESS _I TEL 5Oe- &5' - X0760 _ FAX _ { TYPE OR OCCUPANCY TYPE COMMERCIAL ED CATIONAL © RESIDENTIAL PRINT CLEARLY NEW: Ell RENOVATION: Ed REPLACEMENT: PLANS SUBMITTED: YES�]I NO[d FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBtj=H CROSS CONNECTION DEVICEDEDICATED SPECIAL WASTE SYSTEM • Ih9�IIIIAIIIIIII®111IfI, • F. r, M.I.M. F�FM- FM FM- fMFM-I WMFM- FMFM M(�I� DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHR _ _ INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Z NO IF YOU CHECKED YES, PLEASE INDICAT�tYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND �Q 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 [Q AGENT J0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE S NAME _ _,__ GtCd _ 4 . _.F�e/s w i LICENSE # 3 32.SIGNATURE IMP _ _, JP Q CORPORATION # P PARTNERSHI#=LLC COMPANY NAME �!ADDRESS ;ITY � ori i1!✓ __.._............iISTATE_ ZIP Lsa-- ,5 TEL X CELL _ 6 EMAIL O ❑ z w LU LL J i ' The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ( ie Pf P1R LIZZ Address: e�21 T)1164 �//- i City/State/Zip: LDrY�O G�t'r'vl NY 03 603– L13c/— Y60a Are u an employer? Check the appropriate box: 1. ff I am a employer with -3 4. ❑ I am a general contractor and I employees (full`and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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. ❑ Remodeling 8. '❑ Demolition 9. ❑ Building addition 10.❑ ectrical repairs or additions 11. Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. I am an employer that is providing workers' compensation insurance for my employees Below is the policy anal job site information. I , Insurance Company 4_Y6. Policy # or Self -ins. Lie. 9: Expiration Date: y Job Site Address: 5 Wir2lX l vin /( City/State/Zip: Aqr f- , / '�ye ' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure tosecurecoverage 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. I do hereby certto under the pains and penalties oer'u that the information provided above,,is true and correct. Phone #• 603— Y 3 `i— Y -b0 U Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Ole 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 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 burn 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, M.A. 02111 Tel, # 617-72.7-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Faze # 617-727-7749 v Ww-mass,gov/dia ".COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS f REGISTERED AS A PLUMBING COi.P. I ISSUES THE ABOVE LICENSE TO: I'GH AD` -'M :PERRY i. i. C".'M P:. PLUMBING & HEATING LI �. �I 8:0 NASHU'A RD UNIT .,B4 IW j LONDONDERRY NH 03053-346:4= i �3313 05/01/14 162574 f i Fold, Then Detach Along All Perforations -4 `' COMMONWEALTH OF MASSACHUSETTSMM'S AND ASFITTERS r Lit ENSED AS A MASTER PLUMBER t _ ISSUES THE ABOVE LICENSE TO: I 41 CHAD :MICHAEL PERRY 8.0:NASHUA RD m 'JI T `Ci:4 _N :- :L;ONDO.NDERRY NH 03053-3464: 13052 05/01/14 162575 I Fold, Then Detach Along All Perforations i This certifies thatA(', .. p5�,�e,_,,,,,,,,,,,,,,, has permission for gas instatration ...6K h,, qft ............. in the buildings of .. .............................. .�_ . at ... �..... �.�i.orth Andover, Mass. Fee .. .�!,, Lic. No..� 1'j.ur .. 114Ae .................... ... GASINSPECTOR Check # 8626 J1 A . 110 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATEaz-P PERMIT # ' JOBSITE ADDRESS %T�1N1 !KIST -2M^_ 1Z ��2 OWNER'S NAME GOWNER ADDRESS : ' / DL TELF7� _ FAX TYPE OR PT RIN OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL �( CLEARLY NEW: Q RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES VII NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER_ - CONVERSION BURNER COOK STOVE _ I _ _. _ I DIRECT VENT HEATER __TL DRYER FIREPLACE FRYOLATOR FURNACE ------ -- --- GENERATOR GRILLE INFRARED HEATER --- LABORATORY COCKS - - _ :1 --T _—( MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER dATER HEATER THEIR INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 NO[�_! / IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IM,i OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERE] AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tr a and accurate o the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co p lance ith al rtinent rovision of the _ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / t --- PLUM PLUMBER-GASATTER NAME U(/ 5 t _.-, l/C/f ivI/1/1 _ _ LICENSE # 1/ i i�y I SIGNATURE —� MP NMGF - JP 0 JGF LPGI CORPORATION []# [:—= PARTNERSHIP Q#= LLC E]# COMPANY NAME: GIUICsy1i1/ p�/�� ADDRESS CITYUI?J�I� _.. _. _.__.. _. -- --- - - - STATE _2�j_,ZIP �GS�_. TEL 60 7/-- - -- j FAX CELLI. -__ -- _ EMAIL J1 A . 110 H °z 0 H U W W z O y❑d W �- `�' ~ W H I°z m ft w = � 3 Cl) wco a r5W a O w w w w c a z a a a U 5 J H a CL Q D) w mw F- w W H O z 0 H U W A4 C7 Cx7 The Commonwealth of Massachusetts Department of Industriql Accidents Office of Investigations 600 Washington Street U1W Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Lk -S 6; Address: ZY ,jC/4�7� City/State/Zip: !/<) f /l1, j - Phone #: 6d 3 SM Are you an employer? Check the appropriate bog: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2.14 I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # l• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL 11.❑ 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. ❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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. I do hereby cerlo under the pains�d penaf'ties ofperjury that the information provided aboye is tie and correct. Phone # • & 6) S to % 7 %/ k ' Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License IeA 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 #: V, 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 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 loeal 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 ofpublic 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the 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 burn 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 Massachu setts Department of Industrial .Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel # 617-727-4900 ext 406 or 1-877-MASSAF,E Revised 5-26-05 Fax # 61.7-727-7749 www-mus.govfdia k ainitu6is Ui M., w ' �' 1.0 LI) q 1�4 ka 0 w 1.0 U-wu) in WZLS LLJ LL w > Ono wo x z u LLI =) JQ Mtn X,: it< (wn G CL ,ui UJ Cl Z) LL, L,) .z I LLJ LLI ..r eo% Z 0 '-JLUl CLU (.D Lu U) 0 CO GENERATOR APPLICATION DATE: 3I 1�I�3 LOCATION: ZS W fNDKI Sl FSI SIM RD, OWNERS NAME:-�wvOI✓ F-2-aM GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: )61u�/e- pvu�ske- PHONE NUMBER: 40 3 r4 � V 7(,P- ELECTRICAL RESIDENTIAL GA COMMERCIAL TEMPORARY LOCATION OF GENERATOR: �4c-(�✓�. �� ^"ZONING DISTRICT: *CONSERVATION APPROVAL North •• - ..March 18, 2013 Interstates Interstate Major Roads Roads 1:i Easements ❑ MVPC Boundary Parcels Andover 1"=172ft N WA ,%ORTM 3?O� 4t``D r• ��OOL A o ��SSACHUS�� Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION North Andover MIMAP March 18, 2013 109,0.0044 109.1-0063 #15 109.0-0062 109.041041 109.0-0048 #30 109.0-0035 109.0-0047 #570 109.0-0061 #42 #45 109.0-0060 109.0-0049 #56 109.0-0005 109.0-0059 #70 #59 109.0-0058 J��� \\�� #80 109.0-0050 ' \ R2 \ 109.0-0057 #75 109.0-0051 % / #94 j � #85 Z \�\ r � 109.0-0056 #108 \ / VI, 109.0-0052 109.0-0055 109.0-0053 Andover `? 109.0-0069 109.0-0034 Rail Line Interstates =y Wetlands Exempt Lands Zoning Busine C Busine 5 1 District s 2 District Horizontal Datum: MA Slaleplane Coordinate System, Datum NAD83, — Interstate D Busine s 3 District Meters Data Sources: The data for this map was produced by Merrimack —Major Roads p Busine s 4 District 14ORTN Valley Planning Commission (MVPC) using data provided by the Town of Roads ®Gener O Planne Business District Commercial Dev f to q� O tt*� rtt O North Andover. Additional data provided by the Executive Office of Environmental AftairslMassGIS. The information depicted on this map is t71 Easements ` Cortido Development Dist ? • O ,; L for planning purposes only. It may not be adequate for legal boundary C3 MVPC Boundary CCorrido O Corrido Development Dist Development Dist O — ` "' - to $- 13 definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING [3Municipal Boundary Zoning Overlay Industri Industri it 1 District 12 District ., t « y THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY THE OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT E3 Adult Entertainment 6 Induslri it 3 District K c ` ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF E3Downtown Overlay District C3 Historic District O Industri Reside it S District�. 1 District °.+*.o e�`y'h THIS INFORMATION o Water Protection Reside ce ce 2 District 7 gSAC1"4 O Parcels C. Ridece 3 District i'.i Hydrographic Features 111 — 172 h de de ode ce 4 District ce 5 District Streams „age ce 6 District esidential District This certifies that .......... . has permission for gas installation .. -?•?. ................... . in the buildings of .. at. .fir .....'. .' .. ! .... , North Andover, Mass. GASINSPECTOR Check # u6C9 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK z u�` CITY r MA DATE a/ / 3 PERMIT # b JOBSITE ADDRESS OWNER'S NAME Cc GOWNER ADDRESS r_ - TE�/7-3 -099AX TYPE OR PRINT ,._ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:2111, RENOVATION: Qi REPLACEMENT: 0 PLANS SUBMITTED: YES[] NOM APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12T=1 BOILER IF----IF---71f- 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 [O NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [Y OTHER TYPE INDEMNITY E] BOND E] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Ej AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru d accurate to the bes m Howl ge v and that all plumbing work and installations performed under the permit issued for this application will be in com i ce with al Vent rovi ' n of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME,�t-%n� LICENSE SI URE MP E�f MGF [j JP [D JGF E] LPGI CORPORATION ff # � PARTNERSHIP 0# ; LLC E]# COMPANY NAME: ��,p / -r ADDRESS CITY --- Lr _ Qa?C1 .. ZIP STATE �.. TEL R) _.- - - .GL-�t�_�c'�c�'' FAX _ ;, CELL `fit' .r_._ i � EMAIL .: , 2 f O C z b n y 0 z 0 m x Cl) � 'Do -o r n � 0 b r Y Z. Cl) 7�m M l�1 X y U) --I p m a m ; O cr O ay ❑o z z r z CA n y °z z O y t�1 CA t 1 4 �' _ -- :t3:1l�ilC:�t`.:i• ::•i-.; c: L{i' t'.ti1�W'��'_vc'x4.1�1:.Z 6-�.. -o - - - - PLUMBERS AND GAS RS L,iCENSED AS k JOURitI1;YMAN P E LEHAVIC _` TAllN MR IA 02� " — -*��; � ';' = ' " ��tiv��SC•�S = :-fes' - • PLUMBERS AND GASFIiTERS_ , == UCEN_SED AS A MASTER PLUME .R ISSUES T-?= *'BojiE LICENSETO--�. _ =KEVit3t LEMANE _ .~ =:255- SG.HS T- t-_`#`AUN NA 02' I � -L - -.4 V4 1 Date..5.1.3.112> TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......7 L! �L has permission to perform ......................................... et, 6;'e ........................................................... wiring in the building of ....... F6z.o . . ....................................................................... at L7 North Andover, Mass. Fee..... ... ................. ....................... . .................... ............... . ......... Lic. NAO CAL IN. /EROit Check * ") K ap (Aon !-;� Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: i I Zo City or Town of: NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Is, Location (Street & Number) --45 /�J�� K� S� t-r�r,� N� Owner or Tenant Lo r, Si r l vy-CL- Telephone No. 9w,(o ? 5 Fkl Owner's Address -q5t &I y- - Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building S,G(2 rl c Utility Authorization No. Existing Service U Amps JW / IXO Volts Overhead ❑ Undgrd No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:�rA/-?;o d Completion ofthe fnllnwino tahle may he waived h„ tho 1--tnr fW;— No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets 'Z No. of Hot Tubs Generators KVA No. of Luminaires �i Above In- Swimming Pool 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 No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number I Tons IKW I No. of Self -Contained Detection/Alerting Devices I i No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers X 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 BathtubsNo. 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 . f E ctrical Work: �91as c� (When required by municipal policy.) Work to Start: 3 ZJ 13 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: 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 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: �y� ; 5 c ,1(� G7Y t LEL (_ Y, �5 �' 7zn S . �2 c LIC. NO.: v Licensee: (aWYzvk« Signature Z 5 - LIC.NO.: Lf�F (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.• 06 S Address: eLa&t Alt. Tel. p *Per M.G.L c. 147, s. 57-61, security work requires Dep&6ent of Publ' Safety "S" ' ense: Lic. No. PWNER'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: $ 13,5 . Signature Telephone No. loe 5 9 v IYEALTH OF AiMACHAIETTS RED MASTER ELE1;TRtCtAi MUES THE AWVE LICENSE TO +f ELECTRICAL .A.Lj* :T 3 LAWRENCE JR P4D'"X 603 R NH 03$21- -4 IR 87/31/13 9535• .AS iii G JdUAWYiUlAAt ISSUES THE ABOVE UMSE T0:' At-09RT J LAWRENCE JR D$ii<Et. NH 03-621-0 !gin E 87/31/13 85U3 ARTIIISAN� 0 Q���CR TO TNF a�A� PEOPLE To Whom It May Concern; I, Albert J. Lawrence, Jr. license number 4O8MR give Ubaldo Arguello, approval to apply for permits in The Town of North Andover, on behalf of Artisan Electrical Contractors, Inc. If you have further requests or concerns feel free to contact me at my office (603) 743-4005 or cellular (603) 235-6410. Thank you, Albert . Law nce "Serving the Seacoast Since 1987" PO Box 603 a Dover, New Hampshire 03821 6 Phone: (603) 743.4005 0 Fax: (603) 743-4040 ` I � � / � ' / I Date .. 9.......:... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. /� � i...E! � fair !:.................... %J .............. ......................................... has permission to perform ........................ -e< ......... IC: wrong in the building of .......................... f'C6.J�....................................................... at ....L7.5�.... 1.. ...ff�.. ��.. , North Andover, Mass. Fee...�.J U............ Lic. No. ....�.u6..... ............ � l...........:...4= a! ........ ELECTRICAL INSPECTOR Check* 2 TS V�j // Official Use Only (...cco-�mmonrueaf a� J1Ia11achu.3e�s Y aLJePartinr.rtt o��ire �evutceS Permit i+lo. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ptev, I/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance witb the Massachusetts Electrical Code (MEC), 527 C. 12.110 (PLEASE PRINT INAWK OR TITPE.4LL ?NFORMATIOld} ]Date: City or Town of: 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 �`2 Owner's Address Telephone No. $' 6'/ 'Q ff S Is this permit in conjunction with a building permit? Yes ❑ No 1:5 (Check Appropriate Box) Purpose of Building �— p ��4 7/Z0Utility Authorization No. Existing Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters — New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the follomwingtable may be waived by fire [nspector of fPires. No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators o2 7 KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ d. d o. o mergency Lighting & am Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. a Detection and Initiating Devices No. of Ranges To— No. of Air Cond. Tons Na. of Alerting Devices rs No. of Waste Disposers eat p Totals: umber ons a. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Beating KW al Local 13Conncection F1 Other No. of Dryers HtiAlinces Heating Appliances XW Security System..* No. of Devices or Equivalent No. of Water, Heaters o. of No. o Si 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 aaarrronoi aen", i,/ ue 1-4 Of "a rayu..a.. } ..•� _. �. .. -- -- - Estimated Value of Electrical Work: (When required by municipal policy.) Work to Starr_ 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 wart: 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 of pedjury, that the inforrmatio n this app! cation is true and complete. FIRM NAME: f1�20J _' LIC. NO.: lal&e) Licensee: "�i�if f �P.ele462 5 �, Signature LIC. NO.: 8 �J (yapplicable, enter "exempt" in the license nwnber line.) r Bus. Tel. No.;�rD � f Address: :- J} �' 6T .'S` . /+�© AlL,Tel. No. *Per M.G.L. c. 147, s. 57-61, security work requires Departm of Public Safety "5" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the censee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive s requirement. I am the (check one) - offer ❑ owner's � eIIt OwnerlAgent PERMIT FEE. $ . U0 Si ature Telephone -lo. 2�2l-� V'2 A' ' vvt G'.1. It _L Rhode Island Department of Labor and Training Division of Workforce Regulation and Safety ELECTRICAL CONTRACTOR A-004260 JOURNEY ELECTRICIAN B-011876 JOHN M BARROS 164 EAST STREET FOXBORO MA 02035 Administrator Expiration Date REG:: •.= BARROS. CONPANTE-t INC : JOHN .BARROS "= _ 164 EAST ST: _ . !IA 026 SO —22- 53, �j =48 STATE OF NEW HAMPSHIRE 8tML0il0 OF OLEMMAL"FEi'Y& UCEMMM j WYMJOHN BARROS' 9.0006 M t 2 *• 3. - .r EXPIRES: pW3012&W MA.!E306T E R AS.A IEEE•J _ RI NipN. ELECTRilA1T " -=JOHfli BARROS_ ..1 -'EAST ST - - - Fff ;HtiRD NA 02035;- �248fl3 E� --07/31113 8x3247 _` GENERATOR APPLICATION DATE: 2I2 -9I13 LOCATION: 15 0-,-Jj OWNERS NAME: GENERATOR kw 2-� I< -Lx,) NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR:'�``�Ir PHONE NUMBER: ELECTRICAL RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: -�`��" CLAN eA I-ILLcM 'ZONING DISTRICT: *CONSERVATION APPROVAL Town of North Andover I* Page 1 of 1 Select , Parcels 1 �........ ............... .. . _. ..... t . .. (show all) Owner Prop_ID Address FLORA, STEVEN K 109.0-0051-0000.0175 WIN DKIST FARM R1 1 selected To Mailing Labels To Spreadsheet ]I Property 11 Building Permits 11 Planning Septic PuE Print Ownerl FLORA, STEVEN K Owner2 LORRAINE L FLORA Address 75 WINDKIST FARM ROAD PropertyID 109.0-0051-0000.0 Lot Size 1.62 A Fiscal Year 2013 Land Use 101 Code �,.. aaeMr—k WIRY RN -V co mt'iallml does not Mae snywamntst eWe5W a "Pried. n& emw* any legal LIN ky or responsblly top d,e a=tacy. Ccmpletene9s. &LSK*m "d ft Geograptsc kftmaren Systwm jGM Data m, anyother dale pmwcW herein. she dsta doers not race the pude of a prokmso al ejyey and Ras no regal t>esdng m ele nt/e sRepa=sem. bcatmitt orexistsce a a 9�spnic tmt�re, wopctY Yne: wPdu6csl nu9on. hsensmack Vatley �nn�n8 Gxmt�an requesttZ C m any use of M kt&WL9on heaam�nad bys eawm to ka mume aro the L%"Vnwk WSW Planning ComNssoll'scalreeat mat k makes no Warrsnaeso+ '�.� ltartmis asto the aCprraCydaad axmrnat;on. Myuse or Cvs iltmmstertl ls�sle raclPienCsovm nsk. http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx 2/28/2013 Town of North Andover Page 1 of 1 Q Base Map Zoning 2012 Aerials Watershed Zone IFUtilities Size OE]F Help Scale 1" = 144 ft V09 MUM 109.0-0059 #70 109.0.0095 V59 ' 199.0#050 1".M518 #80 J. #75 `s R2 f Nor f 1091-0951 f� f f #85 � 199.0-0052 r� Andover+ #97 109.0-0053 109.0-W9 Get Pictometry Imag, Go v3.2.0 AppGeo Save Map as Image i a Select Parcels l � (show all) y -- _.. .- .............- Owner Prop_ID —'Add'ress---- FLORA STEVEN K 109.0-0051-0000 0,75 WINDKIST FARM Rt 1 selected To Mailing Labels To Spreadsheet Print Ownerl FLORA, STEVEN K Owner2 LORRAINE L FLORA Address 75 WINDKIST FARM ROAD PropertyID 109.0-0051-0000.0 Lot Size 1.62 A Fiscal Year 2013 Land Use 101 Code i MaMtnadk Way ganr ng ibmtnssion does not make any waMrrty, eaaeased or ImFked. twr assure Any Wo lat fifty Or msPensDlity for the Mxutac)k cam lewvrss, or t�eUAhes ct the Geograpr,c wotmatun SWaat iGI9} Data orany ober data provided herein. fine data does not take the place of a poresswnat a^" and ttss no �-+ iegat tm2aMg cn the iroa stuaps ".�e.loCati-Jn, da%kta^�oe of a geographic fEot,rE, property eie, arpd'&al repesentaticm Me'MtacR Veaay Piat" Cemmisson requests ` Mat any use Of INS trddmta9on Ile ACWM90M by a retetetwe to its sauce and the Mernmack Vaaey Pin" that it makes no w&MVesot representations L" to the accuracy as sato tM(rmaGom Any use of tnis aAoomtian is at Vie reetpents own Ask http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx 2/28/2013 Addendum to contract dated with: Barros Companies 164 East Street Foxboro, MA 02035 508-543-5118 This sheet gives us an approximate on site location for your new GENERAC fully automatic home standby generator. Due to site conditions, we will try to install the generator as close to these parameters/dimensions as possible. But it is possible that the actual installation site may be slightly own below. Accepted by: FRONT OF HOUSE TO/T0 39dd 00 S0NNV9 ZT6b6V5809 90:60 6TOZ/8Z/Z0 W IL `I �M 3� ,3 y Q `v W f ° z Z < 0 0 y In F Ir r d w Q W W p Q z U z z N OJ O O ;I r � a L t7 Z_ O J m 3r y W K W < W <Z Z 0 r y W ¢ U W Z ° < my_ ° 31 U Z 0 0 LL LL 0 W N y ° 9 I_a � PXJ y f a W Z QZ 0 _ ° 0 m LL y W 0 Z W p W yp 0 0 N I ar d 4 0 O J N 4 Z 3 m 0 1� X W IL O< 1 Z 0 H J V , 1h.0 ? Ift �� IL Z �t 0 � J `I �M 3� ,3 y Q `v W f ° z Z < 0 0 y In F Ir r d w Q W W p Q z U z z N OJ O O ;I r � a L t7 Z_ O J m 3r y W K W < W <Z Z 0 r y W ¢ U W Z ° < my_ ° 31 U Z 0 0 LL LL 0 W N y ° 9 I_a 3 �Ni V 0mm '� 0 Ol ODN�p p>0=-Di3� TG)G1 UI oonwwoomDD*On OOZE ccpmc00> A XZ_'D r10 m W vmnn m ZZ N D;tn DOI� .. O�Jmo O Am m„Z,nn7cOO tn�z A� Dfn; O pPomOD 0m =N ZZp 2>000 LA0> p p� 0-+ T mm ZD _ O m N a y T Z T. ; �= p> Z Z Z N G7 NS Z Z O O r D •y W a O N 3; a s O N O n w m G7 N Z A O D 3 0 m ; y 0 p D 0 �_ Z Z In O N tt c s ; Z 7C = < N 3= 0 v mDO mZ7o m Zm0 G) m y O �^ O D o { is j Z < N Z fit _ N 0 s I I I I I I I'I I I� �' f_ I I I 1111) 1 •I I_ Z O m 0 m— 0 c p D D Z D p S to O m -ti T T 0 v i -- mmO> ti 3 O N Z D O X y D n<-� 1 D O D '� 0 D N O C mm D -� .--� y n to O T; 2 A p n 0 Z t0 3 O T T m Z T Z C Z{ T O O D 2 p D Zi pm N C O TO V i T D n�tn�0 Dn��mm D7om ,.. Om�D-ymmS O S S Om. v D Z m n (� p > n m- Z -+ i N D0 0 Z 2; Z p n p fJ > p 1 - mZ0 ti m Z y >� O A ,{ Z m3; 02 O pTOaoN<r03 X v m upi ,�n„n � T m 0 O N~gip DZ •Ki��� mN. C �_ P T nN p D Z I 1 'i•� 1_LJ.�_ `I 11 a � Z< p 1D1 T A T D D m Z Gi V p T m Z Z N X 4 i o O p A Z T ,1 .1 I ISI I �'11!J m p � HI�-=L I I I F I I I I I I IW I TIMI- I I I 11" 6)ON N (mj1rN Zm ND0 Z Z cpi m Di n 0�0 wo* p3►n mx _ xN_n 66-1 �Z° mN3 Co m000 �- NsN v r 0600 Z 06 �NO a*y m z_Z n io O 0-4 N v nz x0 mm Y)-q m 00 3 i FORM U - VERIFICATION FORM 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: !�! ,��5 li�G.- Phone ZYZ _ LOCATION: Assessor's Map Number Z1127 Parcel 3 Subdivision !/tiG�/Li!t ��5 Lot(s) Street _ A0(11W Z,-5 i�2N7 s f J St. Number 7S RECO ATIO OF GENTS: Conservation' Administrator Comments Town Comments Food Inspector - Health ��i�%� Septic Inspector -Health Comments Use Only************************ Date Approved 41Z / 7 Date Rejected Date Approved Date Rejected Date Approved Date Rejected C(7 /D Public Works - sewer/water connections - driveway permit ��%c� 9 % Fire Department �ku'J h1q/0Wl/w-(6116k, feceived by Building Inspecto Date O z w O 0 F=4 � m c c i C N � C 0 • :g O Hc ca CD vE * �,� �` S� N. ; c `ramc mCS o m CD�Ol** FN me a«. . O o m m3�p y C' J � y t0 E o : CLU y m 0m p C O Q d C Z cjy O m '� Z :opo = m :In ~ w y m ~ W ._.. p umlD 1; C H •y •0Zcc O C 0 a V •� CJ m V •Cl �j0 y a •- O-0 �1 _ a`y20 = 1- t S a 4 m E L - e6 CIO V1 O y C 0 cm 0 C: Cf m `O Cs c 'c N m t O Z O J 0 5 r cm o_ y O O 'E m m ow CL ~ �•+ y-- 3 as 0 0 cc C2 d T.rm4 co o � Cc CD 'v C CD CL V CO) c C C c CLCOD cm v tx w pOa (� V \ w n chi or C w° b U x a a w w W V chi w tE n�' w w � b b G o E � m c c i C N � C 0 • :g O Hc ca CD vE * �,� �` S� N. ; c `ramc mCS o m CD�Ol** FN me a«. . O o m m3�p y C' J � y t0 E o : CLU y m 0m p C O Q d C Z cjy O m '� Z :opo = m :In ~ w y m ~ W ._.. p umlD 1; C H •y •0Zcc O C 0 a V •� CJ m V •Cl �j0 y a •- O-0 �1 _ a`y20 = 1- t S a 4 m E L - e6 CIO V1 O y C 0 cm 0 C: Cf m `O Cs c 'c N m t O Z O J 0 5 r cm o_ y O O 'E m m ow CL ~ �•+ y-- 3 as 0 0 cc C2 d T.rm4 co o � Cc CD 'v C CD CL V CO) c C C c CLCOD cm Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (bell w� *owf kc - Map and Parcel Ab9lyPurpose of Application (check below) Phone ber of Applicant: r/Single Family _ Two Family 9V.i-2azo t the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. �-- ature- of OWner & Authorized Agent who signed the Attached Building Permit Dafe form must be attached to the Building Permit upon application for such permit. N2 735 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. 3o 9 L 7 Application by the undersigned is hereby made to connect with the town water main in Street, subject to the rules and regulations of the Division of Public Works, The premises are known as No. L or subdivision lot no. 5 Z, (f Owner Address 61? Contractor Address pplicant's Sig ature PERMIT TO CONNECT WITH The Board of Public Works hereby grants permission to to make a connection with the water main at _ t-1./ l If subject to the rules and regulations of the Division of Public Works. Inspected by Date WATER MAIN Ic hoz-0-320 Street Street Board; f Pu is Works By See back for rules and regulations �za "rk, . RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be 1" type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4Y2 foot rod and brass plug type cover. I y GEORGE PERNA DIRECTOR Date: TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET. 01845 NORTH .moo DRIVEWAY PERMIT 1� 7 Telephone (508) 685-0950 Fax (508) 688-9573 LOCATION: 7-5 CrJ�GG��r�� BUILDER: phone: OWNER: G�`�rhZ'�� ZZ C phone: The North Andover Superintendent of Highway Utilities & Operations MUST be notified of the grade and set -back from street established in any driveway entry onto any street or way maintained by the TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval of such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. Remarks: Approval: 41 -It :1i�dOON QQO�- Al WyAd oda I10-�I�ilg/I 5,101 NXdMA 1N0�A ::Mme I S�AWON ANI J jO �i-imimi SW�d�1SI�QNIM I �1-�►-��`�! lv'6j'18zo�,A °311111 021d --4f 4*2pe II II II II II II II II II Ii II II II II II II II II II II II II II II II .I II II II II II II I I II II II N II II II II II II II II II II II II II N II II II II II II II II II II II 11 II II II II II II II II II II II II II II — — I--1 Il �A9 Nh'1�Q NO AIII NS�WON �NI� AO �i�u limi �5WW�;51MNIM : uulr�a .�-. - �! ?,,IJV 1-1-1 �.A II II II II II II II II II II it II II it II 11 II II II II II II II II II II II II II II II II II II II II II dAdOON GlQO-- SNOWAIII AS 5AWOH �]NI-j -jO NAci inn .A�a ''O' i ►g ��I Mx 6 ,1.01 5VVwA;5NdNIM l0. 1-19/1 BMX NDUVAIll;Al _====IT====TE__________________� I I 1 1 1 ------------------- ------------------- 110•,1- 119/1 M NOUVA111 J.HM d�dOON GIGIOJ- ,�A , Widd001�1Shcd 1 S�IINON ANld d0 N:j:mICl,.i ,� ;oda ► ►0- ► I a ► ►g / I 6101 5WwJ;5NdNIM - '�11111�"0'Ld d NOON & IOJ- :�g Nd1d �001� QNO��S 1 -AO 2,,i imimi. / 1i� oda110-11%S-119/1 � Zl SW�d� ,�SI�QNIM �-�- ��I) '� /�' B 'D'i B� 4 N ,- �---------- 110 WlJ NXVMO1 a� sKWON ANIS -jO NAci inn •d1111 l�a'O�d M u9 -.I �- .0-.6 119-Z (NM1N) MO?d/ --------- - 1 110-191 /� -104 '�J' MI A TYM YIMA v w0j"a ------------------- t--___ I ------- 1 �oea ono bona ad I uo-.lX n0 ib uo-4x no -,91 I I I i I I I i i I i I amAl G21d0A' m a la I 94 nxu UU 119/6 IAW O1 r91 111) _ I i CSM S11dM adl aOOM 'I'M � I I I I i I I I•KMd �1S2M9 e- � I I I I I I I I r I I I I I I I I f I I I I 10--Z (-) �iP'JN07 V d01 I I I I r lop. 4.b /101-4 ..Z/Ior,4 I s� I I I � I � � I lw_ N 0 ------------------I m I I I I � I I - I I I o I 1 I I I I � ir--------------- -� nz I I g I � m .iZ /I 9-.9 uZ /I Z-,9 I I I F —1 I Q r m I I I I � I I - I I I o I 1 I I I I � ir--------------- -� nz I I g I � m .iZ /I 9-.9 uZ /I Z-,9 F —1 I I " L_J L I I—T — NN I N)m &a1 -I 210 SWw 1d.'.4HIM I i Wd114 W&IS zp L— — — —_--- --_-------- -� -----------------7 _ I I I --------------------J i I r --j I r I I I I I I )mg &w 210 5w I I Idd15 RW WYA WK I i MOM Z)Nu6XM0XM.,9 i I I 1�lOd Wb�A I I i I 1 L — — — — —--———— — — — — — — I I -------------- I 4 N a 4 d AdOON cl dO; 'A9 NMVbA WIJ �IW�I�NU01 A;5U imim; 51WOH -AN I -A -jO N-:G in j �J� � � : Ya 110-1 l i i� / I � ,1,01 SWM 1SI�QNIM d IdODN 6610J- .�� Nb1d 9NIM� W01� QNO��S , G �AWOH AN I J �O d �Gl'11�1 y e dldooH aao�-6,V 1:� , Nb'1d JNIWddJ d001� X;V imm 5AWOH ANI J Ao �i-imine l .oda X0-11- 19 /aI 101 SWddd ,�SI�QNIM-.�-��I - '9'0'10`x'! °a111117TObd cIAdOUN QCIO.I- Wld !9NIMJ �OOd 5AWON ANI -A -AO zIAGa1inii .oda / ��O�,I���g _ �m ��U1117� Obd F C 14 -- �� d I dOOH QQO-L •AA NM N0015 NO% S �tNDN ANI -A AD d iQ'l ni tot ti l]n.� dldooH aao.L L 'A9 NMNbA II��I�IIV /I ,yea :m N0015 9Nlaliw !MIM SAWoH ANI -A -jO di-AMIR I Zl SWW� , OdNIM ��'Wi17�"OYJd CERTIFICATE OF USE & OCCUPANCY Town of North Andover euname veimurvume.r 0.t.-3/i�/9s> THIS CERTIFIES THAT THE BUILDING LOCATED ON _ ? W /1,J8t 37r__" MAY BE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STA4 BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. ► p �,' °+.rye ✓,�� :JAC14 S� CERTIFICATE ISSUED TO S ADDRESS zo< r ing Inspector T v IF— "'1 v � y d . � d 10 OCD ' St Z ca CL O �• = ? O CL CO) a� �o d O p CD CD O CLQ d CD CD O CD C CD y. CL v y CD I � v CO2 O 'O Z CD O � CD C CD cn VJ O cn C 0 C O ?�ow� z d y ZE CO cr y CO) Mm: O 0 H m dC -. d 1 M m� o y y � : IE m O O C CO's 2>4 C CV Z O y C) � O CD Er5'a - y � CL ..► .•► m O y n-o CL O CD d y cr 06 d C a•c to m y y to O O C7 = O : _ 1 : A ?• = CD m . m o 1p . CD: o, a): ate: :A Oc, CD Im co c o O = CD: . % omq 0 0 c . Im n -.n W) Oil _'y N rt Q lk CA IN omq 0 0 c . (1W i �l L Office use ONy - _ u 1 r=MOM> of da j-dfs Permit No 71 &A Fee Chedted \ BOARD OF FIRE PREVENTION REGULATIONS 527 CUR 12:00 3M 0eave bWxk) .1.-.;:.z� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL " WORK Ali Hreric to be performed in acr rdartce with the Massachusetts Eectricai Code, 527 CSI 12:100 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Mate CM or Town of NORT14 AN110VER To the Ins ecto of Wires: The udersigned applies for a permit to perform the electrical work described // below. Location (Street Number) L �r(� �Vi N` Owner or Tenant ( �l Uri �-f�—,f r �/ I .� 412, L% LL C'.,Wner'S Address l v � f 27 Is ;his permit in ccnjunc:ion with a buil(Zirg �errnit: Yes Z No r (Check Appropriate Box) 9� ?urccse ct Builcirc J f Alb 9 �'4 M ! Ly A/VL L -Lt "It' Utility Autncnzatien No. %D Existing Sarlice Amos ._1 Vcits Cverread 'i.- Uncgrrte C No. of Meters New Service Lb–Amps /—�fetts Cvernead r UndSmd ji No. of Meters Numoer of Feeders and Ampacity r kh ,l L "V �o N J/ n/60 l.ccation and Nature of Proposed c �:eC^cat Ncrx � /l���Z L I—f122 /c y ©w L : Ati Total Nc. of L;n:cng Cuuets Na. zf i No. �r-ransformers acs KVA =eve-- No. at Lig-tang 7- xtures SN+n'°_c. M;r1.; c _ -,c _ i Generators KVA '• i No. at Emergency Ugnung No. ct Receotac:e Cuttets No. of Cil aur❑ers j 3arery Units No. at Switch Cuttets I No. at 'as 3_rrers ( FIRE AL._1%,RMS No. of Zones 7atat No. ct Cetection arta j No. at Ranges Na. _: as Carc. =Ms g I Imtiaun Oevtcas I C• No. ct tsccsats _ Nc.ct gates 'o s C.V' No. at Sounaing Cevices No. ::r Sart Cantacnea No. of Cisnwasners ==a^-arAre3-__.:ng K.v Ca:ec:cniSourtcing Ceweas ' Muntc:oai Ctner .'�— —: j NO. Jf VNerS :"@d^g �evtC�S — t No. at .14 C. a: I Law Vattage No. of water Heaters KW i Signs Evas:S Winne t No- Hvcm Massage Tubs 1I I No. ct Motors ora+ ^P C TH !NSI:RANC= CCV=RAGE: ?•-,rsuant M :rte rec_xernerls c. :tasSncG._Set:s ;@neral caws '2�NC I rave a current Liaotiity Insurance Pout/ :nc_c:rg ; zr::etee CCera^ens Caverage or ;ts sues:anttal ecutvaient. YES - nave Sucmineo valid groat at same :a :rte t:... tcs. YES :ZNC _ :t you nave cr%ec ea YES. :tease inctcate :rte yFe at coverage Jv cnecxing trio accroonate Dox. INSURANCE r_ 3CNO = OTHER = (Please Scec:�:) (Exwranon Oatet Esumatea Value at Eiectrccal Work 5 Worx to Start tnscec_cn --ata Recues:ec: Signea uncer :rte Penatti/es at perjury n MRM NAME flit+i�I✓i ` tom' �(f6lrtO Y� L L C Raugn Final LRC. NO. .LIC. NO. Licensee t �1 3us. -7.1. No. l/✓c5 l C Ir J?n Ata- ALL lel. No. Acaress CWNER'S INSURANCE WAIVER: I am aware :not 7e Licensee ct:es ret :+ave :tie insurance coverage or 4s suostantial eau+valant as e- cu+rea oy Massaenusetm General Laws. aria that —r" signature on :r cerrnct acC+icanon -a-es encs reawroment Qw*+er Agent (Please crteex one) Cr V O eceoncne No. PERMIT F7» S �)o (Signature at Owner Cr Agent) i No 1 347 Date ... . Z,�/ZO„ 7 ° ' "a TOWN OF NORTH ANDOVER ,� °c p PERMIT FOR WIRING This certifies that.......o.e........ �.%. / .............. ............................ has permission to perform ..... m.f..W....... . S !N.. ............................. wiring in the building of ...-� .z')..�..✓L!. ru...... v.�.�.�G.a .......................... at .... .. North Andover, Mass. .... Fee..3-7.7.-.UJ Lic. No..;(k,?(&............................................................. rr ELECTRICAL INSPECTOR ft C I') f 197 04:13 399.40 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4t mmunwtal� of �` adpM m Permit o. Use OnlyU, (a y 11pin ntm of Public $afttg 0=pancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 521 MR 12:00 L 3190 Qeave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 12 - i 3 ' 17 Qi* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) % S W/ of k/ 97 Owner or Tenant Cf.)) t w (% I i (A 5 -42— Owner's Address Is this permit in conjunction with a building permit: Yes .� No El (Check Appropriate Box) Purpose of Building R -es i d -e rl t t t Utility Authorization No. Existing Service Amps —J Volts Overhead Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead Unogrna No. of Meters Number of Feeders ano Ampacity c' Location and Nature of Proposed Electrical Work -- J pc cw i j ( e, vim! No. of Lighting Outlets I No. of !-lot 7,-cs � I No. of Transformers TotalKV � 4 No. of Lighting FixturesAb I Swimming Pcoi ve,— In- r t grna. _ grno. Generators KVA No. of Emergency Lighting, No. of Receptacle Outlets ( No. of Oil Eurners I Battery Units No. of Switch Outlets No. of Gas Eurners NoOaf RangesI No. cf Air Ccrc. chs Oiai FIRE ALARMS No. of Zones No. of Detection and Initiating Devices Heat To:at Totai No. of Disposals I No.of h -Pur,-.:;s :ahs No. of Sounding Oevicea �'•(' C/ L/ G I No. of Sed Contained No. Of Oishwasners SaaceiArea Heat,rg Ostection/Souncing Devices No. of 0 ere O C Heating ^ ry I g Oevices KW — Municioal Local i—, Connection Other r i! No. of .140. of Low Voltage No. of Water Heaters KW I Signs 9aitasis Wiring y, No. Hydro Massage Tubs I No. of Motcrs Totai HP OTHER: sPC V ✓ r -f'L� %�� �l ✓ INL " is;, INSURANCE COVERAGE. Pursuant ,a the reouirements at 'JassaC,%Sers ;eneral Laws O 1 have a current Liability Insurance Policy inctuaing Carnc:etec Ocerations Coverage or its substantial eouivaient. YES ci NO = 1 have suomineo valid proof of same to the Office. YES 7/ NO = It you have checked YES. please indicate the type at coverage oy checking the appropriate oox. INSURANCE Z�-'t30N0 = OTHER = (Please Scec:�w) • Estimated Value of E!ectncal work S (Excitation Dalai Work to Start 12. Z 3' q -% Insoec:ion Date Aacues:ec: Rough Final S igneo under the Penalties of perjury: FIRM NAME S U t 4Z UC. NO. P, L/ S C— C} Licensee 12�f0OA S;gr.a:ure r.. /vim` UC. NO. Z2?. y -7 D i d- L Ot r a 6il4W f2 FA,1 L!`� Oi �� Bus. T.I. No. Address .Z r !tet Alt. Tel. No, ' • . OWNER'S INSURANCE WAIVER: I am aware that the Licensee toes not nave the insurance coverage or its suostanttal equivalent as re• , quit Massachusetts General Laws, ano that my signature on in;s -ermit application waives this requirement. Owner Agent ` ( sass heck OM1' :eieonone No. PERMIT FEE S (Signature of Owner or Agenti .-AGAR �t � a N2 I J, S. Date .... /A/ .77 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ................................ has permission to perform ...... ..... ...(R Vim ................ .. :2 wiring in the building of ........... vJOX)..%.Sd ... ................... at ..... 7.� ...... .................. . North Andover, Mas Fee....3 �0.. Lic. No. I -JV ............................................................... ELECTRICAL INSPECTOR ( V If Lt� 0 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer JC 'Ail Wym YJ Z A 0�19 SIO -.9 w1d wol� 15N :1.1 � --- M, rd I I LAA On 0 oTi I J1 I it 'c' I." I 1. lit -- - - - - - - - - ,l/14-14 "4-.z Location No. Date NORTh TOWN OF NORTH ANDOVER Certificate Occupancy $ .s of �cMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ $ l' TOTAL Check # y / % 1633<< _- Building Inspector l TOWN OF NORTH ANDOVER I BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING > � .�; .•:' ^� :a" �;,�"� �•�01`-�i£tR�$Z�S�.�ltl �,.�..: � '`�` �" �� `..� `rte;. r ,113 z; �^ :,,� y �,'� BUILDING PERMIT NUMBER: �0 DATE ISSUED: �a�-oma SIGNATURE: Building Commissioner/I ctor of Buildings Date CTi /•TT^XT t CTTB 71►TTATn/ ♦ T -T 1-1 Property Address: 1.2 Assessors Map and Parcel Number: V Map Numb Parcel Number 1.3 Zoning Information: 1.4 Proper Dimensions: Zoning District Proposed Use Lot Areas Frontage tl 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Nater Supply M.G.1—C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record -7J'LL% Name (Print) Address for Service c °l7 6,, .f2 Signa re Telephone 2.2 Owner of Record: Name Print i Address for Service: I Signature Telephone OL'l,tivlq J- l,Vl\a11CU1,11VP arlAyIl,La 1 j 3.1 Licen ed/Construction Supervisor:/ ,1Ili " le, � Licensed Construction Supervisor: �dre�, 7- a ignature Telephone 3.2 Registered Home Improvement Co/mpp'�any Name l�/��i/ U a Not Applicable ❑ oS•3/e/ License Number Z/y� 3 Expiration Date Not Applicable ❑ /3 :�6 5�6j Registration Number Expiration Date V M X z z M go 0 0 z 0 -.Tf 1 TT/11kT A/ n T n 1 cl e -1en/41 NEILIIVPI 4 - WUMAZAJ %-%JlMLIIW%XXV11 ILTL Y.L v a✓r S --k-1 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 buildi rmit. Signed affidavit Attached Yes ...... No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) XAddition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: 5)x01 --of /ekeF d1�,<- d' iSZ-pis --� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY - ,k 1. Building 8d� r (a) Building Permit Fee Multiplier 2 Electrical �^ (b) Estimated Total Cost of Construction 3 Plumbing --- Building Permit fee (a) x (b) 0 4 Mechanical (HVAC)' - 5 Fire Protection'"'-- 6 Total 1+2+3+4+5 — Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, X S-74eve-m /� //�Oy� as Owner/Authorized Agent of subject property. Hereby authorize �Cie111� /� flir ✓1l to act on My beltal i all n r la ve to work authorized by this building pennit application D� Sigii'afure of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1 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 Print Name Si ahue of Owner/Anent Date IN 11MIN NO. OF STORIES SIZE BASEMENT OR SLAB ST D KD SIZE OF FLOOR TIMBERS l 2` 3 SPAN DIMENSIONS OF SILLS DlIvIENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X ,MATERIAL OF CHDA EY IS BUILD94G ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE C©' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone 0 am a homeowner performing all work myself. F7I am a sole proprietor and have no one working in any capacity �l am an employer providing workers' compensation for my employees working on this job. Comanv name: (.,"o1 A",`A l Address /0 �? t Sr City' /a 10,4- Phone #: 97Lf, (A-4 [+-I Policv # t'� rl- c4 B ?33 O A ` Company name: Address -- City Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify and the pains and enalties of perjury that the information provided above is true and correct nnta Print name ��Arl�3 J /?"SGATe//.' Phone # 97if AofZ 93aO Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andover t4oRTH Building Department o ` 27 Charles Street North Andover, Massachusetts 01845 * E -i- 4 (978) 688-9545 Fax (978) 688-9542 '* 9q«.�M.�• �9SSAC HUsti��y DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit# the debris resulting from the 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 /at: Facility locatio Signature Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. 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