HomeMy WebLinkAboutMiscellaneous - 75 WINDSOR LANE 4/30/2018Date ......f..." -5......i..... .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
. .
This certifies that .............. yo ....... "4 . &<......................
has permission to perform ........ ..............................................
wiring in the building of E...... 5,A0?7;(: ..... ......................
v
rth Andover, Mass.
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Fee .. ................. L .. ....
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ELEcrRICAL'INSPEcroi(V
Check #
Commonwealth of Massachusetts official use ora
Department of FireServices; Pennit qo. 7/3,s
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
v. 9/US] save blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massaobusetts Electrical Code TRI CAL WORK
(PLEASEPRII 1W,VVKOR MEALL RWORMA O ff. 52< ; 12.00
City or Town of: Date:
BY this application the undcrsi "rI t_e To the Inspector of Wires:
gni groes notice of his or her intention to perform the electrical work described below.
Location (Street &Number) . I A I,' , A e _ — i
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? yes --�~
Purpose of Building No C3 (Check Appropriate Box)
Existing Service
Utility Authorization No.
`t1°'p$ ----L—Volts Overhead ❑ U d d ❑
New------ sell. .Ace Amps /
___..",__.__Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Worki
�� A -
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
0.0 ater
1 Heaters KW
No. Hydromassage Bathtubs
OTHER:
i�
n gr No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Of Ceil.-Susp. (Paddle) Fans No
Tr,
Of Hot Tubs ice
mmiag Pool Above
nd. ❑ n- o,
Bal
of Oil Burners FH
of Gas Burners
of Air Cond. Total ---T`
zX.11 QLOij
'e 2!U be Mqt d by the Inspecto,
. or
tnsformers
ISA
aerators
KVA
o mergency $ �
g
to Units
No. 01
;E ALARMS
No. of Zones
o )0 etect on an
Initiating Devices
of Alerting Devices
Space/Area Heating KW
Local ❑
Heating Appliances KW
ecurrty
0.0o'o
51 ns Ballasts
No. of
Data Wlr
No. 01
110. of MotorsTotal HP
a ecomr
❑ Other
6 5`q
Estiriiated Value of�l lec h ical Work: Attach additional detail �} desired or as required by the Inspector of Wires:
Work to Start: 0 tO� (When required by municipal policy.)
accordancested in P P c3'•)
INSURANCE COVERAGE: Unlosss waived by th owrequner, n penm't the psrforman a of electrr urn celetion
the licensee Provides Proof of liability al work may issue unless
insurance including "completed operation" coverage or its substantial equivalent 17:e
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office
CHECK ONE: INSURANCE ® BOND ❑ OTHER
rcertify, underthe (specify:) (" 'i, ` l t� 03) o
par anC pt7 �hfperju ,that the information on is application is true and eomplet�
FIRM NAME:
Licensee: LIC. No.:
Signature LIC. NO.:
ilfaPPlicable, ent exempt"� rhe livens number line,) \�16
- lllllll
Address: W�9 Bus. Tel. No.: X491 N3 -pp p
*Security System Contractor Licenser
OWNER'S WS required for this work,if Alt. Tel. NO. -
am WAIVER. 1 am aware that the Licenses dol es not have lthe liability number here:
required by law. By my signature below, I hereby waive this requirement. I am the (check One oinsurance wner normally
Owner/Agent owner's a ent
Signature
Telephone No. 1i?7� FEE: $
Location
No.Date /0—r��tis'
-i* . N� TOWN OF NORTH ANDOVER
oUP 0
�a
Certificate of Occupancy $
,ss ^° • E<� Building/Frame Permit Fee $
acwus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
18734
Building Inspector`
' TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
e
by
1
APPLICATION TO CONSTRUCT REP RENOVAT.OR DEMOLISH A ONE OR TWO FAMILY DWELLING
t . -,:; _ ,y .i, �`.. `S'�F ' ��T^ , ^ ,, . f,.. ;...., �y �,Y � � s x ✓�xs fir, .r h.+i' i3_r
BUILDING PERMIT NUMBER: DATE ISSUED. --""
SIGNATURE:
Kling Cotfifilissioner/12§Fdor of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Fj-
Zoning District Proposed Use
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Reqttired Provide Required Provided
Re red Provided
1
1.7 Weer Supply M.G.LCAO. 54) 1.5. Flood Zone Information:
zone
1.8 Sewerage Disposal System:
Public ❑ Private ❑ outside Flood Zone ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
nc Is rlc : Yes O
2.1 Owner of Record
Cr -k' ; NL( !C�U A / :j over"
Name (Print Address for Service
yt
Si tore Telephone
2.2 Owner o Rec .
Name Print Address for Service:
Signature Telephone
'SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
COV&—AlAy1— e r;
Licensed Construction Supervisor:
a2��3 /7� 16# />� a �
��U
License Number
Address
s
35-9-3Expi
� l G
tion ate
Si ature Telephone
RECEIVE]
3.2 Registered Home Improvement Contractor
Not Applicable ❑
SEP 14 2005
Company Name
-27— ) 9 '
+' V /UJ
Registration Number G DE ,
Address
91!:21 3 00J
xp1r on gite
SiDatum Telephone
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit. ,
Signed affidavit Attached Yes .......❑ No ....... ❑ 2
SECTION 5 Descri tion of Proposed Work check all a ble
New Construction ❑
Existing Building ❑
Repair(s)
Alterations(s) XAddition
[
❑
Accessory Bldg. ❑
Demolition ❑
—
Other ❑ Specify
Brief Description of Proposed Work:
11,11 �� o� Iw5e
�y (
&a a2 lel X g
Aa keg.
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Com leted b permit a licant
O "CIALUSI; ONLY``
1. Building
oZ Q®
(a) Building Permit Fee
Multi lier
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbingBuilding
Permit fee (a) X (b)
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 CONTRACT -OR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Her authorize to act on
behalf, in all rs relative to work authorized by this building permit application ®s
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, 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
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINIBERS 1 2ND 3RD
SPAN
DIMENSIONS OF SII.LS
IIIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS 13UILDING CONNECTED TO NATURAL GAS LINE
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FORM U - LOT RELEASE 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 or requirements.
APPLICANT FILLS OUT THIS SECTION
LOCATION: Assessors Map Number iD 4. I)
,PRONE 4'��--c1a 3 — 39Y 3
PARCEL
LOT (S)
(§mf) �TREET 7V G 11-2,0 � 4'� QST. NUMBER F
TION
OFFICIAL USE ONL
OF TOW1Q )WENTS:
DATE APPROVED
DATE REJECTED
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
,TH
TH
TE
DATE APPROVED
i
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT.
FIRE DEPARTMENT RECEIVE®
RECEIVED BY BUILDING INSPECTOR Dy�1 _1_4_2QQ5
Revised 9197Im
BUILDING DEPT.
Department of Indu&Wd Accidents
Offiee of Investigadons
600 Washington Street
Bosto#, MA 02111
www.massgov/dia
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electridans/Plumbers
Name(Businesstorgurizationindividnai):
Address:
City/State/Zip: /i/.elrirJ, V Phone #'
Are y9v an employer? Check the appropriate box:
Type of project (required):
I. I am a employer with i L 4. ❑ I am a general contractor and I
employeei (full and/or part-time).• have hired tie sub -contractors 6 El New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sbeeL t 7. C Remodeling
ship and have no employees These sub -contractors bave S. ❑ Demolition
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ Weare a corporation and its 9 C] Building addition
10.❑ Electrical airs or additions
required.] Officers have exercised their m7
airs
❑ I 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 repair
insurance required.] t employees. [No worker'
comp. insurance required.] 13.❑ Other
- nny uypz n.. % cuca3at UUA n i muco MIq EMM UIU IDE kneel Oelow ■lowme aft wortm,compensidion m
t Homeowners who submit this eff&vit indw tied they an dams an work and then hes amide couhsclm mint submit a new ofrldavit iadicatiir g suck
tCont wom that check this box mut atteded m sddidon l sheet shown S the nam of the sdb-= senor and their wortas' amp pobcy Mfomwliam
I am an employer that 6 providing xVrbers' compensadon imurance for my employees. Below is &e Pella job she
information. i
Insurance Company
9- 110C F3®�97-,A
C /9
Policy ti or Self -ins. Lie. M Expiration Date:
Job Site Address: lit (.[ Ak4a g-, 4yi e-
City/StatcfZip: ®A
Attach a copy of the workers' compensation policy declaration page (showing the policy number and mWiratlon date).
Failure to secure coverage as requiref under Section 25A of MGL c. 152 can lead to the ' penalties of a
fine m $1,500.00 and/or one-year »�osititm of criminal
up Y % 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 Aiaeby certify udder the pains and pew of perjwy tlYat Me
JJ LOwmation provided above 6 &w and eorr+eet
./7 A
use only. Do not write in this area, to be completed by city or town opclaL
City or Town:
PermWLicense 0
Issuing Authority (drele one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector S. Plumbing Inspector
Phone 0:
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enVloyee.
Pursuant to this statute, an employLe is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An em pW er is defined as "an individual, partnership, association, corporation or other legal entity, or any two or mon
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of au individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three aparnnents 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 152,125C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of is 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 covera`e required."
Additionally, MGL chapter 152, 425C(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 ID 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-contractar(s) name(s), address(es) and phone numbers) 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 doe 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 two that the application for the permit or license is being requested, not the Department of
Industrial Accideats. Should you bsve any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the num fiber listed below. Self-insured eompmn should enter their
self-insurance license umber on the appropriate line. -
City or Town OHiclals
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 he to contact you regarding the applicant
Please be sure to fill in the permit/lieme number which will be used as a reference number. In addition, an applicant
that mist submit multiple permittlicense 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 � been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid a 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 bice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a caL
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 east 406'or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 wwwmm.gov/dia
_ Board of Building Regulations and Standards
• — HOME IMPROVEMENT CONTRACTOR,
— Registration: 141949 E
Expiration: 3/2/2006
Type: DBA
COVENANT CONSTRUCTION
MARLIN SHEARER
273 HIGH RD.,i
NEWBURY, MA 01951
Administrator
�.
_6T. 1
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 066141
Birtwite 05/01/1.970
xplres 05/01/005 Tr, no: 13373 i
Restricted 00
MARLIN R SHEARER
273 HIGH ROAD
NEWBURY, MA 01951 Arirriinic+rte+nr
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. , NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: Z'S- is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
7;eI W -C%0 fVC Cy'-- /,4,VdVXX
(Location of Facility)
Lig/re of Permit Applicant
Fire Department Sign off-
p g
Dumpster Permit
Date
LAURETANI `N
# 34311
UV fes.. L A tai E.
(F:_DaME_V_L'f
J ENr1 I FEs: zoh>
JOHN S. LAURETANI
►. F,RO•FESSIONAL LAND SURVEYOR,��i`�` 'AN SURVEYING COMPANY
)O' HEREBY CERTIFY THAT THE
kBOVE MORTGAGE INSPECTION . 77 Rumf9ro, Avenue, Waltham, MA 02154 (617) 893-6477
'"00'WAS PREPARED FOR
C4UntYfr'`i W t1�E FUNDjrt[- IN
:ONNECTIONWITH ANEW MORTGAGE �A rY
�1NDmo1-'IS NOT INTENDED OR REPRE- 1gage Inspection Plan
3ENTED TO BE A LAND OR PROPERTY
°!NE SURVEY. NO CORNERS WERE
THE LOCATION OF THE ORIGINAL
-DWELLING SHOWN HEREON EtTHI±R
RECORDED AT COUNTY REGISTRY OF DEEDS
BOOK 23$10 PAGE— L.C. Cert. #
3ET. IT CANNOT BE USED FOR ES-
WAS IN COMPLIANCE WITH THEl QCAL
PLAN REFERENCE: ELAij A 102-52
rABLISHING FENCE, HEDGE OR
3L!ILDING LINES. THE LAND AS SHOWN
APPLICABLE ZONING BY LAW IN E^
BRAWN PERTOWN OF __ ASSESSOR'S
aEREON IS BASED ON CLIENT FUR-
'FECT WHEN CONSTRUCTED WITH -RE-
MAP # PARCEL # DATED
2.
1 w 11'4 7�c:�LA
VISHED INFORMATION AND MAY BE
SPECT TO HORIZONTAL DIMENSIONAL
ADDRESS: 2
2T N rIDD�1El2 M A
W6JECT TO FURTHER OUT -SALES,
REQUIREMENTS ONLY), OR IS EXEMPT
_
T
MAKINGS, EASEMENT -SAND RIGHTSOF
.FROM VIOLATION ENFORCEMENT: AC-
BORROWER.
NAY. k RESPONSIBILITY IS EX-
TION UNDER MASS. G.L. TITLE VII,CH .P.
SEC. 7, UNLESS OTHERWISE
G
SUBJECT DWELLING LIES IN FLOOD ZONE
f.ENDEDHEREINTOTHELANDOWNER
1R
-40A,
NOTED OR SHOWN HEREON. A ;CON
AS SHOWN ON NATIONAL FLOOD INSURANCE PROGRAM FLOOD
. OCCUPANT, IT IS NOT INTENDED
FIRMATORY INSTRUMENT SURVEY
INSURANCE RATE MAP DATED JUNE �515F03
CO BE RECORDED.
1S. ADVISED WHEN STRUCTURES ARE
COMMUNITY _ PANEL # �Syv9S3 00�o t33 .
:.,
DATE, b 22. 9
SHOWN TO BE 1' OR LESS, FROM
FIELDED DRAFTED CHECKED
CLIENT �`LNAJIAA
PROPERTY OR REQUIRED ZONING
BY
JSG-
'CLIENT REF.# �5 Ili 3139
Io S_9 S
SETBACK LINES.
DATE
F.B.---PGE.
J.O.#
It
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATIaTO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
`i6bSeetiali� Oltiei>dUee
BUILDING PERMIT NUMBER. DATE ISSUED/Zi
SIGNATURE:
Building_Cotbhiissioner/Ingxctor of Buildings Date
CF.CT1nN 1- CTTF 1Nrr11DMA1"nN
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
15- f lAll)07 7 +.2
D CSG 6 -Map �
Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
- X 1$
Zoning District Proposed Use Lot Areas Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1.7 water S 1.3. Flood Zone Information: Sewerage Disposal System:
�p1yM.G.LC.40. S4) 1.8
Public 0 Private ❑ -1 1Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑
TI
SECON 2 - PROPERTY OWNERSHMAUTHORIZED AGENT rlc is ric : es O
2.1 Owner of Record
Gkar-
Name (Print Address for Service:
Si ture Telephone
2.2
Name Print
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
3.2 Registered Home Improvement Contractor
Company Name
Address
Telephone
Address for Service:
R
X
3
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go
Not Applicable ❑
6., G:._ /z/
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License Number
5
Expt hon ate
RECElV
0
Not Applicable ❑
SEP 1
4 2005
Registration Number
M
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Expi on to
SECTION 4 - WORKERS COMPENSATION (XG.L C 1.52 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... 0 '
SECTION 5 Description of Proposed Work check all a ble ~`
New Construction 0 Existing Building 0 Repair(s) Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition 0 Other ❑ Specify _
Brief Description of Proposed Work:
�1e'- i11%� 1--r7�16Aa SCS /%-I`
M
CW/0- -fie s
r
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost ( Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
020 0e)
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (I-IVAC
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
as Owner/Authorized Agent of subject property
Her Y authorize , to act on
b -hall, in all i6at rs relative to work authorized by this building permit application.
AS 5
Signature of Owner i Date
SECTION 7b OWNER/AU'THORIZED ACENT DECLARATION
I, 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
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRABERS 1 ` 2 ND3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DfMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TI-HCKNESS
SIZE OF FOOTING X
MATERIAL OF ClT^'FY
IS BUILDING ON SOLID OR FILLED LAND
IS 13UILDING CONNECTED TO NATURAL GAS LINE
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COVENANT Construction
General Contracting & Fine Carpentry
273 High Road
Newbury, MA 01951
Health Agent
Town of North Andover
RE: 75 Windsor Lane
Greg and Nancy Smith Residence
Description of Project: Rebuild 12' X 10' screen porch on existing sono tube footings.
One of the existing sono tubes is 4 foot 6 inches from the existing septic tank. The other
two footings exceed the town's 5 foot regulation. The porch will be reconstructed as a
12' X 13'3" structure. No additional footings will be poured.
Date ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
lj�,, 64? Z�C-7-4�-
Thiscertifies that .............................................................................................
has permission to perform ........... ktTG�
...................................
wiring in the building of ....... ...................................................
'7 S- Wi .................
at
North Andov r, Mass.
........................................
Fee.......... 777:�7.. Lic. No...) ... V ... $Fq.-33
. .......... ..........
.r ELECTRICAL INSPECTO�
Check #
10700
Conunonwea[t/i o� ///a��ac�xu�afsa
.UeFarlmeat 11 ira Saruice9
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. % 19 7e
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (ME), 52)/Z -
City
CMR 12.00
(PLEASE PRINT WINK OR TYfPI=C1QVe-k1(
4A TION) Date: ''7 or Town of: 0A To the Inspe oro Wires:
By this application the undersigned gives notice ofhis of her inten 'on to perf rm the electrical work described below.
Location (Street & Number) (iL%
Owner or Tenant 674e ' 1, ` Telephone No.
Owner's Address
Is this permit in conjunction with a b�iildinfpermit? Yes No ❑ (Check Appropriate Box)
V1Cr e j 11 I k" Utility Authorization No.
Purpose of Building S
Existing Service Amps/ 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: 0
-40
(^nn nierli�w ..III... ILII-..._�_ •.L!
No. of Recessed Luminaires 7
=, 11I.J.".1y1fix
No. of Ceil: Susp. (Paddle) Fans
+uuIr may oe ivaivea Dv me inspector o/ Wires.
o. of Tota
Transformers KVA
No. of Luminaire Outlets -5-
No, of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In-
nd. d.
o. o mergency ig ing
Bo Units
No. of Receptacle Outlets L
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection an
InitiatingDevices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump
Totals:
I Number onso.
oSelf--Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal 11 Other
Connection
No. of Dryers
No. o Water KW
Heaters
Heating Appliances KW
o, of No. of
Signs Ballasts
Securityyste s,
f Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
elecommunications Wiring:
No. of Devices or Equivalent
OTHER:
nrracn aaauronai detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: ®- Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the Iicensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that sucht�t
e is in force, and has exhibited proof of sre to the pe it issuing -office
.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) iC7j;� l 12 J�
I certify, under Are Pat and pen t' of erjrrry, l/ t t/re in rnration on tfils"app`kcatlstf'rs_ true aitrl onf e
FIRM NAME:
�'
LIC. NO.:�� 7
Licensee: ��h� h �✓ CJ�j fi Signature LTC. NO.:
(Ifapplicable, ent "ex em t" in the license number li y / Bus. Tel. No.•
Address: .> i /l1 Ou�1,7 Alt. Tel. No.:-
*Per M.G.L. c. 147, s. 57-61, security wc# requires Dep ent 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 ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
' Office of Investigations
kvi 600 Washington Street
Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: . eA,& k' !✓1 S ��
City/State/Zip: t �8
Phone #: q70 U-)
Are yo n employer? Check the appropriate box:
1. am a employer with q
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ 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
IOXElectrical 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.
I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. A j _ —1
Insurance Company
W -I
Policy # or Self -ins. Lic. #: 5J<�axg1 os4 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.
Ido hereby cert der to a d penalties of perjury that the information provided abo e is uuue and correct.
Signature: nAte. _3 A
344
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 #:
Informati®n and Instruction's
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, Mil, 02111
TeX, # 617-727-4900 oxt 406 or 1-877,MASSAFB
Revised 5-26-05 Fax # 617-727-7749
�ww.mass,govfd�a
FORM U - LOT RELEASE FORM
/B'oards
NSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
and Departments having jurisdiction have been obt
A
aine . This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
AO-PLICANT
FILLS OUT THIS SECTION
.,\ LOCATION: Assessor's Map Number /D 4. `j
SUBDIVISION
TREET 7V
l_
OFFICIAL USE ONL
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
nvarC%o 1 VK-Hr-ALTH
PARCEL
LOT (S)
,ST. NUMBER 75—
DATE APPROVED
DATA REJECTED a
Ser
.os --
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT RECEIVED
71ECEIVED BY BUILDING INSPECTOR DA .E► . J ' 5
Rsvtssd 9197Im
BUILDING DEPT
TOWN OF NORTH ANDOVER
• BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Tbir, Set",NNAMd
>�I�e
BUILDING PERMIT NUMBER: I DATE ISSUED:
SIGNATURE:
Building Commissioner/IngWor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel
ap Number
Number:
Parcel Number
rT
1.3 Zoning Information:
J 0o�
Zonis District Proposed Use
1.4 Property Dimensions:
Lot Area
�
f— —
Fronts ft
1.6 BUILDING SETBACKS ft
Not Applicable ❑
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided Recpired
Provided
1
ECEI1/
p
1.7 Nater Supply M.G.LCAO. 34)
Public ❑ Private 0
1.5. Flood Zone Information: 1.8
Zone Outside Flood Zone 0 Municipal
Sewerage Disposal System:
0 On Site Disposal System ❑
�l<a iivn� L-rAvrMJK1I I -1..1w1It, Ul�U UE i2S NO
2.1 Owner of Record
Name (Print Address for Service:
Sipdture Telephone
2.2
Name Print
Address for Service:
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
fir'' 1/&W1),vr— 1144�41A-) X' S j&d Pt V'i
Licensed Construction Supervisor:
Address
Telephone
3.2 Registered Home Improvement Contractor
Company Name
.2-7-3 lhtll A, ,)
Address
— 7,. 3 - j's-1.3
3 3 Te?5
T
M
z
C
I to
v
Z
rT
PC
MINOR
Not Applicable ❑
C
License Number
ExpirationAate
ECEI1/
p
ra
Not Applicable ❑
SSP 1 4 2005
Registration Number BUILDING DET
r
2A oe-�
MINOR
Z
^
Expi on to
SECTION 4 - WORKERS COMPENSATION (M.G.L C 1.52 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... ❑
SECTION 5 Description of Proposed Work check rJl a able
New Construction ❑ Existing Building ❑ Repair(s) 5r Alterations(s) "X Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description] of Proposed Work: /� ,
0/--�
r
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
t o oe)
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTnR APPLIES FOR BUILDING PERMIT
;Herau
6 t�-� _, as Owner/Authorized Agent of subject property
thorize to act on
lf; in all 6-rathIrs relative to work authorized by this building perntit applicatio
Signature of Owner Date f
rfiRCT10N 7h OWNFR/AUTHORIZED ACFNT DECLARATION T
I. - 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
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FI.00R TIMBERS 1' 2 ND 3RD
SPAN
DIMENSIONS OF S111S
DLML ENSION;S OF POSTS
DrMENSIO S OF GIRDERS
H 1EIGHT OF FOUNDATION TIBCKNESS
SIZE OF FOOTING X
MATF.WAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS 13UILDING CONNECTED TO NATURAL GAS LINE
Of
JOHN S.
3 LAURETANl 'N
# 34311
49n.__
UJ I l,� D S C) iz.,.
CFD2ME -L'i
LAO E
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