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Home My WebLink AboutMiscellaneous - 759 GREAT POND ROAD 4/30/2018I Date.. �A/! ... ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING A4 This certifies that /�� .......... ... ............ 6 ...................... has-permissiontoperform- ..:�.4�4.V(/ . .......... .............................................................. wiring in the building of ..`F: ..... ..... 7 at ....................................... ............ ........ . . orth Andover, Mass. fee.......... c: LiNo. ...... ................... t_. ELECTRICAL INSPECTOR Check 4 42 Commonwealth of Massachusetts Official Us my �- Permit No. UcJ Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6/15/15 City or Town of: NORTH ANDOVER 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) 759 GREAT POND ROAD Owner or Tenant JOSH & ASTRID SHEEHAN Telephone No. Owner's Address SAME Is this permit in conjunction with a building permit? Yes No X BLDG PERMIT # Purpose of Building SINGLE FAMILY Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters �g Number of Feeders and Ampacity (� Location and Nature of Proposed Electrical Work: ADD LIGHTING IN BEDROOMS Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total 14 Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA 19 No. of Luminaires Swimming Pool Above El In- 0 No. of Emergency Lighting 19 grnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMSNo. of Zooes . No. of Switches No. of Gas Burners No. of Detection and 8 Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices Tons No. of Waste Disposers Heat PumpNum.ber. ............................... Tous ............ KW ............. .... I No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Ele9trical Work: $4,000.00 (When required by municipal policy.) Work to Start: 6/12/15 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C n ess 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 ❑X BOND ❑ OTHER ❑ (Specify) I certify, under the pains and penalties ofperjury, that the information on this application is true and comp FIRM NAME: MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON, INC LIC. NO.: A10421 Licensee: MICHAEL KELLER Signat6re C. NO.: E25006 (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.: 603-394-0117 Address: 27 WOODMAN ROAD, SOUTH HAMPTON, NH 038 Alt. Tel. No.: _ *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.: _ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law ture below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. 603-231-6068 By my signa- Owner/Agent PERMIT FEE: $ ^� Signature Telephone No. 7A Vl\ -i r , The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON, INC. Address: 27 WOODMAN ROAD Citv/State/Zip: SOUTH HAMPTON, NH 03827 Phone #: 603-231-6068 Are you an employer? Check the appropriate box: 1. JZ I am a employer with 1 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. employees and have workers' [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.JZ Electrical repairs or additions 1.1.❑ 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 wolc,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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. TRAVELERS Insurance Company Name: Policy # or Self -ins. Lic: #: INUB-0008592-9-14 Job Site Address: 759 Great Pond Road Expiration Date: 7/16/2015 City/State/Zip: N. Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1 500.66'a4br one-year imprisonment, as well,as civil penalties in the form of a STOP WORK ORDER and a fine; of up to $250.0Wa &y against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investiaations;of'the bIA for insurance coeraize verification. I do hereby cel ilfy'undti{e pains a0p knalties of perjury that the information provided abowe.,is true and correct. /% _ _ 6/15/15 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 #: 27 WOODMAN' 03827- Date.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... 1. ................ has permission for gas installation inthe buildings of ................. .................. ............................................................... at ... 15n........... ......... �?c ........ . North Andover, Mass. ....... ........ FeeA. -PD Lic. No....... ....................................................... GASINSPECTOR Check # 9667 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 finder the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITTER NAME: M A r . tb LICENSE # f 355 SIGNAT RE COMPANY NAME: I ADDRESS: � JCn rt-,& S 1 - CITY: CITY: 1 1 11cAd 1-t fOiN S I / _ g36 -Z/ 9 3 CELL. 97 � TEL:?,3 6- Z� MASTER [JOURNEYMAN ❑ LP INSTALLER ❑ M ZIP:. Gy, 4 FAX: EMAIL: )RATION PARTNERSHIP ❑ # LLC fi MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK G TYPE OR PRINT CLEARLY CITY: 4jo j rin /%ja1 Vf_,^ I MA. DATE: / PERMIT4q'[ JOBSITE ADDRESS: A to — OWNER'S NAME: As t/ie.0 SAPe /1e� �c"EL ` _93J-31 %(( FAX: OWNER ADDRESS: is 1 q-�, OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: gr' RENOVATION:.❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO APPLIANCESZ FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14. BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE Z FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFJOP UNIT TEdTk UN IEATER UP ENTED ROOM HEATER � WATER HEATER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial eq ivalent which meets the requirements of MGL. Ch. 142 YES 0 ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee 8oes not have the insurance coverage required by Chapter 142 of the . Massachusetts General Laws, and that my signature on this p emit application waives this requirement. e CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 finder the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITTER NAME: M A r . tb LICENSE # f 355 SIGNAT RE COMPANY NAME: I ADDRESS: � JCn rt-,& S 1 - CITY: CITY: 1 1 11cAd 1-t fOiN S I / _ g36 -Z/ 9 3 CELL. 97 � TEL:?,3 6- Z� MASTER [JOURNEYMAN ❑ LP INSTALLER ❑ M ZIP:. Gy, 4 FAX: EMAIL: )RATION PARTNERSHIP ❑ # LLC fi f ��' . , �`` ,. rartmentl of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston. MA 02114-2017 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: -e_. Are you an employer? Check the appropriate bog: 1. t �f I am a employer with .3 4. [] Ian employees (full and/or part-time).* hav 2. ❑ I am a sole proprietor or partner- list( ship and have no employees The working for me in any capacity. eml [No workers' comp. insurance con 5. We required] 3. ❑ I am a homeowner doing all work off myself. [No workers' comp. ngi insurance required.] t c. 1 Phone #: k-" R-26_- Z 15 a general contractor and I Type of project (required): hired the sub -contractors 11 6. El New construction on the attached sheet sub -contractors have :)yees and have workers' . insurance.* re a corporation and its ;rs have exercised their of exemption per MGL Z, § 1(4), and we have no :)yees. [No workers' . insurance reouired.l 7. [] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 LF0 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' information. Insurance Company Name: Policy # or Self -ins. Lic. Job Site Attach a copy of the workers' compensation policy c Failure to secure coverage as required under Section 25 fine up to $1,500.00 and/or one-year imprisonment, as of up to $250.00 a. day against the violator. Be advised Investigations of the DIA for insurance coverage verifii I do hereby certify under the pains and 7 F:3 4!�— 2/ Official use only. Do not write in this area, to be City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. 6. Other insurance for my employees Below is the policy and job site 7 d Expiration Date: 3/d Y / If City/State/Zip: laration page (showing the policy number and expiration date). of MGL c. 152 can lead to the imposition of criminal penalties of a 11 as civil penalties in the form of a STOP WORK ORDER and a fine at a copy of this statement may be forwarded to the Office of that the information provided above is true and correct. by city or town officiaL Permit/License # Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: I Phone #: COMMONWEALTH OF MASSACHUSETTS q a`" PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP MARK MAGN(F1CO Z _ %\x MAGNI F i CO EROS PLB(iGT,GAS FlTTIt' y A h 1 s 3 FOREST ST t_ M I DDLETON MA O i 949-2015 - 3266 ;_-5/01/16 204666 _ �o COMMONWEALTH OF MASSACHUSETTS ` M PLUMBER'S AND GASFITTERS ISSUES THE FOLLOWING LICENSE 7' LICENSED AS A MASTER PLUMBER MARK B MAGNIFICO < frf 31 FOREST STREET MIDOLETON MA 01849-201 f '^ 1355 09/01/16 204667 ,r COM"ONWEEA! T" Cc *,I;ASSACHUSETt'S BOARD OF PLUMBERS AND GASFITTERS 3� ISSUES THE FOLLOWING LICENSE;d LICENSED AS A JOURNEYMAN PLUMBER t uu n P a {s MARK. B MAGNIFICi k 31 FOREST ST F V r10i1l.ETON MA 01949-2015 r 25002 05/01/16 204668 A t Ail cy x t n,�. 19 This certifies that Date.AZ.. k .q�.......... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform...................... wiring in the building, of .............. ::4 ........ Al ........................................................ at .. .7..C.;.... .Z..l.. ....... rth And over, Ms . 2;b Fee.. ............. Lic. No ............... ". ELECTRICAL INSPECTOR Check # 21.B B 8' Commonwealth of Massachusetts Official Use Qnly Permit No. Department of Fire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2/25/14 City or Town of: NORTH ANDOVER 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) 759 GREAT POND ROAD Owner or Tenant JOSH & ASTRID SHEEHAN Telephone No. Owner's Address SAME Is this permit in conjunction with a building permit? Yes X No BLDG PERMIT # Purpose of Building SINGLE FAMILY Utility Authorization No. _T Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters 9 F— New Service Amps Number of Feeders and Ampacity Volts Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: KITCHEN & DINING ROOM REMODEL, ADD RECESS LIGHTS IN LIVING ROOM Completion of the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No, of Cei6-Susp. (Paddle) Fans No. of Total 16 Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA 20 No. of Luminaires Swimming Pool Above ❑ In- ❑ No. of Emergency Lighting 20 grnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones 17 No. of Switches No. of Gas Burners No. of Detection and 7 Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices Tons No. of Waste Disposers Heat PumpNumber - ........_ Tons KW ..................... ................ No. of Self -Contained I Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other I Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $7,000.00 (When required by municipal policy.) Work to Start: 2/24/14 Inspections to he requested in accordance with MEC Rule 10, and upon completion. INSURANCE C n ess 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 Ts— CHECKproof of same to the permit issuing office. 1,�' CHECK ONE: INSURANCE ❑X BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON, I vNC LIC. NO.: A10421 Licensee: MICHAEL KELLER Signature'�!✓ C. NO.: E25006 (Ifapplicable, enter "exempt" in the license number line)Bus. Tel. No.: 603-394-0117 Address: 27 WOODMAN ROAD, SOUTH HAMPTON, NH 03827 Alt. Tel. No.: 603-231-6068 *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen 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 signa- ture below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. itis The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON, INC. Address: 27 WOODMAN ROAD Citv/State/Zin: SOUTH HAMPTON, NH 03827 Phone #: 603-231-6068 Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 2 4. ❑ 1 am a general contractor and I 6. ❑New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. Demolition workingfor me in an capacity. y p �'• employees and have workers' comp. insurance.: 9. ❑Building addition. [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. TRAVELERS Insurance Company Name: Policy # or Self -ins. Lic. #:INUB0008592913 Expiration Date: JULY 16, 2014 Job Site Address: 759 GREAT POND ROAD City/State/Zip: N. Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration. date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 2/25/14 Phone #: 603-931-6068 l 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 #: ` ,� + - 27 WOODMAN -RD 838 ` 103,91 Date........ . ................ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . 11Z This certifies that .... . . ........................ f ......................................................................................... has permission to perform ....G!.....:��........................ a ........................... '25 plumbing in the buildings of ............................ d -,J ........................................................ x1d al ...... 4 ....................................................................................... North Andover, Mass. Fee.,N . . ....... Lic. No. .............................................................. PLUMBING INSPECTOR Check # 6V -)V 112-1115 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t, . UV CITY Q�c J1 MA DATE l ( PERMIT # JOBSITE ADD SS OWNER'S NAME J fAQTV4,, �✓� POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW: DIRENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES ® NOD FIXTURES 1 FLOOR--> BSM 1 2 3 4 5 6 7 8 19 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I DISHWASHER DRINKING FOUNTAIN ii { FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) I J _.� ____I ____ I _.-_--I -__-I ___j --(__.___.1 KITCHEN SINK I !_J -_i ___j ___-_ _._._i _____.J _-_J ._.__t --__I LAVATORY-- ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL 4 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i_I OTHER _. ____ __j I _---- _f -__-J INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES,0 NO D Lff,YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW j LIABILITY INSURANCE POLICII OTHER TYPE OF INDEMNITY © BOND Q OWNER'S INSURANCE WAIVER: l 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 [2 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur a to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ LICENSE #F —10-3 —t5-11 SIGNATURE MP'A JPCORPORATIONn# PARTNERSHI _I# LLCU(�:11 �,I�Cralgvt y_p COMPANY NAME (`+(fr" e rLl - ADDRESSht CITY [AW— '_ _� STATE ZIP aQ87 TEL D:3• a FAX CELL �td6 EMAIL '-�_._..... - " -- - -- - - , _ I __ --- COD Oz U ! IN, o z cn El uj ioL :M. uj < LU V) -Lu LU co O z 0 L) IL tL LLJ Lu O z z it 1, it The Commonwealth ofMassachusetts Department of lndustrigl Accidents Office of Investigations kvi 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): �16_ T� (Mt_ LIL Address: City/State/Zip: PhoneCoO�- Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 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. ❑ 1 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. ❑ Electrical 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. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached anadditional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name; 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 insurgtce coverage verification. X do hereby certi er palnPA4nd penalties ofperjury that the information provided above is true and correct. use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employeiis 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 Industdai .Accidents Office of Investigations 600 Washington Street Boston, MA. 0.2111 Tel, # 617-727-4900 ext 406 or 1-877 MASSAFE Revised 5-26-05 Fax # 61.7-727-7749 i ww-mass,gov/dia. Date... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... \4�XAC� \/ ..... has permission for gas installation ...................................................... r - inthe buildings of ...... - ........................................................................ w...... . 81—a. --T...../.' North Andover, Mass. Fee.M—.,.. Lic. No.1.1.5......... IY4 . .................................................. GAS INSPECTOR Checl # A77 9109: 112711-3 .MMM WWW WWW WWWWW WW . ffffM�.'�WWWWW WWWW W WW I BERWYN FNIK (taiI W F1Wf FO �►�WfF (- �>�f�IT�F�-i GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY nI BOND 0 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate f4the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian 1 P ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME�,� ��- LICENSE# 1031 SIGNATURE MP� MGF ) JP [ ] JGF j LPGI � CORPORATIOfII�] # � PARTNERSHIP ®#� � LL �i�' -� COMPANY NAME:JA��v►.� ADDRESS CITY L STATE ZIP 090 TEL �gI 1 C� FAX 1�- — 9 CELL. W04EMAIL--- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` G TYPE OR PAZ CLEARLY CITY _ MA DATE l PERMIT # 111Jv `lam JOBSITE ADDRESS ►fi' , OWNER'S NAME II _ OWNER ADDRESS TEL �IFAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL NEW: E] RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER Za t.: _Y... - . _ L 11. - L:,_J 1 -:j BOOSTER -- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE .MMM WWW WWW WWWWW WW . ffffM�.'�WWWWW WWWW W WW I BERWYN FNIK (taiI W F1Wf FO �►�WfF (- �>�f�IT�F�-i GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY nI BOND 0 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate f4the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian 1 P ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME�,� ��- LICENSE# 1031 SIGNATURE MP� MGF ) JP [ ] JGF j LPGI � CORPORATIOfII�] # � PARTNERSHIP ®#� � LL �i�' -� COMPANY NAME:JA��v►.� ADDRESS CITY L STATE ZIP 090 TEL �gI 1 C� FAX 1�- — 9 CELL. W04EMAIL--- fy O z z 0 H U W a Lon W e 0 Z ZO W >- N Con F- W W a LU F- Z a � ~ W r4 a w W� w w C0 0 a a a U J ' H a a a x i— w LL H O z 0 H U a C�7 r The Commonwealth of Massachusetts - Department of Industria[Accidents Office of Investigations • 600 Washington Street Boston, MA. 02111 W. www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narne (Business/Organization/Individual): , `�� (,Q�` PS LLC Address:�I�-�.'1 City/State/Zip: Phone #: 6W - -9L �9 ,-000a— Aran employer? Check the appropriate box: 4. ❑ I I Type of project (required): 1. am a employer with am a general contractor and 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors # Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 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. El We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.01 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.] i 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. r'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an'idditional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address:. Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cert'!�d�the pa r and penalties ofperjury that the information provided above is true and correct. Riannmr . %� --- . hate. 11. G � � 7 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 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 maybe 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 (ifnecessary) 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 Conmonwealth, of Massachusetts Aepa ento:fIndustrial.A,ccidents Offlce QfIntvestigations 690 Washington Street Boston} MA, 02111 Tei, # 617-727-4900 ext 406 or 1-877rMASS.AFE Revised 5-26-05 hay, # 617-727-7749 www-mass,govfdxa COMMONWEALTH OF MASSACHUSETTS`,: I Date.6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatle 7 k .. ................. ........................ has permission to perform ... ......... ..... ....... -7 ........... ................. wiring in the building of ............... ............................................................. at....7756i North�...... ............. I ...... ass. Fee....�� Lic.No!�.lwl ELEcrm;l� NSPECTOR Check 1.0879 Official Use only Commonwealth of Massachusettts a , Department of Fire Services Pem"tNo, Occupancy and Fee Checked ' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT)NINK OR TYPE ALL INFORMATION) Date: 4 ' "? � ? J City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his orher intention to perform the electrical work described below. Location (Street & Number) V9 G,�A-7 /pN,p kr>_ Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with buildin ermit? Yes ❑ No (Check Appropriate Box) Purpose of Building ��+,/[Tz itY'^, Gy£L Ll N&_ Utility Authorization No. Existing Service,,708 Amps /c7y /61Y b 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: qv57-4 oL QJI RZ"t- rd P ;F I- 5 S t7 `t a1.W L>rr. Pe -VG Completion o the ollowin table m be waived hv the Inspector of Wires. o. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA [No.of Luminaire Outlets No. of Hot Tubs Generators KVA o. of Luminaires Swimming Pool Above ❑ In- rnd. nd. ® o. o mergency ig mg Batter 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 Initiatin Devices Ranges No. of Air Cond. Total No. of Alerting Devices Waste DisposersHeat toof Pump Number Tons KW _ No. of Self -Contained Dyettection/AlertiziL, Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other Connection No. of Dryers No. of WaterNo. Heaters K Heating Appliances KW Ballasts No. of asts Si s Bal Security Systems:*. of Devices or E uivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Value of Electrical Work: D D (When required by municipal policy.) Work to Start: 16 ' td Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE'S BOND ❑ OTHER ❑ (Specify:) Icertify, under the aI and peva ties ofperjary, that the 1H orntatior on this application is true and cor-tip'ete. FIRiVINAME: ►'�1✓ r00 -Ye ��'AN"CL6C.Y4�F-c -z-PQ LTC. NO.- F - ,S Licensee: 01445 Signata—Z - LIC. NO.: (Ifapplicable, enter " xempt"int licens n mberline. Bus. Tel. No.: ,23( ata Address: 0 k) -m ",q • 6 /V6 YAlt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. RiRT FEE. $ 1 S f I _ • .L+�JI:lWdJ.4'l/ �{��;s�(�Q7�]�/y ��•�i `'ly'{®�'�'�i. .'�+�{��J.�lI��J.`�.�.L �J�;�� ' J.! JC40 U ►3�,JJ.�t�J[ �L+�•LO.Ii e , • .. _ 2asse [+'aflefl- [ j Ple-iuspecizoxt xequiueci ($5O.OU) [ ] �nspectoxs' co7aumenfs: i fr r ffupp cc -tore Signature •• 3ao fn[tials) Date Ro--bspectlonrequired ($50.00) •- f Sizspectoxs' comments: •-G--(1-- 1,L Z 2 • (inspectoxs'ignafure no ixnztials) date 3, IV.NDIRCRODM )N9')TCTZ0W.- Vassed inspectors° coTnxnents: . (inspectors' Signature-• no initials) Date 4, WSPXCTX0N—,9 VXC�': Passed -- [ x Nspectbxs' cammepfs: Yaued-- �ig�zature � 7no )NBPBCTXON •- OAR: te-inspection xe 'assed [) +ailed [ )-Le-xnspesti aspectoxs' comenfs: Date fru mectorO Signature - no > nifiais) Date 0 G OR TAGS "E TO BE FAZED 017T AM LEFT OSI' ISUE N TM .A -PWA TO BE INSTECTED ISNOT ACCESSIBLY, AND .A RFAWRECTXON O)` _S50,00318 TO BY AGED. . if M The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_�TAM e-_> Address: - 6J 10 6V 4- e- City/State/Zip:k -Pt-A-z'17,vt; 1 M D/ Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2�. � in a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. [J 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 10.0 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.❑ Roofrepairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that checkthis 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 thepolicy 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 STOR WORK ORDER and a fine -of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert�i%�uncle inn enalties of perjury that the information provided above is true and correct. SinnafirrP' \I _.4 ' 1latP• (ll Phone #: 6 y - f 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact 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 iri 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 (ifnecessary) 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. Anew 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 anal fax number: The Gomxoxawealth of massachwetts Depaztent of ZndusWat Accidents Off oe offavesiigations 604 Washingtola. Street Boston, MA, 02111 TO, # 617-727-•4900 est 406 or 1-877,1MASSAFE Revised 5-26-05 Fax # 617;,727-7749 wwwaxxass,�ovfdia 147 Date. � .: 4� .. -e 2 .. . NORTH TOWN OF NORTH ANDOVER pf 4«ao ,s,'t'O p� PERMIT FOR MECHANICAL INSTALLATION P \° ^ #x 9SSACMUSEt,( Ci This certifies that ..r%. .. ....... . a%�-- has permission for mechanical installation . j2vkt. in the buildings of Sh... '.�.C.�'. .�7!`............... at . �� ... ... T..'�� , North Andover, Mass. Fee./.V57n Lic. No...iJ4 J ..................... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: & '& - I L 1r5ti,rtl.3tefi Job Cost- _1611 Plans S-abmitted: WS NO Business License # ILI Business Information: - r Narn�fr��►C Street: I a I ✓i� CitylTown: Telelpii ne: 5 7-6 Permit # %q-4— Permit Fee: Plans Reviewed. YES NO Applicant License # 9GS .Property Owner /1Job Location Information: Name: Street; Citi+/Torwn:fL _m_/4 Telephone: ? 91 -_I,1 ?A' Photo 1.0. required / Copy of Photo 1.1), attached: YES --- NO StattTnil'eal J-1 11�-1-tanrestrictecl Iicerase 7-2 / M-2-xestrirted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. /2 -stories or less Residential: 1-2 family X " Multi -family Condo / Townhouses Other Commercial„ Office I Retail Industrial Educational .institutional Other Square Footage: under 10,000 sq. ft x over 10,000 sq, frt. Number of Stories-. Sheet metal work to be completed: New Work: X Renovation: HVAC Metal Watershed" Roofing Kitchen Exhaust System Metal Chirmrey / Vents _ Air %lancing Provide detailed description of work to be done: I N S-rAwNt- 2 -S 1 -ow.__ 'DULV S�S`f'�m 1 N &bSGtVaLook c The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 Www .mass gov/dia Workers' Compensation Insurance Affidavit: Eniiders/Contractors/Electricians/Plumbers Mlirnnf TnfnrM.M4;__ Name (Business/Organization4ndividual):'��/p L fll� <YS'r6 S �VvC' - - - - .Address: -.-.71 d -- -- -- - vv► is; _., . - �o,, -- — City/State/Zip 1,.J e & f PD 1M - Phone k_ `tl Y 6(9 sol? Are you an employer? Check the appropriate boa: 1 • ❑ I am a employer with 4. El am a general contractor and I employees (full and/or part-time).*' 2.01n aa sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. t slop and have no employees These sub_contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insuranQ9- 5. ❑ We area corporation and its required.] 3. ❑ am a homeowner doing officers have exercised their .I all work Myself . [No workers' comp. right of exemption per MGL c. 152, § 1(4), and we have no in required.] t employees. [No workers' ` comp, insurance required.] *A my E_ I10E2i that checks box r1 must also fll out the section below T T-- Type of project (required):' 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions .1 LEI Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they are 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' omp, policy information. I am an employer that isproviding workers' compensafion insurance for my employees Below is the policy and job site information. Insurance Company Name: : (rNo f E L„Ci Policy # or Self -ins. Lic. #:_ 6 b 6? y g q( 1 S y Expiration Date:_ � • Zg - �Z Job Site Address: -IS 1 6(44T Www City/State/Zip: h hNDOV4& VMp , Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the -.,.% A 1 I A e information provided above is true and correct At—e Date: 6• C- �Z Phone #: uJJzczal 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 6. Other Contact Person: 4. Electrical inspector 5. PIumbing Inspector 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 dweliinghouse'-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 bean 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), addresses) 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 anLLC or LLP does have employees, a policy is required Be -advised that this affidavit maybe submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also be stare to sign and date -the affidavit. The affidavit should be ret -Ted 4 the �?s� or toR-uthe t the ap p lioa ion. fJr tLE EB:i�flt'C1� 1'^ Sb i° L"e'm_'g r�q'T _ 9fed, _ _ JAr T[me_t 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 a`s a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance for your cooperation and should you have any questions, please do not -hesitate to give us a call. .i . , • ' 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. # 617-72.7-4900 ext 406 or 1-8.77-M. ASSAFE Revised 5-26-05 Fax # 6.17-727-7749 OfiVAI AIRCY ___ _— _ 'ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 1 2/1 912 01 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HUB International New England NAME:C FAX PHONE 978 657-5100 AIC.,.):9789880038 AIC, No, Ext EMAIL ADDRESS: 299 Ballardvale St Wilmington, MA 01887 INSURER(S) AFFORDING COVERAGE NAIC# A: Travelers Indemnity Co of CT 978 657-5100 --INSURER INSURED Royal Air Systems, Inc INSURERS: Travelers Indemnity Co of Amer! INSURER C: Atlantic Charter INSURER D: Travelers Indemnity 25658 210 Main Street INSURER E North Reading, MA 01864 INSURER F: a.vvcrwaaca THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL I g SUBR POLICY NUMBER POLICY EFF MM/DD MM/DD/YYYY POLICY EXPMaccident) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY C 16807499C754 9/28/2011 09/28/201 OCCURRENCE $1,000,000 S Ea occur ence $300 OOO (Any one person) $5,000 CLAIMS -MADE � OCCUR --- PERSONAL INJURY $1,000,000 AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: S - COMPIOP AGG s2,000,000 $ LE LIMIT$1,000,000 D X POLICY jRCT LOC AUTOMOBILE LIABILITY BA6226C37311SEL 6/21/2011 06/21/201nt) JURY (Per person) $ tANYAUTO L OWNED X SCHEDULED TOS AUTOS NON -OWNED RED AUTOS X AUTOSPer 0, C. Car BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ accidentve $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUP0249T248 9/28/2011 09/28/2012 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED I X RETENTION s5000$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below OTH- WC STATU- I ER C N / A WCA00520503 0/10/2011 10/1012012X E.L. EACH ACCIDENT $1 OOO 000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Coverage. CERTIFICATE HULUEK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF COVERAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C W 1700 -GV 1V . r... .=. .•. •� ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S628792/M603039 RG002 E Project -�-�+ uvri�f�t _soft 1 Summary Entire House Project Information I For: Sheehan 759 Great Pond rd, North Andover, MA 01906 Notes: Job: Date: 6/5/2012 By: Solditalic values have been manually overridden Calculations approved by ACCA to meet all requirements of Manual J 8th Ed 2012 -Jun -05 07:30:57 Wrlghtsoft' Right -Suite® Universal 2012 12.0.04 Right J® Mobile Page 1 C:\WINDOWS\TEMP\wstmp\e78fe0be-el92-48e8-b801-abl24dd57102.rup Calc=MJ8 FrontDoorfaces: N Weather: Boston, MA, US Winter Design Conditions Summer Design Conditions Outside db 0 OF Outside db 90 OF Inside db 75 OF Inside db 70 OF Design TD 75 OF Design TD 20 OF Daily range t Relative humidity 50 % Moisture difference 33 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 31832 Btuh Structure 19547 Btuh Ducts 0 Btuh Ducts 0 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 31832 Btuh Use manufacturer's data y Rate/swing multiplier 1.00 Infiltration Equipment sensible load 19547 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 1449 Btuh Ducts 0 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area (ft') 1100 1100 Equipment latent load 1449 Btuh Volume (ft') 9900 9900 Air changes/hour 0.45 0.23 Equipment total load 20996 Btuh Equiv. AVF (cfm) 74 38 Req. total capacity at 0.70 SHR 2.3 ton Heating Equipment Summary Cooling Equipment Summary Make Make Trade Trade Model Cond AHRI ref no. Coil AHRI ref no. Efficiency 0 AFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 1185 cfm Actual air flow 1185 cfm Air flow factor 0.037 cfm/Btuh Air flow factor 0.061 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.93 Solditalic values have been manually overridden Calculations approved by ACCA to meet all requirements of Manual J 8th Ed 2012 -Jun -05 07:30:57 Wrlghtsoft' Right -Suite® Universal 2012 12.0.04 Right J® Mobile Page 1 C:\WINDOWS\TEMP\wstmp\e78fe0be-el92-48e8-b801-abl24dd57102.rup Calc=MJ8 FrontDoorfaces: N AL �nrrightsofk Right J® Mobile Report Job: 6/512012 Entire House By: Project lnfor.,mkion I _. For: Sheehan 759 Great Pond rd, North Andover, MA 01906 Component =pllle r • % of load Walls Location: 7551 Indoor: Heating Cooling Boston, MA, US 27.1 Indoor temperature (°F) 75 70 Elevation: 16 ft Ceilings Design TD (°F) 75 20 Latitude: 42°N 3.9 Relative humidity (%) 30 50 Outdoor: Heating Cooling Moisture difference (gr/Ib) 34.4 32.9 Dry bul b (°F) 0 90 Infiltration: 0 Daily range (°F) - 15 (L ) Method Simplified 0 Wetbulb(°F) - 72 Construction quality Average Adjustments Wind speed (mph) 15.0 7.5 Fireplaces 0 Component Btu hiT Btuh % of load Walls 6.8 7551 23.7 Glazing 42.8 8621 27.1 Doors 29.2 1228 3.9 Ceilings 3.7 4043 12.7 Floors 3.9 4267 13.4 Infiltration 4.5 6122 19.2 Ducts 0 0 Piping 0 0 Humidification 0 0 Ventilation 0 0 Adjustments 0 Total 31832 100.0 Component Btuh/re Btuh % of load Walls 2.6 2899 14.8 Glazing 45.3 9143 46.8 Doors 13.2 554 2.8 Ceilings 2.8 3088 15.8 Floors 1.0 1138 5.8 Infiltration 0.6 834 4.3 Ducts 0 0 Ventilation 0 0 Internal gains 1890 9.7 Blower 0 0 Adjustments 0 Total 19547 100.0 Latent Cooling Load = 1449 Btuh Overall U -value =0.103 Btuh/ft2--°F Data entries checked. [Cl Gail SoldNalic values have been manually overridden 2012 -Jun -05 07:30:57 �"`�-• wrightsoft, Right -Suite® U niversal2012 12.0.04 Right J® Mobile Page 1 �• C:\wWDOWS\TEMP\wstmp\e78fe0be-e192-48e8-6801-ab124dd57102.rup Calc =MJ8 Front Door faces: N xA L wrightsoft• Right -J® Worksheet Job: Entire House Date: 6/5/2012 f By: AL 1 Room name Entire House First Floor 2 Exposed wall 150.0 ft 150.0 ft 3 Room height 9.0 ft 9.0 ft heat/cool 4 Room dimensions 1.0 x 1100.0 ft 5 Room area 1100.0 ft' 1100.0 ft2 T 9 Construction U -value Or HTM I Area UP) I Load I Area ft' I Load number (Btuh/ftp-°F) I (Btuh/ft2 or perimeter (ft) (Btuh) or perimeter (ft) (Btuh) Heat Cool Gross N/P/S Heat Cool Gross N/P/S j Heat Cool 6 12C-Osw 0.091 n 6.82 2.62 360 286 1950 749 360 286 19M 749 � 1 Dc2ow 0.570 n 42.75 22.09 53 0 2280 1.178 53 0 2280 1178 11DO 0.390 n 29.25 13.18 21 21 614 277 21 21 614 277 12C-Osw 0.091 a 6.82 2.62 315 247 1682 646 315 247 1682 646 11 1Dc2ow 0.570 a 42.75 63.94 48 0 2031 3037 48 0 2031 3037 LL�__ ppp 11 DO 0.390 a 29.25 13.18 21 21 614 277 21 21 614 277 12C-0sw 0.091 s 6.82 2.62 360 306 2087 802 360 306 2087 802 1D-c2ow 0.570 s 42.75 35.88 54 0 2316 1944 54 0 2316 1944 w 12C-Osw 0.091 w 6.82 2.62 315 268 1831 703 315 268 1831 703 t -G 1Dc2ow 0.570 w 42.75 63.94 47 0 1995 2984 47 0 1995 2984 C 166-19ad 0.049 3.67 2.81 1100 1100 4042 3088 1100 1100 4042 3088 F 19A-1lbsco 0.073 - 3.88 1.03 .1100 1100 4267 1138 1100 1100 .4267 1138 61 c) AED excursion 0 0 Envelope loss/gain 1 25710 16823 1 1 25710 16823 12 a) Intiftration 6122 834 6122 834 b) Room ventilation 0 0 0 0 13 Internal gains: Occupants @ 230 3 690 3 690 Appliancestother 1200 1200 Subtotal (lines 6 to 13) 31832 19547 31832 19547 Less external load 0 0 0 0 Less transfer 0 0 0 0 Redistribution 0 0 0 0 14 Subtotal 31832 19547 31832 19547 15 Dud loads 0% 0% 0 0 -0% 0% 0 0 Totalroom 1951 4 31832 1957 II (c m) I I 1185 I31 I ( 85 Iirregred I Calculations approved by ACCAto meet all requirements of Manual J 8th Ed. wrightsaft` 2012 -Jun -05 07:30:57 Right -Suite® Universal 2012 12.0.04 Right JO Mobile Page 1 C:\WINDOWS\TEMPlwstmp\e78fe0be-el92-48e8-b801-abl24dd57102.rup Calc =MJ8 Front Door faces: N 0 =I ®1 I O LL- I— O in ............ ............ .......... A r. 2c. 2,112 10; 41AM p N.,, 516 2; 2 li�ib`i11ZAIiiCE COVERAGE: i have a current jLa&1V insurance policy or Its equivaient which moats the requirements of M,G,I.. Ch,112 Yes No df.you tiara checked Ygs, indicate the type of ;,overage by chockirig the appropriate box below: A Ilabillty insurance policy ❑' Other tyre of Indeinnity ❑ Bond ❑ i OWNER'$ INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 ofth® Massachusetts Generaf Laws, and that niy signature on this permit appilcatlon wa_ lYN this requirement, Check Ona only Owner ❑ Agent (] Signature of owner or Owners Agent By checking this box[], I hereby certify That all of the details and Information I have submitted (or entered) regarding Phis application ere true and accurate tc the hest of my knowledge and thut an sheat Rota) Work and Intialiations Performed under the permit Issued for this appileat en will ba In curripilance evith all por#Inant provision of the Massachusetts puilding Coda and Chapter 112 of the General l.a'ws, Duct inspection required prior to insulation installation: YES NO Date Comments Final. Inspection Date Cortatnerits TYPO if License-' i - — -- By X Master Tile Master-Reslricted CllylT'cwn —••�• [1Journeyp6rson Fennf,Yi Signature of Licensee FeoE]Journeyperson-Restricted License Number. q_� Check at tnrww.mass.novldp i I Impactor Signature of Permit Approval I Date......................... TOWN OF NORTH. ANDOVER PERMIT FOR WIRING This certifies that ... �51.............................................................. has permission to perform,., -7 ....................... wiring in the building of ....... ........................................................... at ... ...... ...... North Andover, Mass. Fee`� .............. Lic. N66.4�..� ......... Check # 8420 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. p2o BOARD OF FIRE PREVENTION REGULATIONOccupancy and Fee Checked S [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned Ives notice o s or her intents to perfo he electrical work described below. Location (Street & Number) -/ s 7 ?1 KID Owner or Tenant 11-11' (1-1 & O/ys Owner's Address Is this permit in conjunction with a building permit? hl 0 /;�_ P . Yes ❑ No ❑ Telephone No. (Check Appropriate Box) Purpose of Building 1 ? Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: / Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the follom ino tnhlo mm, ho .—i—,4;.. tho r., ..t— -r Lr/; - /d`1 No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In-❑ rnd. nd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* or Equivalent No. of Watery Heaters No. of No. of Signs Ballasts Data Wirmevices g' No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /0 -/ .7 d� Inspections to be requested in accordance with MEC Rule 10, and upon completion. ti~4 INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has ,exhibited proof,of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the aims andpenalties orperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: /S ll' �}llil2l�� Sign LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $�� I Date............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ........... .... . , ... . ...... has permission to perform ........� .................. .............................. wiring in the building of .......... ................................................... at ..... ............ . .............. 6;1) ....... North Andover, Mass. FeelS ... Lic. No.. ............. ........ . . ...... IELEerRicAL INsPEcrofi Check # 7 8866 -C-N Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. re Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER 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) �� til .�� Owner or Tenant A s Owner's Address ' Telephone No. � 5 c�� /� 7` 1�i9�n ?,J _ Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: V"ZI~ i/—� Y ' Completion of thyb1lowing table maybe waived by the Ins ector o Wires. No. of Recessed Luminaires No. of Cel-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- o. o Emergency rg g grnd. ❑ rnd. BagM 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 Initiatin Devices No. of Ranges No. of Air Cond. TonTots No. of Alerting Devices No. of Waste Disposers Heat ump Number . Tons KW No. of Self -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heatin KW Municipal Heating Local ❑ Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems: * No. of Water No. of No. of Devices or Equivalent Heaters KW No. of Data Wiring: Si Dus Ballasts . No. of Devices or Elluivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: OTHER: No. of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. { Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify:) I certify, under the aims andpenalties of perjury, that the information on this application is true and complete - FIRM NAME: /��, SLP�72t cL LIC. NO.: Licensee: pal,/ . y9��o Signa LIC. NO.: (If applicable, nter "exempt " in the license number line.) Address: $ T,�/� GL S7- �_�� c� Bus. Tel. No.: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner 11 owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts Department of gndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t' 1 www mtassgov/dia . Workers' Compensation InsRrance Affidavit: Builders/Contractors/Electricians/Plumbers Anoiicant Information Please Print Legibly Name (Business/organiration/Individual) Address: City/,State/Zig: Phone #: . Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. F1 am a general contractor and I Type of project (required): employees (full and/or part-time).* 2.[] I am.a.sole proprietor or partner- have Hired the sub -contractors listed on the attached sheet. i 6. ❑ New construction 7• ❑ Remodeling ship and have no employees These su&contractots have 8. [� Demolition working for me .m any capacity. [NO workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition re9required-)l0. red-] . 3. ❑ I am a homeowner doing officers have exercised their ❑ Electrical repairs or additions all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No -workers' comp. `t c. 1.52, § 1(4),'and we have no 12. Roof ❑ repairs insurance required.] employees. [No workers' 13.[] Other comp, insurance required_] -•.7 _rr••..a,,..., u=2w Dox If i must also tett out the section below showing their workers' oorrtpensation policy information. t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. ,conttacton; that check this box must attached an additional sheet showing the name of the sub-contractvts and their workers • comp policy iniomiatioa. ! am an employer that is.provfding:workers' compensation insurance for my. employees. ---- Below is the policy and job site . information Insurance Company Name: 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 dove* rage as required tinder 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 WORT{ ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature:. Date - Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person Phone #: Information and Instructions' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner -of a dwelling house having not more than three 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 tine commonwealth nor any of its political subdivisions shall enter into any contract for the performance of pubiic 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating -current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of'the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT. required to complete this affidavit The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 446 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT. TO DO GASFITTING `(Print or Type) • • . 1VO-ii4tid06L,Mass. Date 4-3 19 '77 !T J `� Building Location 75;Q G/'� fbrd N Owner's Name AJU 19'/10(0V r _iii Type of Ocpupancy. l9esidPne New O Renovation O Replacement Plans Submitted: Yes O No O FIXTURES Installing Company NameCheck one:' Certificate , Address P.O. BOX 728 Corporation NORTH ANDOVER, MA. 01845 O Partnership t Business Telephone 5®$ 7a42_q9 ,�O`` Firm/Co. Name of Licensed Plumber or Gas Fitter 2a er1 6 otic kat/ INSURANCE • COVERAGE: I have a cue liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IVNo O If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy f� � Other type of indemnity O Bond O OWNER'S INSURANCE -WAIVER: I am aware that the licensee does nol have the insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner O Agent O I hereby certify that all of the details and information I have submitted for entered) In the above application are true and accurate to Ow best ci"knowledge and tha all plumbing work and. IrIlabons performed under the permit issued for this application will be in compliance with all pertinent provisions of Arc Massachusetts Stator Cas Code and Chapter 142 of the GermeuJ La -L ..aI of licenx: .. By Plumlrr aafiner Title ,a1e, "awe of licensed Plumber or Gas Fitter Cirv/Town IoumeYrnan ®�_ License Number APPROVED (OFFICE USE ONLY) Sth FLOOR 7th FLOOR Installing Company NameCheck one:' Certificate , Address P.O. BOX 728 Corporation NORTH ANDOVER, MA. 01845 O Partnership t Business Telephone 5®$ 7a42_q9 ,�O`` Firm/Co. Name of Licensed Plumber or Gas Fitter 2a er1 6 otic kat/ INSURANCE • COVERAGE: I have a cue liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IVNo O If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy f� � Other type of indemnity O Bond O OWNER'S INSURANCE -WAIVER: I am aware that the licensee does nol have the insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner O Agent O I hereby certify that all of the details and information I have submitted for entered) In the above application are true and accurate to Ow best ci"knowledge and tha all plumbing work and. IrIlabons performed under the permit issued for this application will be in compliance with all pertinent provisions of Arc Massachusetts Stator Cas Code and Chapter 142 of the GermeuJ La -L ..aI of licenx: .. By Plumlrr aafiner Title ,a1e, "awe of licensed Plumber or Gas Fitter Cirv/Town IoumeYrnan ®�_ License Number APPROVED (OFFICE USE ONLY) a:..a-�-r;rr=�=w�+wY�.. wry' v,��, ��.F_..:. -.. ��lsGNll'*``_'s mss- ...-•y,n=.�c .•�v..;�-�- ._r i. T2 2564 Date':. f, ` Y 40RT" � TOWN OF NORTH ANDOVER Of41 .. 1y PERMIT FOR GAS -INSTAL, TION ' �9SSACHUSE<S� - ., a. 2'•. -pp �i This certifies that J4,,1.;. /? . Pis has permission for gas installation. in the buildings of _ at S. ... �f? r .. ... � Andover, -MJ Feer%?.,." .. Lic. No..b.� Z.. GAS INSPECTOR WHITE: Applicant CANARY' Building Dept... :PINK: Treasurer GOLD File'' ;4� MASSACHUSETTS UNIFORM APPLICATION FOR (Print or Type) NORTH ANDOVER Mass. tuilding Location 2 �q GtP�'f PO/74 i1U� Owners PERMIT TO DO GASFITTING Date /- Permit # , Name Cud ht l ? Urn Q • New "� Renovation -] Replacement Plans Submitted I] -F- C (Print or Type) Check one: Certificate Installing Company Name /,1/11 e Sock P6,rP Q Corp. 1/ Address /fid X 7 '; -� Q Partner. /V0 /-,�ndoyer a- Q Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter j2a b El,- 13 t3lonc /i-' Insurance Coverage: Indicate t:ie type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Q Insurance Waiver: I, the undersicned, have been made aware that the licensee of thi application does not h e any one of the above three insurance coverages. �. Signature of owner/agent of property Owner Q Agent I hctcby certify that aR of the devils and information I have submitted (or entered) in above application are true and accurate to the best of mY knowledge and that all plumbing worst and instattations ;=formed under Perr:tit i=cd for this apptiction will be in complianoa with ad pertinent provisians of the Massachusetts State Cas Cade and Chapter 142- of the Ccneral LawL .. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE.: `r ,pA 71—Plurriber Gasfitter Signature of Licensed TT aster Plumber or Gasfitter Journeyman License Number _ Vs Of t) � F a3 � v CUA La Os Z < G O Q tII H N W EW. N W Z V W cC W '� Q r W �. QJ W O W H Qf Z F- < 2 w t7 Q O W ? tt W t.- C.T i f. G W ,� y� z d W J < C f" y- V! m — O Z us O to — \i _ aO W �+ D V C y O t�7 L t<1 -4 I Ole. 1— sua—asrtT. { I ( I i I l BASEMEXT IST FLOOR I I { I { I I I I I { I I I l ZM0 FLOOR I { I I I { ( I I I I I I f I 3R0 FLOOR I I I I I I I I I I I I I { I I 4TH FLOOR { I { I I I I I { { I I STH FLOOR ( I ( ( I I I I ( I y 6TH FLOOR I I I 7TH FLOOR I M I I I I I I I aTH FLOOR I (Print or Type) Check one: Certificate Installing Company Name /,1/11 e Sock P6,rP Q Corp. 1/ Address /fid X 7 '; -� Q Partner. /V0 /-,�ndoyer a- Q Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter j2a b El,- 13 t3lonc /i-' Insurance Coverage: Indicate t:ie type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Q Insurance Waiver: I, the undersicned, have been made aware that the licensee of thi application does not h e any one of the above three insurance coverages. �. Signature of owner/agent of property Owner Q Agent I hctcby certify that aR of the devils and information I have submitted (or entered) in above application are true and accurate to the best of mY knowledge and that all plumbing worst and instattations ;=formed under Perr:tit i=cd for this apptiction will be in complianoa with ad pertinent provisians of the Massachusetts State Cas Cade and Chapter 142- of the Ccneral LawL .. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE.: `r ,pA 71—Plurriber Gasfitter Signature of Licensed TT aster Plumber or Gasfitter Journeyman License Number 'Yr - Date ... ...... f 6 . 205 V f NaRTM TOWN OF NORTH ANDOVER a ct 3? 't 1 f° PERMIT .FOR GAS INSTALLATION :$ a ?� 9SSACMUIn SES .. This certifies that .. } .... �G. G% £' has permission for gas ' stallation in the buildings f �.,i %`% ,.. .. At ..� .. :. �/.. f ., North Andover, Mass. s Fee. .�r.----Lic. No.. . r5-7 -73 GAS INSPECTOR WHITE: Ap CANARY: Building Dept. PINK: Treasurer GOLD ,F"' _. .�,'-t__.x.,.�_,3:•'a�.c�!±. �-N . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINQ (Print of Type) NORTH ANDOVER, Maas.. Date Ig� Bulldln r Qom"' Local I Permit # % Y� �j U r(_ jl�c'i fr Namer_s�J�9��r New Renovation ❑ Replacement p Plans Submitted: Yes ❑ No O Installing Company Name �--( cow k one: CeNHlcate Address ,4 0zz e [i Partnership O Firm/Co. Business Telephone Name of Licensed Plumber or t3as Fitter � INSURANCE COVERAGE: Check one 1 have a current liability Insurance policy or its substantial equivalent. Yes ❑ No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy p Other type of Indemnity C7 Bond O OWNER'S INSURANCE WAIVEn: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: %nature of Owner x Owner's Agent Owner O Agent ❑ ( hereby certify that all of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In complia pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the ws. nce with all p , "7 T me of License: Title Plumber na ure o cx se um at or as er Gaslllter City/'Townaster license Number !// . L,Joumeyman APP1140lED (OFFICE USE ONLY) C N m x m N i 'y M, M z A v � r n N b o m .� :.: n O p -1 o a• � O , Z o o v z o M m � n m o C4 m 0 � I N C O '11 • z A r a � N 't1 •z rn p � e i F N m x m N i 'y M, M A v � r n N b rn n O p -1 z � O Z o o N m x m N m M, M v n ; O p z � o o v z o M m � n o C4 m 0 O O , z A r a � N 't1 •z o � ROAD Date ...!, ORTO,, doveu �.O1ivi1 FwN' OF NORTH 32 ht PERMIT FOR -GAS I, f� This certifies that .... has permission for ga installation in the buildings of at .. .... ` t' ..P?7ief;. , Nor Fee. Lic. No..�.C, GAS INS WHITE: Applicant CANARY: Building Dept. PINK: Tr( Location �� q �� d ��% )Pj No. &YDate NORTq TOWN OF NORTH ANDOVER Certificate of Occupancy $ Nus �� Building/Frame Permit Fee $ 3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 30 y Check # 3 L' 16480 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISHONE OR TWO FAMILY DWELLING '� 4�. a. w „' :181E••• Viae.:. @x. � k kr_ 5k ��A ."% BUILDING PERMIT NUMBER: zC, DATE ISSUED: SIGNATURE: M 6L-1-- BuildingCommissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: IC)3 Map Number Parcel Number ^ V' 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided ">rm 1.7 Water 1.5. Flood Zone Information: Supply M.G.L.C.40. r54)S Public ❑ Private t7' �# �� Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Name (Print) Address for Service Si afore Telephone wner of Record: T Ka,�L L • 1 b' �/►/I o /LtejI /SSI Cit ri° f�G �lLt Name Print GG Address for Service: p� ,< 17 Sig6ature f Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.'ii Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ ConWany Name Registration Number Address Expiration Date Signature Telephone T M Z O O Z M 90 O on r M r YI SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a lIcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: u.� rO w i S. ova 's L. "A base cal I AR4 +-0 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant 1. Building CIALTSEEONLY, =� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X (b) O Ii 30 J 4 Mechanical HVAC 5 Fire Protection _ 6 Total. 1'+2+3+4+5 - �+ -� �' �+ 3' } (Jv7� Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r ,�060�er/Ahorized Agent of subject property / I Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS iST 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH VINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I 9 North Andover Building Department Tei: 978-688_9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40'S 54, a condition of Building Permit Number is -that. the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A.. The debris will be disposed of in: Qr s nt (Location of Facility) i ature of Permit A plicant -�� 03 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building inspector Tel: 978-688=9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE n JOB LOCATION 75 (� rea+a (� CYkA 1k)-at1 Number J Street Address Section of Town "HOMEOWNER,PP '759 Grud- Ccs (97�) Qt6-S_Uy 97ED76Z - 579V Number Home Phone Work Phone PRESENT MAILING ADDRESS ( �rcol+ (?&Y O( F El City Town State Zip Code The current exemption for %omeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. �2.vat�-eo k6 t6N� 0 a Town of North Andover Building Department "SSacmuSEs 27 Charles Street North Andover MA 01845 Tel: 978-688=9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE n JOB LOCATION 75 (� rea+a (� CYkA 1k)-at1 Number J Street Address Section of Town "HOMEOWNER,PP '759 Grud- Ccs (97�) Qt6-S_Uy 97ED76Z - 579V Number Home Phone Work Phone PRESENT MAILING ADDRESS ( �rcol+ (?&Y O( F El City Town State Zip Code The current exemption for %omeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. M 4 M O z 1 W�7 w Wco Oon v O w aQi cn U A a o p w O a: U �n C w W W OC w w W U a W p aG y cn C w QZW m O w' C w a w v 7 W o b cn 0 C/) CD O O Z O C y coM E L co C O O m 0 - CO) O O .y C O .0 0. H �Mo _0 U U) IrW W W U) CD c o L t+ o V C) N y � c civ Q fr a c : � o m� i tQ V m , N Q 4rCD C o V � V 01 �mm Ol 3 N f N cm a m I •- N e 0 E m -- :_: f &CD 0 :acjI.: cm� = o z SO am 0 m p m w NZ �� o o.� IO�CL cm c .o = CD a N rC+ N m r m y... C C Vf 'E C La v : v N Z o L3 m omc V4 _ a m. ®� .00 h CD O O Z O C y coM E L co C O O m 0 - CO) O O .y C O .0 0. H �Mo _0 U U) IrW W W U) Date ..... 7.-..21 0.3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... � r.1 N a U C �t r ................................................................................ has permission to perform .....Fa. WX 12 1z V`i ° I ................................................................ wiring in the building ofKA i. A:' .................... .......................... ............................... S .......................... . North Andover, Mass. r - Fee...�` ......... Lic. No .............. ... .......... ..� ............... ..................... ELECTRICAL I . SPEPE CTOR Check # -31:15 4639 rrGlg.e%� 6�7 WtSs��s�77S a%antnrent ob �u8!!e Saaetry BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 .1. Official Use Only Permit No. (J Occupancy & Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number %4 R�. Tion . Owner or Tenant �• 67 Owner's Address S� Is this permit in conjunction with a building permit Purpose of Building Existing Service ®� Amps New Service VO Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical ov7,�r c e04701`0 To the Inspector of Wires: Yes 9--' No ❑ (Check Appropriate Box) Utility Authorization Undgmd ❑ Undgmd' ❑ S i,, &,Q No. of Lighting Outlets No. of Hot fuse hp ve submitted valid proof of same to the Office YES = 6>— If you have checked YES please indicate the type of coverage by checking the appropriate box Total f,�1 No. of Transformers KVA �---,J (Expiration Date) Above ❑ In ❑ © No. of Lighting Fixtures Final Swimming Pool grnd ❑ grnd ❑ FIRM NAME d"Pee Generators KVA. No. of Receptacles Outlets - No. of Oil Burners �./� Bus. Tel No. No. of Emergency Lighting Battery Units No. of Switch Outlets ® No of Gas Burners FIRE ALARMS No. of Zone [/ No. of Detection and Initiating Devices No. of Sounding Devices 1 of Self Contained Detection/Sounding Devices lIIJJJ ❑ Municipal ❑ Other Local Connection No. of Ranges //'"� Total No of Air Cond 0 Tons /� No. of Di sal Heat Total Total No. Pumps Tons KW No. of Dishwashers 0No./ Space/Area Heating KW No. of Dryers D Heating Devices KW No. of Water Heaters KW No. of Signs No. of Bailases Low Voltage /!lJ" Wiring No. Hydro Massage Tuds _ D No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = hp ve submitted valid proof of same to the Office YES = 6>— If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE= BOND = OTHER T- (Please Specify) (Expiration Date) `{#{ ,o�1 Estimated Value of Electrical Work 1 a�0 , C) p Work to Start t7_/g — 0-& I Inspection Date Resquested AJO Rough Final Signed r thenaltre Nof p ury FIRM NAME d"Pee LIC. NO. / - Lrkensee�Signature JJ�/L2-�Y, Bus. Tel No. Address � I 6-1,4,. /� �O� a`�"{C�N � h /� rl Alt Tel. No. �a — 94ryic OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITEEE $ (Signatup6 of Owner or Agent) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rry employees working on this job. Company name - Address City. Phone # Insurance. Co. _ - Policy # Company name: Address CW. Phone# Insurance Co. _ _ Policy.# Failure to secure coverage as required. under Section 2M or MGL 152 can lead to -the imposition of criminal penalties of.a.fine up to $1.500:00 an &or one years' impmonmentasvn& as_civil.penalties-nSheSnrmjfa-STDPYj9W -ORDf R,and_afin--ct 3l-WM)-aAW t•me I understand that a copy of this statement may be forwarded to the Office, of Ind of the DIA for coverage verification. l do hereby certify wider the pains and penalties of perjury that the innlorrn h ri provided above a true and coned Signature Date Print name Phone.# Oficial use only do not write in this area to be completed by city or town official' City or Town Permitkicensin4. Building Dept ❑Check if immediate response is required . Licensing Board ❑ Selectman's Office Contact person: Phone# ElHealth Department ❑ Other